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Sunday, August 4, 2024

United States and state-sponsored terrorism

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/United_States_and_state-sponsored_terrorism

The United States has at various times in recent history provided support to terrorist and paramilitary organizations around the world. It has also provided assistance to numerous authoritarian regimes that have used state terrorism as a tool of repression.

American support for terrorists has been prominent in Latin America and the Middle East. From 1981 to 1991, the United States provided weapons, training, and extensive financial and logistical support to the Contra rebels in Nicaragua, who used terror tactics in their fight against the Nicaraguan government. At various points the United States also provided training, arms, and funds to terrorists among Cuban exiles, such as Orlando Bosch and Luis Posada Carriles.

Various reasons have been given to try to justify this support. These include destabilizing political movements that might have aligned with the Soviet Union during the Cold War, including popular democratic and socialist movements. Such support has also formed a part of the war on drugs. Support was often geared toward ensuring a conducive environment for American corporate interests abroad, especially when these interests came under threat from democratic governments.

Cuba

A memorial to Cubana Flight 455

Starting in 1959, under the Eisenhower administration, the U.S. government had the Central Intelligence Agency recruit operatives in Cuba to carry out terrorism and sabotage, kill civilians, and cause economic damage.

In 1961 the U.S. government, through the military and the CIA, engaged in a far more extensive campaign of state-sponsored terrorism against civilian and military targets in Cuba. The terrorist attacks killed significant numbers of civilians. The U.S. armed, trained, funded and directed the terrorists, most of whom were Cuban expatriates. Andrew Bacevich, Professor of International Relations and History at Boston University, wrote of the campaign:

In its determination to destroy the Cuban Revolution, the Kennedy administration heedlessly embarked upon what was, in effect, a program of state-sponsored terrorism... the actions of the United States toward Cuba during the early 1960s bear comparison with Iranian and Syrian support for proxies engaging in terrorist activities against Israel

Among the most prominent of these terrorists were Orlando Bosch and Luis Posada Carriles, who were implicated in the 1976 bombing of a Cuban plane. Bosch was also held to be responsible for 30 other terrorist acts, while Carriles was a former CIA agent convicted of numerous terrorist acts committed while he was linked to the agency. They and other Cuban exiles involved in terrorist acts, including Jose Dionisio Suarez and Virgilio Paz Romero, two exiles who murdered the Chilean diplomat Orlando Letelier in Washington in 1976, were released by the administration of George W. Bush.

Orlando Bosch

Bosch was a contemporary of Fidel Castro at the University of Havana, where he was involved with the student cells that eventually became a part of the Cuban revolution. However, Bosch became disillusioned with Castro's regime, and participated in a failed rebellion in 1960. He became the leader of the Insurrectional Movement of Revolutionary Recovery (MIRR), and also joined efforts to assassinate Castro along with Luis Posada Carriles. The CIA later confirmed that they had received support from Bosch in 1962, but ceased contact with him after he requested financial support to mount airstrikes against Cuba in 1963. He was the head of Coordination of United Revolutionary Organizations, which the FBI has described as "an anti-Castro terrorist umbrella organization". Former U.S. Attorney General Dick Thornburgh called Bosch an "unrepentant terrorist".

In 1968, he was convicted of firing a bazooka at a Polish cargo ship bound for Havana that had been docked in Miami. He was sentenced to 10 years in prison and released on parole in 1974. He immediately broke parole and traveled around Latin America. He was eventually arrested in Venezuela for planning to bomb the Cuban embassy there. The Venezuelan government offered to extradite him to the United States, but the offer was declined. He was released quickly and moved to Chile, and according to the US government, spent two years attempting postal bombings of Cuban embassies in four countries.

Bosch eventually ended up in the Dominican Republic, where he joined the effort to consolidate Cuban exile militants into the Coordination of United Revolutionary Organizations (CORU). The CORU's operations included the failed assassination of the Cuban ambassador to Argentina, and the bombing of the Mexican Embassy in Guatemala City. Along with Posada, he worked with the DINA agent Michael Townley to plan the assassination of Letelier, which was carried out in September 1976. Two other Cuban exiles involved in the assassination, Jose Dionisio Suarez and Virgilio Paz Romero, were later released by the administration of George H.W. Bush. Bosch was also implicated in the 1976 bombing of a Cuban plane flying to Havana from Venezuela in which all 73 civilians on board were killed, although Posada and he were acquitted after a lengthy trial. Documents released subsequently showed that the CIA had a source with advance knowledge of the bombing. The U.S. Justice Department recorded that Bosch was also responsible for 30 other attacks. He returned to Miami, where he was arrested for violating parole. The Justice department recommended that he be deported. However, Bush overturned this recommendation, and had him released from custody with the stipulation that he "renounce" violence.

Luis Posada Carriles

Luis Posada Carriles at Fort Benning, Georgia, 1962

Luis Posada Carriles, a former CIA agent who has been designated by scholars and journalists as a terrorist, also came into contact with Castro during his student days, but fled Cuba after the 1959 revolution, and helped organize the failed Bay of Pigs invasion. Following the invasion, Carriles was trained for a time at the Fort Benning station of the U.S. Army. He then relocated to Venezuela and became the first head of the National Directorate of Intelligence and Prevention Services (DISIP), Venezuela's intelligence agency, and came into contact with Orlando Bosch. Along with Bosch and others, he founded the Coordination of United Revolutionary Organizations, which has been described as an umbrella of anti-Castro terrorist groups.

In 1976, Cubana Flight 455 was blown up in mid-air, killing all 73 people on board. Carriles was arrested for masterminding the operation, and later acquitted. He and several CIA-linked anti-Castro Cuban exiles and members of the Venezuelan intelligence agency DISIP were implicated by the evidence. Political complications quickly arose when Cuba accused the US government of being an accomplice to the attack. CIA documents released in 2005 indicate that the agency "had concrete advance intelligence, as early as June 1976, on plans by Cuban exile terrorist groups to bomb a Cubana airliner." Carriles denies involvement but provides many details of the incident in his book Los caminos del guerrero (The Warrior's Paths).

After a series of arrests and escapes, Carriles returned to the CIA fold in 1985 by joining their support operations to the Contra terrorists in Nicaragua, which were being run by Oliver North. His job included air dropping military supplies, for which he was paid a significant salary. He later admitted to playing a part in the Iran-Contra affair. In 1997, a series of terrorist bombings occurred in Cuba, and Carriles was implicated. The bombings were said to be targeted at the growing tourism there. Carriles admitted that the lone conviction in the case had been of a mercenary under his command, and also made a confession (later retracted) that he had planned the incident. Human Rights Watch stated that although Carriles might no longer receive active assistance, he benefited from the tolerant attitude of the U.S. government. In 2000, Carriles was arrested and convicted in Panama of attempting to assassinate Fidel Castro.

In 2005, Carriles was held by U.S. authorities in Texas on a charge of illegal presence on national territory, but the charges were dismissed on May 8, 2007. On September 28, 2005, a U.S. immigration judge ruled that Carriles could not be deported, finding that he faced the threat of torture in Venezuela. Likewise, the US government has refused to send Carriles to Cuba, saying he might face torture. His release on bail on April 19, 2007, elicited angry reactions from the Cuban and Venezuelan governments. The U.S. Justice Department had urged the court to keep him in jail because he was "an admitted mastermind of terrorist plots and attacks", a flight risk and a danger to the community. On September 9, 2008, the United States Court of Appeals for the Fifth Circuit reversed the District Court's order dismissing the indictment and remanded the case to the District Court. On April 8, 2009, the United States Attorney filed a superseding indictment in the case. Carriles' trial ended on April 8, 2011, with a jury acquitting him on all charges. Peter Kornbluh described him as "one of the most dangerous terrorists in recent history" and the "godfather of Cuban exile violence."

Colombia

U.S. General William P. Yarborough was the head of a counterinsurgency team sent to Colombia in 1962 by the US Special Warfare Center. Yarborough was one of the earliest proponents of "paramilitary ... and/or terrorist activities against known communist proponents."

The first Colombian paramilitary groups were organized by the Colombian government following recommendations made by U.S. military counterinsurgency advisers who were sent to Colombia in the early 1960s during the Cold War to combat leftist politicians, activists and guerrillas.

Paramilitary groups were responsible for most of the human rights violations in the latter half of the ongoing Colombian conflict. According to several international human rights and governmental organizations, right-wing paramilitary groups were responsible for at least 70 to 80% of political murders in Colombia in a given year during the 80s and 90s. Paramilitary violence and terrorism there was principally targeted to peasants, unionists, indigenous people, human rights workers, teachers and left-wing political activists or their supporters.

Plan Lazo

In October 1959, the United States sent a "Special Survey Team", composed of counterinsurgency experts, to investigate Colombia's internal security situation, due to the increased prevalence of armed communist groups in rural Colombia which formed during and after La Violencia. Three years later, in February 1962, a Fort Bragg top-level U.S. Special Warfare team headed by Special Warfare Center commander General William P. Yarborough, visited Colombia for a second survey.

In a secret supplement to his report to the Joint Chiefs of Staff, Yarborough encouraged the creation and deployment of a paramilitary force to commit sabotage and terrorist acts against communists, stating:

A concerted country team effort should be made now to select civilian and military personnel for clandestine training in resistance operations in case they are needed later. This should be done with a view toward development of a civil and military structure for exploitation in the event the Colombian internal security system deteriorates further. This structure should be used to pressure toward reforms known to be needed, perform counter-agent and counter-propaganda functions and as necessary execute paramilitary, sabotage and/or terrorist activities against known communist proponents. It should be backed by the United States.

The new counter-insurgency policy was instituted as Plan Lazo in 1962 and called for both military operations and civic action programs in violent areas. Following Yarborough's recommendations, the Colombian military recruited civilians into paramilitary "civil defense" groups which worked alongside the military in its counter-insurgency campaign, as well as in civilian intelligence networks to gather information on guerrilla activity. Among other policy recommendations, the US team advised that "in order to shield the interests of both Colombian and US authorities against 'interventionist' charges, any special aid given for internal security was to be sterile and covert in nature." It was not until the early part of the 1980s that the Colombian government attempted to move away from the counterinsurgency strategy represented by Plan Lazo and Yarborough's 1962 recommendations.

Armed Forces Directive No. 200-05/91

In 1990, the United States formed a team that included representatives of the U.S. Embassy's Military Group, U.S. Southern Command, the DIA, and the CIA in order to give advice on the reshaping of several of the Colombian military's local intelligence networks, ostensibly to aid the Colombian military in "counter-narcotics" efforts. Advice was also solicited from the British and Israeli military intelligence, but the U.S. proposals were ultimately selected by the Colombian military. The result of these meetings was Armed Forces Directive 200-05/91, issued by the Colombian Defense Ministry in May 1991. However, the order itself made no mention of drugs or counter-narcotics operations at all, and instead focused exclusively on creating covert intelligence networks to combat the insurgency.

Human Rights Watch concluded that these intelligence networks subsequently laid the groundwork for an illegal, covert partnership between the military and paramilitaries. Human Rights Watch argued that the restructuring process solidified links between members of the Colombian military and civilian members of paramilitary groups, by incorporating them into several of the local intelligence networks and by cooperating with their activities. In effect, HRW believed that this further consolidated a "secret network that relied on paramilitaries not only for intelligence, but to carry out murder". Human Rights Watch argued that this situation allowed the Colombian government and military to plausibly deny links to or responsibility for paramilitary human rights abuses. Human Rights Watch stated that the military intelligence networks created by the U.S. reorganization appeared to have dramatically increased violence, stating that the "recommendations were given despite the fact that some of the U.S. officials who collaborated with the team knew of the Colombian military's record of human rights abuses and its ongoing relations with paramilitaries".

Human Rights Watch stated that while "not all paramilitaries are intimate partners with the military", the existing partnership between paramilitaries and the Colombian military was "a sophisticated mechanism, in part supported by years of advice, training, weaponry, and official silence by the United States, that allows the Colombian military to fight a dirty war and Colombian officialdom to deny it." As an example of increased violence and "dirty war" tactics, Human Rights Watch cited a partnership between the Colombian Navy and the MAS, in Barrancabermeja where: "In partnership with MAS, the navy intelligence network set up in Barrancabermeja adopted as its goal not only the elimination of anyone perceived as supporting the guerrillas, but also members of the political opposition, journalists, trade unionists, and human rights workers, particularly if they investigated or criticized their terror tactics."

Los Pepes

In 1992, Pablo Escobar escaped from his luxury prison, La Catedral. Shortly thereafter, the Calí drug cartel, dissidents within the Medellín cartel and the MAS worked together to create a new paramilitary organization known as Perseguidos por Pablo Escobar ("People Persecuted by Pablo Escobar", Los Pepes) with the purpose of tracking down and killing Pablo Escobar and his associates. The leader of the organization was Fidel Castaño. The Calí cartel provided $50 million for weapons, informants, and assassins, with in hope of wiping out their primary rivals in the cocaine business. Both Colombian and U.S. government agencies (including the DEA, CIA and State Department) provided intelligence to Los Pepes.

The Institute for Policy Studies is searching for details of connections the CIA and DEA had to Los Pepes. They have launched a lawsuit under the Freedom of Information Act against the CIA. That suit has resulted in the declassification of thousands of documents from the CIA as well as other U.S. agencies, including the Department of State, Drug Enforcement Administration, Defense Intelligence Agency and the U.S Coast Guard. These documents have been made public at the website "Pepes Project"

Italy

The Years of Lead was a period of socio-political turmoil in Italy that lasted from the late 1960s into the early 1980s. This period was marked by a wave of terrorism carried out by both right-wing and left-wing paramilitary groups. It was concluded that the former were supported by the United States as a strategy of tension.

General Gianadelio Maletti [it], commander of the counter-intelligence section of the Italian military intelligence service from 1971 to 1975, stated that his men in the region of Venice discovered a right-wing terrorist cell that had been supplied with military explosives from Germany, and alleged that US intelligence services instigated and abetted right-wing terrorism in Italy during the 1970s.

According to the investigation of Italian judge Guido Salvini, the neo-fascist organizations involved in the strategy of tension, "La Fenice, Avanguardia nazionale, Ordine nuovo" were the "troops" of "clandestine armed forces", directed by components of the "state apparatus related to the CIA."

Any relationship of the CIA to the terrorist attacks perpetrated in Italy during the Years of Lead is the subject of debate. Switzerland and Belgium have had parliamentary inquiries into the matter.

Piazza Fontana bombing

Plaque in memory of the 17 victims of the terrorist bombing in Piazza Fontana

The Piazza Fontana Bombing was a terrorist attack that occurred on December 12, 1969, at 16:37, when a bomb exploded at the headquarters of Banca Nazionale dell'Agricoltura (National Agrarian Bank) in Piazza Fontana in Milan, killing 17 people and wounding 88. The same afternoon, three more bombs were detonated in Rome and Milan, and another was found undetonated.

In 1998, Milan judge Guido Salvini indicted U.S. Navy officer David Carrett on charges of political and military espionage for his alleged participation in the Piazza Fontana bombing et al. Salvini also opened up a case against Sergio Minetto, an Italian official of the U.S.-NATO intelligence network, and "collaboratore di giustizia" Carlo Digilio (Uncle Otto), who served as the CIA coordinator in Northeastern Italy in the sixties and seventies. The newspaper la Repubblica reported that Carlo Rocchi, CIA's man in Milan, was discovered in 1995 searching for information concerning Operation Gladio.

A 2000 parliamentary report published by the center-left Olive Tree coalition claimed that "U.S. intelligence agents were informed in advance about several right-wing terrorist bombings, including the December 1969 Piazza Fontana bombing in Milan and the Piazza della Loggia bombing in Brescia five years later, but did nothing to alert the Italian authorities or to prevent the attacks from taking place." It also alleged that Pino Rauti (current leader of the MSI Fiamma-Tricolore party), a journalist and founder of the far-right Ordine Nuovo (New Order) subversive organization, received regular funding from a press officer at the U.S. embassy in Rome. "So even before the 'stabilising' plans that Atlantic circles had prepared for Italy became operational through the bombings, one of the leading members of the subversive right was literally in the pay of the American embassy in Rome", the report says.

Paolo Emilio Taviani, the Christian Democrat co-founder of Gladio (NATO's stay-behind anti-Communist organization in Italy), told investigators that the SID military intelligence service was about to send a senior officer from Rome to Milan to prevent the bombing, but decided to send a different officer from Padua in order to put the blame on left-wing anarchists. Taviani also alleged in an August 2000 interview to Il Secolo XIX newspaper: "It seems to me certain, however, that agents of the CIA were among those who supplied the materials and who muddied the waters of the investigation."

Guido Salvini said "The role of the Americans was ambiguous, halfway between knowing and not preventing and actually inducing people to commit atrocities."

According to Vincenzo Vinciguerra, the terrorist attack was supposed to push then Interior Minister Mariano Rumor to declare a state of emergency.

Nicaragua

From 1979 to 1990, the United States provided financial, logistical and military support to the Contra rebels in Nicaragua, who used terrorist tactics in their war against the Nicaraguan government and carried out more than 1300 terrorist attacks. This support persisted despite widespread knowledge of the human rights violations committed by the Contras.

Background

The U.S.-supported Nicaraguan Contras

In 1979, the Sandinista National Liberation Front (FSLN) overthrew the dictatorial regime of Anastasio Somoza Debayle, and established a revolutionary government in Nicaragua. The Somoza dynasty had been receiving military and financial assistance from the United States since 1936. Following their seizure of power, the Sandinistas ruled the country first as part of a Junta of National Reconstruction, and later as a democratic government following free and fair elections in 1984.

The Sandinistas did not attempt to create a communist society or communist economic system; instead, their policy advocated a social democracy and a mixed economy. The government sought the aid of Western Europe, who were opposed to the U.S. embargo against Nicaragua, to escape dependency on the Soviet Union. However, the U.S. administration viewed the leftist Sandinista government as undemocratic and totalitarian under the ties of the Soviet-Cuban model and tried to paint the Contras as freedom fighters.

The Sandinista government headed by Daniel Ortega won decisively in the 1984 Nicaraguan elections. The U.S. government explicitly planned to back the Contras, various rebel groups collectively that were formed in response to the rise of the Sandinistas, as a means to damage the Nicaraguan economy and force the Sandinista government to divert its scarce resources toward the army and away from social and economic programs.

Covert operations

The United States began to support Contra activities against the Sandinista government by December 1981, with the CIA at the forefront of operations. The CIA provided the Contras with planning and operational direction and assistance, weapons, food, and training, in what was described as the "most ambitious" covert operation in more than a decade.

One of the purposes the CIA hoped to achieve by these operations was an aggressive and violent response from the Sandinista government which in turn could be used as a pretext for further military actions.

The Contra campaign against the government included frequent and widespread acts of terror. The economic and social reforms enacted by the government enjoyed some popularity; as a result, the Contras attempted to disrupt these programs. This campaign included the destruction of health centers and hospitals that the Sandinista government had established, in order to diminish their influence upon the populace. Schools were also destroyed, as the literacy campaign conducted by the government was an important part of its policy. The Contras also committed widespread kidnappings, murder, and rape. The kidnappings and murder were a product of the "low-intensity warfare" that the Reagan Doctrine prescribed as a way to disrupt social structures and gain control over the population. Also known as "unconventional warfare", advocated for and defined by the World Anti-Communist League's (WACL) retired U.S. Army Major General John Singlaub as, "low intensity actions, such as sabotage, terrorism, assassination and guerrilla warfare". In some cases, more indiscriminate killing and destruction also took place. The Contras also carried out a campaign of economic sabotage, and disrupted shipping by planting underwater mines in Nicaragua's Port of Corinto. The Reagan administration supported this by imposing a full trade embargo.

A mug shot of Oliver North, who conducted covert operations in support of the Contras

In fiscal year 1984, the U.S. Congress approved $24 million in aid to the contras. However, the Reagan administration lost a lot of support for its Contra policy after CIA involvement in the mining of Nicaraguan ports became public knowledge, and a report of the Bureau of Intelligence and Research commissioned by the State Department found that Reagan had exaggerated claims about Soviet interference in Nicaragua. Congress cut off all funds for the contras in 1985 with the third Boland Amendment.

As a result, the Reagan administration sought to provide funds from other sources. Between 1984 and 1986, $34 million was routed through third countries and $2.7 million through private sources. These funds were run through the National Security Council, by Lt. Col. Oliver North, who created an organization called "The Enterprise" which served as the secret arm of the NSC staff and had its own airplanes, pilots, airfield, ship, and operatives. It also received assistance from other government agencies, especially from CIA personnel in Central America. These efforts culminated in the Iran-Contra Affair of 1986–1987, which facilitated funding for the Contras using the proceeds of arms sales to Iran. Money was also raised for the Contras through drug trafficking, which the United States was aware of. U.S. Senator John Kerry's 1988 Committee on Foreign Relations report on Contra drug links concluded that "senior U.S. policy makers were not immune to the idea that drug money was a perfect solution to the Contras' funding problems".

Propaganda

Throughout the Nicaraguan Civil War, the Reagan government conducted a campaign to shift public opinion to favor support for the Contras, and to change the vote in Congress to favor of that support. For this purpose, the National Security Council authorized the production and distribution of publications that looked favorably at the Contras, also known as "white propaganda," written by paid consultants who did not disclose their connection to the administration. It also arranged for speeches and press conferences conveying the same message. The U.S. government continually discussed the Contras in highly favorable terms; Reagan called them the "moral equivalent of the founding fathers." Another common theme the administration played on was the idea of returning Nicaragua to democracy, which analysts characterized as "curious," because Nicaragua had been a U.S.-supported dictatorship prior to the Sandinista revolution, and had never had a democratic government before the Sandinistas. There were also continued efforts to label the Sandinistas as undemocratic, although the 1984 Nicaraguan elections were generally declared fair by historians.

Commentators stated that this was all a part of an attempt to return Nicaragua to the state of its Central American neighbors; that is, where traditional social structures remained and American imperialist ideas were not threatened. The investigation into the Iran-Contra affair led to the operation being called a massive exercise in psychological warfare.

The CIA wrote a manual for the Contras, entitled Psychological Operations in Guerrilla Warfare (Operaciones sicológicas en guerra de guerrillas), which focused mainly on how "Armed Propaganda Teams" could build political support in Nicaragua for the Contra cause through deceit, intimidation, and violence. The manual discussed assassinations. The CIA claimed that the purpose of the manual was to "moderate" the extreme violence already being used by the Contras.

Leslie Cockburn writes that the CIA, and therefore indirectly the U.S. government and President Reagan, encouraged Contra terrorism by issuing the manual to the contras, violating Reagan's own Presidential Directive. Cockburn wrote that "[t]he manual, Psychological Operations in Guerrilla Warfare, clearly advocated a strategy of terror as the means to victory over the hearts and minds of Nicaraguans. Chapter headings such as 'Selective Use of Violence for propagandistic Effects' and 'Implicit and Explicit Terror' made that fact clear enough. ... The little booklet thus violated President Reagan's own Presidential Directive 12333, signed in December 1981, which prohibited any U.S. government employee—including the CIA—from having anything to do with assassinations."

International Court of Justice ruling

The International Court of Justice in session

In 1984, the Nicaraguan government filed a suit in the International Court of Justice (ICJ) against the United States. Nicaragua stated that the Contras were completely created and managed by the U.S. Although this claim was rejected, the court found overwhelming and undeniable evidence of a very close relationship between the Contras and the United States. The U.S. was found to have had a very large role in providing financial support, training, weapons, and other logistical support to the Contras over a lengthy period of time, and that this support was essential to the Contras.

In the same year, the ICJ ordered the United States to stop mining Nicaraguan harbors, and respect Nicaraguan sovereignty. A few months later, the court ruled that it did have jurisdiction in the case, contrary to what the U.S. had argued. The ICJ found that the U.S. had encouraged violations of international humanitarian law by assisting paramilitary actions in Nicaragua. The court also criticized the production of a manual on psychological warfare by the U.S. and its dissemination of the Contras. The manual, amongst other things, provided advice on rationalizing the killing of civilians, and on targeted murder. The manual also included an explicit description of the use of "implicit terror."

Having initially argued that the ICJ lacked jurisdiction in the case, the United States withdrew from the proceedings in 1985. The court eventually ruled in favor of Nicaragua, and judged that the United States was required to pay reparations for its violation of International law. The U.S. used its veto on the United Nations Security Council to block the enforcement of the ICJ judgement, and thereby prevented Nicaragua from obtaining any compensation.

Kosovo

Monument to Serbs killed by Kosovo Liberation Army in Mitrovica
Staro Gracko massacre memorial

The FR Yugoslav authorities regarded the ethnic Albanian Kosovo Liberation Army (KLA) as a terrorist group, although many European governments did not. In February 1998, U.S. President Bill Clinton's special envoy to the Balkans, Robert Gelbard, condemned both the actions of the Yugoslav government and of the KLA, and described the KLA as "without any questions, a terrorist group". UN resolution 1160 took a similar stance. At first, NATO had stressed that KLA was "the main initiator of the violence" and that it had "launched what appears to be a deliberate campaign of provocation".

The United States (and NATO) directly supported the KLA. The CIA funded, trained and supplied the KLA (as they had earlier trained and supplied the Bosnian Army). As disclosed to The Sunday Times by CIA sources, "American intelligence agents have admitted they helped to train the Kosovo Liberation Army before NATO's bombing of Yugoslavia". In 1999, a retired colonel said that KLA forces had been trained in Albania by former US military working for MPRI.

Former Canadian ambassador James Byron Bissett wrote in 2001 that media reports indicated that "as early as 1998, the Central Intelligence Agency assisted by the British Special Armed Services were arming and training Kosovo Liberation Army members in Albania to foment armed rebellion in Kosovo. ... The hope was that with Kosovo in flames NATO could intervene". According to Tim Judah, KLA representatives had already met with American, British, and Swiss intelligence agencies in 1996, and possibly "several years earlier".

After the war, the KLA was transformed into the Kosovo Protection Corps, which worked alongside NATO forces patrolling the province. In the following years, however, an ethnic Albanian insurgency emerged in southern Serbia (1999–2001) and in Macedonia (2001). The EU condemned what it described as the "extremism" and use of "illegal terrorist actions" by the group active in southern Serbia. Since the war, many of the KLA leaders have been active in the political leadership of the Republic of Kosovo.

Syria

The United States has provided extensive lethal and non-lethal aid to many Syrian militant groups fighting against the Syrian government, an ally of Russia, during the Syrian Civil War. The Syrian government has directly accused the United States of sponsoring terrorism in Syria. The United States government was also criticized by Iran for its silence following the beheading of a child by the Islamist group Nour al-Din al-Zenki, a group that is a recipient of US military aid and is accused of many war crimes by Amnesty International.

Turkish president Recep Tayyip Erdoğan has also accused the United States of supporting ISIS in Syria, claiming Turkey has evidence of U.S. support for ISIS through pictures, photos, and videos, without further elaborating on said evidence or providing any.

An investigation by journalists Phil Sands and Suha Maayeh revealed that rebels supplied with weapons from the Military Operations Command in Amman sold a portion of them to local arms dealers, often to raise cash to pay additional fighters. Some MOC-supplied weapons were sold to Bedouin traders referred to locally as "The Birds" in Lajat, a volcanic plateau northeast of Daraa, Syria. According to rebel forces, the Bedouins would then trade the weapons to ISIL, who would place orders using the encrypted WhatsApp messaging service. Two rebel commanders and a United Kingdom weapons monitoring organization maintain that MOC–supplied weapons have made their way to ISIL forces.

Another study conducted by private company Conflict Armament Research at the behest of the European Union and Deutsche Gesellschaft für Internationale Zusammenarbeit found that external support for anti-Assad Syrian rebels "significantly augmented the quantity and quality of weapons available to [ISIL] forces", including, in the most rapid case diversion they documented, "anti-tank weapons purchased by the United States that ended up in possession of the Islamic State within two months of leaving the factory."

Saturday, August 3, 2024

Pregnancy

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Pregnancy
 
Pregnancy
Other namesGestation
A woman in the third trimester of pregnancy
SpecialtyObstetrics, midwifery
SymptomsMissed periods, tender breasts, nausea and vomiting, hunger, frequent urination
ComplicationsMiscarriage, high blood pressure of pregnancy, gestational diabetes, iron-deficiency anemia, severe nausea and vomiting
Duration~40 weeks from the last menstrual period (38 weeks after conception)
CausesSexual intercourse, assisted reproductive technology
Diagnostic methodPregnancy test
PreventionBirth control (including emergency contraception)
TreatmentPrenatal care, abortion
MedicationFolic acid, iron supplements
Frequency213 million (2012)
DeathsPositive decrease 230,600 (2016)

Pregnancy is the time during which one or more offspring develops (gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.

Pregnancy usually occurs by sexual intercourse, but can also occur through assisted reproductive technology procedures. A pregnancy may end in a live birth, a miscarriage, an induced abortion, or a stillbirth. Childbirth typically occurs around 40 weeks from the start of the last menstrual period (LMP), a span known as the gestational age. This is just over nine months. Counting by fertilization age, the length is about 38 weeks. Pregnancy is "the presence of an implanted human embryo or fetus in the uterus"; implantation occurs on average 8–9 days after fertilization. An embryo is the term for the developing offspring during the first seven weeks following implantation (i.e. ten weeks' gestational age), after which the term fetus is used until birth.

Signs and symptoms of early pregnancy may include missed periods, tender breasts, morning sickness (nausea and vomiting), hunger, implantation bleeding, and frequent urination. Pregnancy may be confirmed with a pregnancy test. Methods of birth control—or, more accurately, contraception—are used to avoid pregnancy.

Pregnancy is divided into three trimesters of approximately three months each. The first trimester includes conception, which is when the sperm fertilizes the egg. The fertilized egg then travels down the fallopian tube and attaches to the inside of the uterus, where it begins to form the embryo and placenta. During the first trimester, the possibility of miscarriage (natural death of embryo or fetus) is at its highest. Around the middle of the second trimester, movement of the fetus may be felt. At 28 weeks, more than 90% of babies can survive outside of the uterus if provided with high-quality medical care, though babies born at this time will likely experience serious health complications such as heart and respiratory problems and long-term intellectual and developmental disabilities.

Prenatal care improves pregnancy outcomes. Nutrition during pregnancy is important to ensure healthy growth of the fetus. Prenatal care may also include avoiding recreational drugs (including tobacco and alcohol), taking regular exercise, having blood tests, and regular physical examinations. Complications of pregnancy may include disorders of high blood pressure, gestational diabetes, iron-deficiency anemia, and severe nausea and vomiting. In the ideal childbirth, labor begins on its own "at term". Babies born before 37 weeks are "preterm" and at higher risk of health problems such as cerebral palsy. Babies born between weeks 37 and 39 are considered "early term" while those born between weeks 39 and 41 are considered "full term". Babies born between weeks 41 and 42 weeks are considered "late-term" while after 42 weeks they are considered "post-term". Delivery before 39 weeks by labor induction or caesarean section is not recommended unless required for other medical reasons.

Terminology

Title page from an 18th-century book about pregnancy
William Hunter, Anatomia uteri humani gravidi tabulis illustrata, 1774

Associated terms for pregnancy are gravid and parous. Gravidus and gravid come from the Latin word meaning "heavy" and a pregnant female is sometimes referred to as a gravida. Gravidity refers to the number of times that a female has been pregnant. Similarly, the term parity is used for the number of times that a female carries a pregnancy to a viable stage. Twins and other multiple births are counted as one pregnancy and birth.

A woman who has never been pregnant is referred to as a nulligravida. A woman who is (or has been only) pregnant for the first time is referred to as a primigravida, and a woman in subsequent pregnancies as a multigravida or as multiparous. Therefore, during a second pregnancy a woman would be described as gravida 2, para 1 and upon live delivery as gravida 2, para 2. In-progress pregnancies, abortions, miscarriages and/or stillbirths account for parity values being less than the gravida number. Women who have never carried a pregnancy more than 20 weeks are referred to as nulliparous.

A pregnancy is considered term at 37 weeks of gestation. It is preterm if less than 37 weeks and postterm at or beyond 42 weeks of gestation. American College of Obstetricians and Gynecologists have recommended further division with early term 37 weeks up to 39 weeks, full term 39 weeks up to 41 weeks, and late term 41 weeks up to 42 weeks. The terms preterm and postterm have largely replaced earlier terms of premature and postmature. Preterm and postterm are defined above, whereas premature and postmature have historical meaning and relate more to the infant's size and state of development rather than to the stage of pregnancy.

Demographics and statistics

About 213 million pregnancies occurred in 2012, of which, 190 million (89%) were in the developing world and 23 million (11%) were in the developed world. The number of pregnancies in women aged between 15 and 44 is 133 per 1,000 women. About 10% to 15% of recognized pregnancies end in miscarriage. In 2016, complications of pregnancy resulted in 230,600 maternal deaths, down from 377,000 deaths in 1990. Common causes include bleeding, infections, hypertensive diseases of pregnancy, obstructed labor, miscarriage, abortion, or ectopic pregnancy. Globally, 44% of pregnancies are unplanned. Over half (56%) of unplanned pregnancies are aborted. Among unintended pregnancies in the United States, 60% of the women used birth control to some extent during the month pregnancy began.

Signs and symptoms

Melasma: pigment changes to the face due to pregnancy
In the later part of pregnancy the uterus takes up much of the abdomen.

The usual signs and symptoms of pregnancy do not significantly interfere with activities of daily living or pose a health-threat to the mother or baby. However, pregnancy complications can cause other more severe symptoms, such as those associated with anemia.

Common signs and symptoms of pregnancy include:

Timeline

Comparison of dating systems for a typical pregnancy
Event Gestational age

(from the start of the last menstrual period)

Fertilization age Implantation age
Menstrual period begins Day 1 of pregnancy Not pregnant Not pregnant
Has sex and ovulates 2 weeks pregnant Not pregnant Not pregnant
Fertilization; cleavage stage begins Day 15 Day 1 Not pregnant
Implantation of blastocyst begins Day 20 Day 6 Day 0
Implantation finished Day 26 Day 12 Day 6 (or Day 0)
Embryo stage begins; also, first missed period 4 weeks Day 15 Day 9
Primitive heart function can be detected 5 weeks, 5 days Day 26 Day 20
Fetal stage begins 10 weeks, 1 day 8 weeks, 1 day 7 weeks, 2 days
First trimester ends 13 weeks 11 weeks 10 weeks
Second trimester ends 26 weeks 24 weeks 23 weeks
Childbirth 39–40 weeks 37–38 weeks 36–37 weeks

The chronology of pregnancy is, unless otherwise specified, generally given as gestational age, where the starting point is the beginning of the woman's last menstrual period (LMP), or the corresponding age of the gestation as estimated by a more accurate method if available. This model means that the woman is counted as being "pregnant" two weeks before conception and three weeks before implantation. Sometimes, timing may also use the fertilization age, which is the age of the embryo since conception.

Start of gestational age

The American Congress of Obstetricians and Gynecologists recommends the following methods to calculate gestational age:

  • Directly calculating the days since the beginning of the last menstrual period.
  • Early obstetric ultrasound, comparing the size of an embryo or fetus to that of a reference group of pregnancies of known gestational age (such as calculated from last menstrual periods), and using the mean gestational age of other embryos or fetuses of the same size. If the gestational age as calculated from an early ultrasound is contradictory to the one calculated directly from the last menstrual period, it is still the one from the early ultrasound that is used for the rest of the pregnancy.
  • In case of in vitro fertilization, calculating days since oocyte retrieval or co-incubation and adding 14 days.

Trimesters

Pregnancy is divided into three trimesters, each lasting for approximately three months. The exact length of each trimester can vary between sources.

  • The first trimester begins with the start of gestational age as described above, that is, the beginning of week 1, or 0 weeks + 0 days of gestational age (GA). It ends at week 12 (11 weeks + 6 days of GA) or end of week 14 (13 weeks + 6 days of GA).
  • The second trimester is defined as starting, between the beginning of week 13 (12 weeks +0 days of GA) and beginning of week 15 (14 weeks + 0 days of GA). It ends at the end of week 27 (26 weeks + 6 days of GA) or end of week 28 (27 weeks + 6 days of GA).
  • The third trimester is defined as starting, between the beginning of week 28 (27 weeks + 0 days of GA) or beginning of week 29 (28 weeks + 0 days of GA). It lasts until childbirth.
Timeline of pregnancy, including (from top to bottom): Trimesters, embryo/fetus development, gestational age in weeks and months, viability and maturity stages

Estimation of due date

Distribution of gestational age at childbirth among singleton live births, given both when gestational age is estimated by first trimester ultrasound and directly by last menstrual period. Roughly 80% of births occur between 37 and 41 weeks of gestational age.

Due date estimation basically follows two steps:

  • Determination of which time point is to be used as origin for gestational age, as described in the section above.
  • Adding the estimated gestational age at childbirth to the above time point. Childbirth on average occurs at a gestational age of 280 days (40 weeks), which is therefore often used as a standard estimation for individual pregnancies. However, alternative durations as well as more individualized methods have also been suggested.

The American College of Obstetricians and Gynecologists divides full term into three divisions:

  • Early-term: 37 weeks and 0 days through 38 weeks and 6 days
  • Full-term: 39 weeks and 0 days through 40 weeks and 6 days
  • Late-term: 41 weeks and 0 days through 41 weeks and 6 days
  • Post-term: greater than or equal to 42 weeks and 0 days

Naegele's rule is a standard way of calculating the due date for a pregnancy when assuming a gestational age of 280 days at childbirth. The rule estimates the expected date of delivery (EDD) by adding a year, subtracting three months, and adding seven days to the origin of gestational age. Alternatively there are mobile apps, which essentially always give consistent estimations compared to each other and correct for leap year, while pregnancy wheels made of paper can differ from each other by 7 days and generally do not correct for leap year.

Furthermore, actual childbirth has only a certain probability of occurring within the limits of the estimated due date. A study of singleton live births came to the result that childbirth has a standard deviation of 14 days when gestational age is estimated by first trimester ultrasound, and 16 days when estimated directly by last menstrual period.

Physiology

Capacity

Fertility and fecundity are the respective capacities to fertilize and establish a clinical pregnancy and have a live birth. Infertility is an impaired ability to establish a clinical pregnancy and sterility is the permanent inability to establish a clinical pregnancy.

The capacity for pregnancy depends on the reproductive system, its development and its variation, as well as on the condition of a person. Women as well as intersex and transgender people who have a functioning female reproductive system are capable of pregnancy. In some cases, someone might be able to produce fertilizable eggs, but might not have a womb or none that can sufficiently gestate, in which case they might find surrogacy.

Initiation

Fertilization and implantation in humans.

Through an interplay of hormones that includes follicle stimulating hormone that stimulates folliculogenesis and oogenesis creates a mature egg cell, the female gamete. Fertilization is the event where the egg cell fuses with the male gamete, spermatozoon. After the point of fertilization, the fused product of the female and male gamete is referred to as a zygote or fertilized egg. The fusion of female and male gametes usually occurs following the act of sexual intercourse. Pregnancy rates for sexual intercourse are highest during the menstrual cycle time from some 5 days before until 1 to 2 days after ovulation. Fertilization can also occur by assisted reproductive technology such as artificial insemination and in vitro fertilisation.

Fertilization (conception) is sometimes used as the initiation of pregnancy, with the derived age being termed fertilization age. Fertilization usually occurs about two weeks before the next expected menstrual period.

A third point in time is also considered by some people to be the true beginning of a pregnancy: This is time of implantation, when the future fetus attaches to the lining of the uterus. This is about a week to ten days after fertilization.

Development of embryo and fetus

The initial stages of human embryogenesis

The sperm and the egg cell, which has been released from one of the female's two ovaries, unite in one of the two fallopian tubes. The fertilized egg, known as a zygote, then moves toward the uterus, a journey that can take up to a week to complete. Cell division begins approximately 24 to 36 hours after the female and male cells unite. Cell division continues at a rapid rate and the cells then develop into what is known as a blastocyst. The blastocyst arrives at the uterus and attaches to the uterine wall, a process known as implantation.

The development of the mass of cells that will become the infant is called embryogenesis during the first approximately ten weeks of gestation. During this time, cells begin to differentiate into the various body systems. The basic outlines of the organ, body, and nervous systems are established. By the end of the embryonic stage, the beginnings of features such as fingers, eyes, mouth, and ears become visible. Also during this time, there is development of structures important to the support of the embryo, including the placenta and umbilical cord. The placenta connects the developing embryo to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother's blood supply. The umbilical cord is the connecting cord from the embryo or fetus to the placenta.

After about ten weeks of gestational age—which is the same as eight weeks after conception—the embryo becomes known as a fetus. At the beginning of the fetal stage, the risk of miscarriage decreases sharply. At this stage, a fetus is about 30 mm (1.2 inches) in length, the heartbeat is seen via ultrasound, and the fetus makes involuntary motions. During continued fetal development, the early body systems, and structures that were established in the embryonic stage continue to develop. Sex organs begin to appear during the third month of gestation. The fetus continues to grow in both weight and length, although the majority of the physical growth occurs in the last weeks of pregnancy.

Electrical brain activity is first detected at the end of week 5 of gestation, but as in brain-dead patients, it is primitive neural activity rather than the beginning of conscious brain activity. Synapses do not begin to form until week 17. Neural connections between the sensory cortex and thalamus develop as early as 24 weeks' gestational age, but the first evidence of their function does not occur until around 30 weeks, when minimal consciousness, dreaming, and the ability to feel pain emerges.

Although the fetus begins to move during the first trimester, it is not until the second trimester that movement, known as quickening, can be felt. This typically happens in the fourth month, more specifically in the 20th to 21st week, or by the 19th week if the woman has been pregnant before. It is common for some women not to feel the fetus move until much later. During the second trimester, when the body size changes, maternity clothes may be worn.

Maternal changes

The uterus expands making up a larger and larger portion of the abdomen. During the final stages of gestation the uterus may drop to a lower position.
Breast changes as seen during pregnancy. The areolae are larger and darker.

During pregnancy, a woman undergoes many normal physiological changes, including behavioral, cardiovascular, hematologic, metabolic, renal, and respiratory changes. Increases in blood sugar, breathing, and cardiac output are all required. Levels of progesterone and estrogens rise continually throughout pregnancy, suppressing the hypothalamic axis and therefore the menstrual cycle. A full-term pregnancy at an early age (less than 25 years) reduces the risk of breast, ovarian, and endometrial cancer, and the risk declines further with each additional full-term pregnancy.

End of second trimester + 2 weeks (26 weeks of pregnancy)

The fetus is genetically different from its mother and can therefore be viewed as an unusually successful allograft. The main reason for this success is increased immune tolerance during pregnancy, which prevents the mother's body from mounting an immune system response against certain triggers.

During the first trimester, minute ventilation increases by 40 percent. The womb will grow to the size of a lemon by eight weeks. Many symptoms and discomforts of pregnancy, such as nausea and tender breasts, appear in the first trimester.

During the second trimester, most women feel more energized and put on weight as the symptoms of morning sickness subside. They begin to feel regular fetal movements, which can become strong and even disruptive.

Braxton Hicks contractions are sporadic uterine contractions that may start around six weeks into a pregnancy; however, they are usually not felt until the second or third trimester.

Final weight gain takes place during the third trimester; this is the most weight gain throughout the pregnancy. The woman's abdomen will transform in shape as the fetus turns in a downward position ready for birth. The woman's navel will sometimes become convex, "popping" out, due to the expanding abdomen. The uterus, the muscular organ that holds the developing fetus, can expand up to 20 times its normal size during pregnancy.

Head engagement, also called "lightening" or "dropping", occurs as the fetal head descends into a cephalic presentation. While it relieves pressure on the upper abdomen and gives a renewed ease in breathing, it also severely reduces bladder capacity, resulting in a need to void more frequently, and increases pressure on the pelvic floor and the rectum. It is not possible to predict when lightening will occur. In a first pregnancy it may happen a few weeks before the due date, though it may happen later or even not until labor begins, as is typical with subsequent pregnancies.

It is during the third trimester that maternal activity and sleep positions may affect fetal development due to restricted blood flow. For instance, the enlarged uterus may impede blood flow by compressing the vena cava when lying flat, a condition that can be relieved by lying on the left side.

Childbirth

Childbirth, referred to as labor and delivery in the medical field, is the process whereby an infant is born.

A woman is considered to be in labor when she begins experiencing regular uterine contractions, accompanied by changes of her cervix—primarily effacement and dilation. While childbirth is widely experienced as painful, some women do report painless labors, while others find that concentrating on the birth helps to quicken labor and lessen the sensations. Most births are successful vaginal births, but sometimes complications arise and a woman may undergo a cesarean section.

During the time immediately after birth, both the mother and the baby are hormonally cued to bond, the mother through the release of oxytocin, a hormone also released during breastfeeding. Studies show that skin-to-skin contact between a mother and her newborn immediately after birth is beneficial for both the mother and baby. A review done by the World Health Organization found that skin-to-skin contact between mothers and babies after birth reduces crying, improves mother–infant interaction, and helps mothers to breastfeed successfully. They recommend that neonates be allowed to bond with the mother during their first two hours after birth, the period that they tend to be more alert than in the following hours of early life.

Childbirth maturity stages

Stages of pregnancy term
stage starts ends
Preterm - at 37 weeks
Early term 37 weeks 39 weeks
Full term 39 weeks 41 weeks
Late term 41 weeks 42 weeks
Postterm 42 weeks -

In the ideal childbirth, labor begins on its own when a woman is "at term". Events before completion of 37 weeks are considered preterm. Preterm birth is associated with a range of complications and should be avoided if possible.

Sometimes if a woman's water breaks or she has contractions before 39 weeks, birth is unavoidable. However, spontaneous birth after 37 weeks is considered term and is not associated with the same risks of a preterm birth. Planned birth before 39 weeks by caesarean section or labor induction, although "at term", results in an increased risk of complications. This is from factors including underdeveloped lungs of newborns, infection due to underdeveloped immune system, feeding problems due to underdeveloped brain, and jaundice from underdeveloped liver.

Babies born between 39 and 41 weeks' gestation have better outcomes than babies born either before or after this range. This special time period is called "full term". Whenever possible, waiting for labor to begin on its own in this time period is best for the health of the mother and baby. The decision to perform an induction must be made after weighing the risks and benefits, but is safer after 39 weeks.

Events after 42 weeks are considered postterm. When a pregnancy exceeds 42 weeks, the risk of complications for both the woman and the fetus increases significantly. Therefore, in an otherwise uncomplicated pregnancy, obstetricians usually prefer to induce labor at some stage between 41 and 42 weeks.

Postnatal period

The postpartum period also referred to as the puerperium, is the postnatal period that begins immediately after delivery and extends for about six weeks. During this period, the mother's body begins the return to pre-pregnancy conditions that includes changes in hormone levels and uterus size.

Diagnosis

The beginning of pregnancy may be detected either based on symptoms by the woman herself, or by using pregnancy tests. However, an important condition with serious health implications that is quite common is the denial of pregnancy by the pregnant woman. About 1 in 475 denials will last until around the 20th week of pregnancy. The proportion of cases of denial, persisting until delivery is about 1 in 2500. Conversely, some non-pregnant women have a very strong belief that they are pregnant along with some of the physical changes. This condition is known as a false pregnancy.

Physical signs

Linea nigra in a woman at 22 weeks pregnant

Most pregnant women experience a number of symptoms, which can signify pregnancy. A number of early medical signs are associated with pregnancy. These signs include:

Biomarkers

Pregnancy detection can be accomplished using one or more various pregnancy tests, which detect hormones generated by the newly formed placenta, serving as biomarkers of pregnancy. Blood and urine tests can detect pregnancy by 11 and 14 days, respectively, after fertilization. Blood pregnancy tests are more sensitive than urine tests (giving fewer false negatives). Home pregnancy tests are urine tests, and normally detect a pregnancy 12 to 15 days after fertilization. A quantitative blood test can determine approximately the date the embryo was fertilized because hCG levels double every 36 to 72 hours before 8 weeks' gestation. A single test of progesterone levels can also help determine how likely a fetus will survive in those with a threatened miscarriage (bleeding in early pregnancy), but only if the ultrasound result was inconclusive.

Ultrasound

Obstetric ultrasonography can detect fetal abnormalities, detect multiple pregnancies, and improve gestational dating at 24 weeks. The resultant estimated gestational age and due date of the fetus are slightly more accurate than methods based on last menstrual period. Ultrasound is used to measure the nuchal fold in order to screen for Down syndrome.

Management

An infographic showing a flow chart leading to three diagrams, each showing two human figures depicting different lengths of gestation, with a grid showing weight limits for different locations in front of the body
Flowchart showing the recommended weight limits for lifting at work during pregnancy as a function of lifting frequency, weeks of gestation, and the position of the lifted object relative to the lifter's body.

Prenatal care

Pre-conception counseling is care that is provided to a woman or couple to discuss conception, pregnancy, current health issues and recommendations for the period before pregnancy.

Prenatal medical care is the medical and nursing care recommended for women during pregnancy, time intervals and exact goals of each visit differ by country. Women who are high risk have better outcomes if they are seen regularly and frequently by a medical professional than women who are low risk. A woman can be labeled as high risk for different reasons including previous complications in pregnancy, complications in the current pregnancy, current medical diseases, or social issues.

The aim of good prenatal care is prevention, early identification, and treatment of any medical complications. A basic prenatal visit consists of measurement of blood pressure, fundal height, weight and fetal heart rate, checking for symptoms of labor, and guidance for what to expect next.

Nutrition

Nutrition during pregnancy is important to ensure healthy growth of the fetus. Nutrition during pregnancy is different from the non-pregnant state. There are increased energy requirements and specific micronutrient requirements. Women benefit from education to encourage a balanced energy and protein intake during pregnancy. Some women may need professional medical advice if their diet is affected by medical conditions, food allergies, or specific religious/ ethical beliefs. Further studies are needed to access the effect of dietary advice to prevent gestational diabetes, although low quality evidence suggests some benefit. Adequate periconceptional (time before and right after conception) folic acid (also called folate or Vitamin B9) intake has been shown to decrease the risk of fetal neural tube defects, such as spina bifida. The neural tube develops during the first 28 days of pregnancy, a urine pregnancy test is not usually positive until 14 days post-conception, explaining the necessity to guarantee adequate folate intake before conception. Folate is abundant in green leafy vegetables, legumes, and citrus. In the United States and Canada, most wheat products (flour, noodles) are fortified with folic acid.

Weight gain

Weight gain during pregnancy
Measurement of the belly and weight are both performed by pregnant women during her pregnancy

The amount of healthy weight gain during a pregnancy varies. Weight gain is related to the weight of the baby, the placenta, extra circulatory fluid, larger tissues, and fat and protein stores. Most needed weight gain occurs later in pregnancy.

The Institute of Medicine recommends an overall pregnancy weight gain for those of normal weight (body mass index of 18.5–24.9), of 11.3–15.9 kg (25–35 pounds) having a singleton pregnancy. Women who are underweight (BMI of less than 18.5), should gain between 12.7 and 18 kg (28–40 lb), while those who are overweight (BMI of 25–29.9) are advised to gain between 6.8 and 11.3 kg (15–25 lb) and those who are obese (BMI ≥ 30) should gain between 5–9 kg (11–20 lb). These values reference the expectations for a term pregnancy.

During pregnancy, insufficient or excessive weight gain can compromise the health of the mother and fetus. The most effective intervention for weight gain in underweight women is not clear. Being or becoming overweight in pregnancy increases the risk of complications for mother and fetus, including cesarean section, gestational hypertension, pre-eclampsia, macrosomia and shoulder dystocia. Excessive weight gain can make losing weight after the pregnancy difficult. Some of these complications are risk factors for stroke.

Around 50% of women of childbearing age in developed countries like the United Kingdom are overweight or obese before pregnancy. Diet modification is the most effective way to reduce weight gain and associated risks in pregnancy.

Medication

Drugs used during pregnancy can have temporary or permanent effects on the fetus. Anything (including drugs) that can cause permanent deformities in the fetus are labeled as teratogens. In the U.S., drugs were classified into categories A, B, C, D and X based on the Food and Drug Administration (FDA) rating system to provide therapeutic guidance based on potential benefits and fetal risks. Drugs, including some multivitamins, that have demonstrated no fetal risks after controlled studies in humans are classified as Category A. On the other hand, drugs like thalidomide with proven fetal risks that outweigh all benefits are classified as Category X.

Recreational drugs

The use of recreational drugs in pregnancy can cause various pregnancy complications.

Exposure to toxins

Intrauterine exposure to environmental toxins in pregnancy has the potential to cause adverse effects on prenatal development, and to cause pregnancy complications. Air pollution has been associated with low birth weight infants. Conditions of particular severity in pregnancy include mercury poisoning and lead poisoning. To minimize exposure to environmental toxins, the American College of Nurse-Midwives recommends: checking whether the home has lead paint, washing all fresh fruits and vegetables thoroughly and buying organic produce, and avoiding cleaning products labeled "toxic" or any product with a warning on the label.

Pregnant women can also be exposed to toxins in the workplace, including airborne particles. The effects of wearing an N95 filtering facepiece respirator are similar for pregnant women as for non-pregnant women, and wearing a respirator for one hour does not affect the fetal heart rate.

Death by violence

Pregnant women or those who have recently given birth in the U.S. are more likely to be murdered than to die from obstetric causes. These homicides are a combination of intimate partner violence and firearms. Health authorities have called the violence "a health emergency for pregnant women", but say that pregnancy-related homicides are preventable if healthcare providers identify those women at risk and offer assistance to them.

Sexual activity

Most women can continue to engage in sexual activity, including sexual intercourse, throughout pregnancy. Research suggests that during pregnancy both sexual desire and frequency of sexual relations decrease during the first and third trimester, with a rise during the second trimester. Sex during pregnancy is a low-risk behavior except when the healthcare provider advises that sexual intercourse be avoided for particular medical reasons. For a healthy pregnant woman, there is no single safe or right way to have sex during pregnancy.

Exercise

A pregnant woman and her colleague returning from fishing, Gurara River bridge, Kachia, Nigeria.

Regular aerobic exercise during pregnancy appears to improve (or maintain) physical fitness. Physical exercise during pregnancy appears to decrease the need for C-section, and even vigorous exercise carries no significant risks to babies and provides significant health benefits to the mother. Bed rest, outside of research studies, is not recommended as there is no evidence of benefit and potential harm.

The Clinical Practice Obstetrics Committee of Canada recommends that "All women without contraindications should be encouraged to participate in aerobic and strength-conditioning exercises as part of a healthy lifestyle during their pregnancy". Although an upper level of safe exercise intensity has not been established, women who were regular exercisers before pregnancy and who have uncomplicated pregnancies should be able to engage in high intensity exercise programs, without a higher risk of prematurity, lower birth weight, or gestational weight gain. In general, participation in a wide range of recreational activities appears to be safe, with the avoidance of those with a high risk of falling such as horseback riding or skiing or those that carry a risk of abdominal trauma, such as soccer or hockey.

The American College of Obstetricians and Gynecologists reports that in the past, the main concerns of exercise in pregnancy were focused on the fetus and any potential maternal benefit was thought to be offset by potential risks to the fetus. However, they write that more recent information suggests that in the uncomplicated pregnancy, fetal injuries are highly unlikely. They do, however, list several circumstances when a woman should contact her healthcare provider before continuing with an exercise program: vaginal bleeding, dyspnea before exertion, dizziness, headache, chest pain, muscle weakness, preterm labor, decreased fetal movement, amniotic fluid leakage, and calf pain or swelling (to rule out thrombophlebitis).

Sleep

It has been suggested that shift work and exposure to bright light at night should be avoided at least during the last trimester of pregnancy to decrease the risk of psychological and behavioral problems in the newborn.

Stress

The children of women who had high stress levels during pregnancy are slightly more likely to have externalizing behavioral problems such as impulsivity. The behavioral effect was most pronounced during early childhood.

Dental care

The increased levels of progesterone and estrogen during pregnancy make gingivitis more likely; the gums become edematous, red in colour, and tend to bleed. Also a pyogenic granuloma or "pregnancy tumor", is commonly seen on the labial surface of the papilla. Lesions can be treated by local debridement or deep incision depending on their size, and by following adequate oral hygiene measures. There have been suggestions that severe periodontitis may increase the risk of having preterm birth and low birth weight; however, a Cochrane review found insufficient evidence to determine if periodontitis can develop adverse birth outcomes.

Flying

In low risk pregnancies, most health care providers approve flying until about 36 weeks of gestational age. Most airlines allow pregnant women to fly short distances at less than 36 weeks, and long distances at less than 32 weeks. Many airlines require a doctor's note that approves flying, especially at over 28 weeks. During flights, the risk of deep vein thrombosis is decreased by getting up and walking occasionally, as well as by avoiding dehydration. The exposure to cosmic radiation is negligible for most travelers. For pregnant women, even the longest intercontinental fight would expose them less than 15% of both the NCRPM and ICRP limit. Full body scanners do not use ionizing radiation, and are safe in pregnancy.

Pregnancy classes and birth plan

To prepare for the birth of the baby, health care providers recommend that parents attend antenatal classes during the third trimester of pregnancy. Classes include information about the process of labor and birth and the various kinds of births, including both vaginal and caesarean delivery, the use of forceps, and other interventions that may be needed to safely deliver the infant. Types of pain relief, including relaxation techniques, are discussed. Partners or others who may plan to support a woman during her labor and delivery learn how to assist in the birth.

It is also suggested that a birth plan be written at this time. A birth plan is a written statement that outlines the desires of the mother during labor and delivery of the baby. Discussing the birth plan with the midwife or other care provider gives parents a chance to ask questions and learn more about the process of labour.

In 1991 the WHO launched the Baby-Friendly Hospital Initiative, a global program that recognizes birthing centers and hospitals that offer optimal levels of care for giving birth. Facilities that have been certified as "Baby Friendly" accept visits from expecting parents to familiarize them with the facility and the staff.

Complications

Each year, ill health as a result of pregnancy is experienced (sometimes permanently) by more than 20 million women around the world. In 2016, complications of pregnancy resulted in 230,600 deaths down from 377,000 deaths in 1990. Common causes include bleeding (72,000), infections (20,000), hypertensive diseases of pregnancy (32,000), obstructed labor (10,000), and pregnancy with abortive outcome (20,000), which includes miscarriage, abortion, and ectopic pregnancy.

The following are some examples of pregnancy complications:

There is also an increased susceptibility and severity of certain infections in pregnancy.

Miscarriage and stillbirth

Miscarriage is the most common complication of early pregnancy. It is defined as the loss of an embryo or fetus before it is able to survive independently. The most common symptom of miscarriage is vaginal bleeding with or without pain. The miscarriage may be evidenced by a clot-like material passing through and out of the vagina. About 80% of miscarriages occur in the first 12 weeks of pregnancy. The underlying cause in about half of cases involves chromosomal abnormalities.

Stillbirth is defined as fetal death after 20 or 28 weeks of pregnancy, depending on the source. It results in a baby born without signs of life. Each year about 21,000 babies are stillborn in the U.S. Sadness, anxiety, and guilt may occur after a miscarriage or a stillbirth. Emotional support may help with processing the loss. Fathers may experience grief over the loss as well. A large study found that there is a need to increase the accessibility of support services available for fathers.

Diseases in pregnancy

A pregnant woman may have a pre-existing disease, which is not directly caused by the pregnancy, but may cause complications to develop that include a potential risk to the pregnancy; or a disease may develop during pregnancy.

Abortion

An abortion is the termination of an embryo or fetus via medical method. It is usually done within the first trimester, sometimes in the second, and rarely in the third. Reasons for pregnancies being undesired are broad, rape being the most legally accepted.

Birth control and education

Family planning, as well as the availability and use of contraception, along with increased comprehensive sex education, has enabled many to prevent pregnancies when they are not desired. Schemes and funding to support education and the means to prevent pregnancies when they are not intended have been instrumental and are part of the third of the Sustainable Development Goals (SDGs) advanced by the United Nations.

Technologies and science

Assisted reproductive technology

Modern reproductive medicine offers many forms of assisted reproductive technology for couples who stay childless against their will, such as fertility medication, artificial insemination, in vitro fertilization and surrogacy.

Medical imaging

CT scanning (volume rendered in this case) confers a radiation dose to the developing fetus.
A pregnant woman undergoing an ultrasound. Ultrasound is used to check on the growth and development of the fetus.

Medical imaging may be indicated in pregnancy because of pregnancy complications, disease, or routine prenatal care. Medical ultrasonography including obstetric ultrasonography, and magnetic resonance imaging (MRI) without contrast agents are not associated with any risk for the mother or the fetus, and are the imaging techniques of choice for pregnant women. Projectional radiography, CT scan and nuclear medicine imaging result in some degree of ionizing radiation exposure, but in most cases the absorbed doses are not associated with harm to the baby. At higher dosages or frequency, effects can include miscarriage, birth defects and intellectual disability.

Epidemiology

About 213 million pregnancies occurred in 2012 of which 190 million were in the developing world and 23 million were in the developed world. This is about 133 pregnancies per 1,000 women aged 15 to 44. About 10% to 15% of recognized pregnancies end in miscarriage. Globally, 44% of pregnancies are unplanned. Over half (56%) of unplanned pregnancies are aborted. In countries where abortion is prohibited, or only carried out in circumstances where the mother's life is at risk, 48% of unplanned pregnancies are aborted illegally. Compared to the rate in countries where abortion is legal, at 69%.

Of pregnancies in 2012, 120 million occurred in Asia, 54 million in Africa, 19 million in Europe, 18 million in Latin America and the Caribbean, 7 million in North America, and 1 million in Oceania. Pregnancy rates are 140 per 1000 women of childbearing age in the developing world and 94 per 1000 in the developed world.

The rate of pregnancy, as well as the ages at which it occurs, differ by country and region. It is influenced by a number of factors, such as cultural, social and religious norms; access to contraception; and rates of education. The total fertility rate (TFR) in 2013 was estimated to be highest in Niger (7.03 children/woman) and lowest in Singapore (0.79 children/woman).

In Europe, the average childbearing age has been rising continuously for some time. In Western, Northern, and Southern Europe, first-time mothers are on average 26 to 29 years old, up from 23 to 25 years at the start of the 1970s. In a number of European countries (Spain), the mean age of women at first childbirth has crossed the 30-year threshold.

This process is not restricted to Europe. Asia, Japan and the United States are all seeing average age at first birth on the rise, and increasingly the process is spreading to countries in the developing world like China, Turkey and Iran. In the US, the average age of first childbirth was 25.4 in 2010.

In the United States and United Kingdom, 40% of pregnancies are unplanned, and between a quarter and half of those unplanned pregnancies were unwanted pregnancies.

In the US, a woman's educational attainment and her marital status are correlated with childbearing: the percentage of women unmarried at the time of first birth drops with increasing educational level. In other words: among uneducated women, a large fraction (~80%) have their first child while they are unmarried. By contrast, few women with a bachelor's degree or higher (~25%) have their first child while unmarried. However, this phenomenon also has a strong generational component: in 1996, about 50% of women without a university degree had their first child being unmarried while that number increased to ~85% in 2018. Similarly, in 1996, only 4% of women with a BA degree or similar had their first child being unmarried. In 2018, that fraction increased to ~25%.

Many countries have various legal regulations in place to protect pregnant women and their children. Many countries have laws against pregnancy discrimination.

Maternity Protection Convention ensures that pregnant women are exempt from activities such as night shifts or carrying heavy stocks. Maternity leave typically provides paid leave from work during roughly the last trimester of pregnancy and for some time after birth. Notable extreme cases include Norway (8 months with full pay) and the United States (no paid leave at all except in some states).

In the United States, some actions that result in miscarriage or stillbirth, such as beating a pregnant woman, are considered crimes. One law that does so is the federal Unborn Victims of Violence Act. In 2014, the American state of Tennessee passed a law which allows prosecutors to charge a woman with criminal assault if she uses illegal drugs during her pregnancy and her fetus or newborn is harmed as a result.

However, protections are not universal. In Singapore, the Employment of Foreign Manpower Act forbids current and former work permit holders from becoming pregnant or giving birth in Singapore without prior permission. Violation of the Act is punishable by a fine of up to S$10,000 (US$7300) and deportation, and until 2010, their employers would lose their $5,000 security bond.

Teenage pregnancy

Teenage pregnancy is also known as adolescent pregnancy. The WHO defines adolescence as the period between the ages of 10 and 19 years. Adolescents face higher health risks than women who give birth at age 20 to 24 and their infants are at a higher risk for preterm birth, low birth weight, and other severe neonatal conditions. Their children continue to face greater challenges, both behavioral and physical, throughout their lives. Teenage pregnancies are also related to social issues, including social stigma, lower educational levels, and poverty. Studies show that female adolescents are often in abusive relationships at the time of their conceiving.

Nurse-Family Partnership (NFP) is a non-profit organization operating in the United States and the UK designed to serve the needs of low income young mothers who may have special needs in their first pregnancy. Each mother served is partnered with a registered nurse early in her pregnancy and receives ongoing nurse home visits that continue through her child's second birthday. NFP intervention has been associated with improvements in maternal health, child health, and economic security.

Racial disparities

There are significant racial imbalances in pregnancy and neonatal care systems. Midwifery guidance, treatment, and care have been related to better birth outcomes. Diminishing racial inequities in health is an increasingly large public health challenge in the United States. Despite the fact that average rates have decreased, data on neonatal mortality demonstrates that racial disparities have persisted and grown. The death rate for African American babies is nearly double that of white neonates. According to studies, congenital defects, SIDS, preterm birth, and low birth weight are all more common among African American babies.

Midwifery care has been linked to better birth and postpartum outcomes for both mother and child. It caters to the needs of the woman and provides competent, sympathetic care, and is essential for maternal health improvement. The presence of a doula, or birth assistant, during labor and delivery, has also been associated with improved levels of satisfaction with medical birth care. Providers recognized their profession from a historical standpoint, a link to African origins, the diaspora, and prevailing African American struggles. Providers participated in both direct clinical experience and activist involvement. Advocacy efforts aimed to enhance the number of minority birth attendants and to promote the benefits of woman-centered birth care to neglected areas.

Transgender people

Transgender people have experienced significant advances in societal acceptance in recent years leaving many health professionals unprepared to provide quality care. A 2015 report suggests that "numbers of transgender individuals who are seeking family planning, fertility, and pregnancy services could certainly be quite large". Regardless of prior hormone replacement therapy treatments, the progression of pregnancy and birthing procedures for transgender people who carry pregnancies are typically the same as those of cisgender women however, they may be subjected to discrimination, which can include a variety of negative social, emotional, and medical experiences, as pregnancy is regarded as an exclusively female activity. According to a study by the American College of Obstetricians and Gynecologists, there is a lack of awareness, services, and medical assistance available to pregnant trans men.

Culture

The Visitation: Mary, pregnant with Jesus, visiting pregnant Elizabeth, depicted as a statue at the Church of the Visitation in Ein Karem, Israel.

In most cultures, pregnant women have a special status in society and receive particularly gentle care. At the same time, they are subject to expectations that may exert great psychological pressure, such as having to produce a son and heir. In many traditional societies, pregnancy must be preceded by marriage, on pain of ostracism of mother and (illegitimate) child.

Overall, pregnancy is accompanied by numerous customs that are often subject to ethnological research, often rooted in traditional medicine or religion. The baby shower is an example of a modern custom. Contrary to common misconception, women historically in the United States were not expected to seclude themselves during pregnancy, as was popularized by Gone With the Wind.

Pregnancy is an important topic in sociology of the family. The prospective child may preliminarily be placed into numerous social roles. The parents' relationship and the relation between parents and their surroundings are also affected.

A belly cast may be made during pregnancy as a keepsake.

Arts

Images of pregnant women, especially small figurines, were made in traditional cultures in many places and periods, though it is rarely one of the most common types of image. These include ceramic figures from some Pre-Columbian cultures, and a few figures from most of the ancient Mediterranean cultures. Many of these seem to be connected with fertility. Identifying whether such figures are actually meant to show pregnancy is often a problem, as well as understanding their role in the culture concerned.

Among the oldest surviving examples of the depiction of pregnancy are prehistoric figurines found across much of Eurasia and collectively known as Venus figurines. Some of these appear to be pregnant.

Due to the important role of the Mother of God in Christianity, the Western visual arts have a long tradition of depictions of pregnancy, especially in the biblical scene of the Visitation, and devotional images called a Madonna del Parto.

The unhappy scene usually called Diana and Callisto, showing the moment of discovery of Callisto's forbidden pregnancy, is sometimes painted from the Renaissance onwards. Gradually, portraits of pregnant women began to appear, with a particular fashion for "pregnancy portraits" in elite portraiture of the years around 1600.

Pregnancy, and especially pregnancy of unmarried women, is also an important motif in literature. Notable examples include Thomas Hardy's 1891 novel Tess of the d'Urbervilles and Goethe's 1808 play Faust.

Communist society

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