The views expressed are those of the author and do not necessarily reflect the position of FORESIGHT Global Health.
Millions of women each year are diagnosed with pregnancy complications like gestational diabetes and pregnancy hypertension (a precursor to pre-eclampsia, which is characterised by signs of damage to another organ system). Research shows women who experience these conditions during one pregnancy are at very high risk of the same and additional problems in subsequent pregnancies, as well as type 2 diabetes, hypertension and cardiovascular disease later in life, especially if they experience difficulties with post-pregnancy weight loss.
These pregnancy complications, like other non-communicable diseases (NCDs), hit low- and middle-income countries (LMICs) the hardest. Studies from South India and China have found gestational diabetes prevalence rates of around 18%, significantly higher than the global rates of 12-14%. High-risk pregnancies also add to the burden on healthcare systems in LMICs already struggling with lack of access to obstetric care and high rates of maternal and neonatal mortality and morbidity.
There are two key challenges to effectively improve pregnancy outcomes, particularly in LMICs. The first is the ability of the health system to screen women for common medical conditions causing pregnancy complications early enough to identify those requiring treatment and preventive care. This critical area is a major focus of the World Diabetes Foundation (WDF) and many of our partners, and deserves its own discussion.
In this article, I would like to focus on the second challenge, which does not receive nearly as much attention as the first. It is the ability of the health system to follow up with women after an NCD-related pregnancy complication, and to engage and empower the mother and child to mitigate long-term risk by adopting a healthy lifestyle.
A simple check box on a child’s health card indicating the mother experienced a pregnancy complication is an effective strategy that can be implemented in health clinics globally.
WINDOW OF OPPORTUNITY
When a health system successfully diagnoses and manages a pregnant woman with gestational diabetes, pregnancy hypertension or pre-eclampsia, what happens next? What is done to ensure her future good health? Today, this window of opportunity is all too often missed.
The literature offers some insights into why. A review of relevant studies reveals screening for diabetes following a gestational diabetes pregnancy is, in general, low. A Canadian study that investigated why women with a history of gestational diabetes didn’t complete routine screening found the most common reason by far was time pressure. A qualitative study of women attending a high-risk obstetric clinical practice in the United States found multiple barriers to postpartum care, namely tending to their babies’ health issues and adjusting to the new baby (both of which take time they might have spent on themselves), feeling healthy and not in need of care, and being worried about receiving bad news.
Very few studies are available from LMICs, but in decades of work with the World Diabetes Foundation I have witnessed many of the same barriers as those reported in high-income countries. Many women feel healthy and do not see the need for follow-up treatment, while others lack the time or money to prioritise their health.
What’s more, women who have experienced pregnancy complications are often told to adopt healthier lifestyles during and after pregnancy, but with little or no practical guidance on how to do so, and no explanation of why it’s important.
New mothers in LMICs face similar barriers, as well as some additional challenges. Changing family diet and lifestyle, for example, is especially difficult when healthy food is expensive or unavailable, or such changes are not supported by the extended family or community.
As a result, all too many women who have had one pregnancy affected by a complication like gestational diabetes go on to have another, which increases the risk of potentially life-threatening conditions like type 2 diabetes and cardiovascular disease later in life.
PROPOSING A SOLUTION
I believe a simple check box on a child’s health card indicating that the mother experienced a pregnancy complication could interlink maternal health, child health and NCD prevention—and end this vicious cycle.
Most new mothers—in high-income countries and LMICs—visit health services for vaccinations, baby check-ups and other services, and are likely to do so at regular intervals for at least five years. Why not use this opportunity to provide women with postpartum services and education that can transform their lives? Why not connect the mother’s pregnancy complication status to the child’s health card for the benefit of both?
This box, when checked, would trigger an extra five to 10 minutes during health clinic visits to discuss the mother’s lifestyle and check her weight, blood pressure and blood sugar. These services can continue for three to five years post pregnancy, until the child ages out of the childhood vaccination programme.
The result: the mother’s health improves before the next pregnancy, and her risk for serious long-term health conditions is reduced. And there’s an important bonus. A healthier lifestyle for the mother has flow-on benefits for her children, as children born to women who experience pregnancy complications are also at elevated risk of conditions like type 2 diabetes and cardiovascular disease.
When I advocate for this change, people nod with agreement. But for it to work, health systems must be integrated, and silos broken down. An intervention that helps women who have had one high-risk pregnancy avoid future complications—especially if that approach leverages existing health structures and services—is worth pursuing.
Healthcare providers, healthcare planners, public health professionals and policy makers can work together to add a simple check box to children’s health cards, without forgetting to involve the women at risk. •
TEXT – Anil Kapur, Chairman of the World Diabetes Foundation – ILLUSTRATION – Sine Jensen
Before the pandemic crisis, women’s lives were already heavily affected by non-communicable diseases (NCDs), as women constitute the majority of the workforce in the healthcare sector and also function as main caregivers for family members at home. The pandemic has only exacerbated the disproportionate care burdens on women. If we are to build a more equitable world, we must start by addressing such imbalances.
The discovery of insulin in 1921 changed type 1 diabetes from a death sentence to a condition that can be controlled and managed successfully. Yet a hundred years later, children still die from diabetes, especially in low- and middle-income countries (LMICs). What do we need to ensure access and affordability of type 1 diabetes treatment? Both capacity building and innovative financing will play a role in advancing progress.