12th PSRH Conference Vanuatu
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PACIFIC JOURNAL OF REPRODUCTIVE HEALTH
Accepted articles are published online prior to being compiled into an issue on the JournalÂ platform. The next issue is published on the 30th June 2017. Although articles have been reviewed and accepted, the Chief-in-Editor welcomes comments on the articles before final publication.
Articles have not been copy-edited, therefore, there will be some edits before final publication.
EDITORIAL (December 2016 issue)
The growing threat of non-communicable disease to pregnancy health
Corresponding author: Nicola Hawley firstname.lastname@example.org. Yale University, School of Public Health, Assistant Professor of Epidemiology (Chronic Diseases).
For the past three decades, global maternal and child health efforts have focused on ensuring adequate nutrition for pregnant women, access to essential medicines, skilled health providers, safe facilities for birthing, and treating conditions such as prematurity, which remains the leading cause of newborn death.1 As a result, maternal deaths have fallen by almost 45% since 1990 and the mortality of those aged under five years has more than halved.2 But, this global progress stands to be undermined by the rapidly rising prevalence of obesity and related non-communicable diseases (NCDs), such as diabetes and chronic hypertension, amongst the obstetric population.
In the same 25 years since 1990, the global prevalence of obesity has more than doubled and it is young women of childbearing age who are bearing the greatest burden.3,4 Recent data suggests that between 1975 and 2014 the age-standardised global prevalence of obesity increased from 6.4% (95% credible confidence interval (CI): 5.1-7.8) to 14.9% (CI: 13.6-16.1) in women,4 with the average body-mass index (BMI) increasing by 0.5 kg/m2 per decade.3 Over the same period, diabetes rose from 5.0% (CI: 2.9-7.9) to 7.9% (CI: 6.4-9.7) among women5. Recent global prevalence data for raised blood pressure appears to tell a different story, falling from 26.1% (CI: 21.7-31.1) in 1975 to 20.1% (17.8-22.5) in 2014.6 However, examination of this data by age and world region shows that the global prevalence data is masking worrying increases in the prevalence of hypertension among women, particularly those of childbearing age, in Sub-Saharan Africa, South Asia and Oceania.
As the hypertension data suggests, the global burden of NCD is disproportionately concentrated in low- and middle-income countries, with almost three quarters of the 56 million global deaths from NCD occurring in these nations.7 The Pacific Island nations have been consistently highlighted as the world region most afflicted.4-6 NCDs now account for 70% or more of all deaths in the Pacific Islands, with life expectancy actually falling in Tonga as a result.8 The increase in NCD burden seen in the Pacific can be attributed to urbanisation, lifestyle changes associated with rapid economic development such as greater uptake of smoking and alcohol consumption, changes in diet and physical activity, and rising obesity.9 Women are especially prone to NCDs as they generally have a higher likelihood of poverty, lack of education, and physical inactivity compared with men and often experience more barriers to health care.10
Once thought of as diseases of affluence or old-age, NCDs now contribute significantly to morbidity among those of productive and reproductive age in the Pacific. Almost half of NCD deaths occur before the age of 70;7 as such, NCDs are becoming a prominent problem for pregnant women. Given that many Pacific women of childbearing age have little contact with the health care system between school-age and when they become pregnant, it is often during routine antenatal care or even at the time of birth that NCDs are first recognised. This requires that midwives, community nurses, traditional birth attendants, and obstetricians are able to deal with the challenges that a pregnancy complicated by NCDs brings.
One in four maternal deaths are now caused by pre-existing medical conditions such as diabetes, chronic hypertension, and obesity. The health impacts can be exacerbated by pregnancy. Obesity puts a pregnant woman at risk of early pregnancy loss, preterm birth, stillbirth, gestational diabetes and pre-eclampsia, as well as increasing the likelihood that her infant will be macrosomic or born with a congenital malformation11. Similarly, uncontrolled or undiagnosed diabetes in pregnancy or the development of gestational diabetes is associated with an increased risk of other pregnancy complications such as pre-eclampsia, and impacts the infant by increasing the risk of preterm birth, respiratory distress syndrome and hypoglycemia. Diabetes in pregnancy is also associated with the delivery of large for gestational age infants, which can result in life threatening obstructed labour12. Finally, chronic hypertension can result in pre-eclampsia, foetal growth restriction, placental abruption, and preterm birth13. All of these conditions increase the likelihood that a caesarean section delivery may be necessary.
As well as the myriad perinatal complications associated with obesity, diabetes, or hypertension during pregnancy, longer term risks to the health of the mother and child are well recognised. Gestational weight gain exacerbates postpartum obesity, hypertension, and risk of diabetes in the mother, while her child is also susceptible to later obesity and metabolic dysregulation. If the same mother becomes pregnant again, her risk of perinatal mortality is higher, while her child may go on to continue an intergenerational cycle of NCDs when they conceive their own children.
In developed country settings, such as Australia, New Zealand, or the United States, obstetrics and gynaecology practice is already adapting to the new reality of rising NCD prevalence. Dedicated fellowships now train clinicians to treat women who are obese or have diabetes when they become pregnant and specialist clinics are available with the resources, equipment, and expertise to deal with these high-risk patients and their complex health needs and challenging deliveries. In the Pacific, many nations are still dealing with more fundamental issues: trained health care professional shortages, increasing early access to antenatal care, providing safe places for delivery and neonatal care, and improving infection control14-16. But there is an urgent need to simultaneously adapt to and begin to successfully manage the increasing burden of NCDs among pregnant women.
More primary research and greater disease surveillance are needed to understand the current burden of NCDs among pregnant women in the Pacific and to identify sub-sectors of the reproductive age population who are most at risk. Preconception care, at the stage of family planning, should include preventative measures including counseling on weight, nutrition, and physical activity, that may be taken to mitigate risk. Early detection and treatment during pregnancy are essential, meaning that it is important to provide all practitioners tasked with maternal-child health care – from traditional birth attendants to specialist obstetricians – with some level of education about the risks of NCDs to pregnant women and how to detect them; preferably using low-cost strategies appropriate for use in rural, low-resource settings. Public health campaigns and health messaging should continue to target early enrollment into antenatal care to enable early NCD screening and to promote the importance of attending multiple antenatal care appointments during pregnancy for continuity of care. Universal and consistent access to essential medicines for NCDs and implementation of standardised screening protocols should be a priority for clinical providers. Finally, a system of postpartum follow up is needed, providing further screening and longer term care. A pragmatic solution to preventing the adverse health consequences of NCDs in pregnancy would be to promote interventions across three windows of opportunity – preconception, during pregnancy, and postpartum – and to focus on strengthening health systems to provide appropriate pathways of care.11
New infrastructure for these activities is not necessary; many can take place within existing health care systems, and indeed the integration of NCD care and antenatal services may have several benefits. Previous programs in low and middle income countries have been successful in integrating infectious disease care (HIV/AIDS, TB, Malaria and STI care) into antenatal care and family planning services.17-18 Several of the lessons learned from these programs can be applied to integration of NCD care: point-of-care screening and diagnosis, task shifting, adapting existing protocols, and patient-centered care. As well as being an efficient use of existing resources, the major benefit of integrating NCD diagnosis and care into the existing antenatal care infrastructure is that the antenatal care structure is designed for long term follow up. If NCDs can be detected early, treatment implemented and adherence monitored, and adoption of healthful behaviors promoted and reinforced – then there is the potential to influence the long-term health of both mother and baby and indeed, future generations.
Improving maternal child health is a prominent goal of a Pacific-wide health strategy. NCDs in pregnancy represent a significant challenge to the long-term health and development of women and children in Pacific nations and if left unchecked will begin to undermine significant progress in the reduction of maternal and neonatal mortality. With the knowledge that NCDs are becoming increasingly burdensome among women of reproductive age, it is important to take early, preventative action; action that utilizes existing infrastructure and maximises the skills of reproductive health providers. Those working in reproductive health, in all capacities, should be vocal advocates for the importance of this issue, encouraging experts and decision-makers across the Pacific to consider their long-term strategy for managing these diseases.
- World Health Organisation. Preterm Birth Factsheet [Internet]. World Health Organisation; c2016 Nov [cited 2016 Nov 18]. Available from: http://www.who.int/ mediacentre/factsheets/fs363/en/.
- World Health Organisation. Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division [Internet]. WHO Press; 2015 [cited 2016 Nov 16]. Available from: http://apps.who.int/ iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1.
- Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek CJ, et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet. 2011;377(9765):557-67. DOI: 10.1016/S0140-6736(10)62037-5.
- NCD Risk Factor Collaboration (NCD-RisC). Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants. Lancet. 2016;387(10026): 1377-1396. DOI: 10.1016/S0140-6736(16)30054-X.
- NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4.4 million participants. Lancet. 2016;387(10027):1513-1530. DOI: 10.1016/S0140-6736(16)00618-8
- NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19.1 million participants. Lancet. 2016;S0140-6736(16):31919-5. Epub 2016 Nov 15. DOI: 10.1016/S0140-6736(16)31919-5.
- World Health Organisation. Global Status Report on non-communicable diseases 2014 [Internet]. WHO Press; 2014 [cited 2016 Nov 28]. Available from: http://apps.who.int/ iris/bitstream/10665/148114/1/9789241564854_eng.pdf?ua=1.
- Anderson I; The World Bank. The economic costs of non-communicable diseases in the Pacific Islands. A rapid stocktake of the situation in Samoa, Tonga, and Vanuatu, 2012 [Internet]. The World Bank; c2016 [cited 2016 Dec 2]. Available from: http://documents.worldbank.org/curated/en/291471468063255184/pdf/865220WP0Econo0Box385176B000PUBLIC0.pdf.
- Hawley NL, McGarvey ST. Obesity and diabetes in Pacific Islanders: the current burden and the need for urgent action. Current Diabetes Reports. 2015;15:29. DOI: 10.1007/s11892-015-0594-5.
- United States Agency International Division. Addressing the unique needs of men and women in non-communicable disease services 2014 [Internet]. USAID 2014 May [cited 2016 Dec 2]. Available from: https://www.usaidassist.org/sites/assist/files/addressing_gender_ncd_services_ada_may2014.pdf.
- Poston L, Caleyachetty R, Cnattingius S, Corvalán C, Uauy R, Herring S, et al. Preconceptional and maternal obesity: epidemiology and health consequences. Lancet Diabetes Endocrinology. 2016;4(12): 1025-1036. DOI: 10.1016/S2213-8587(16)30217-0.
- Wendland EM, Torloni MR, Flavigna M, Trujillo J, Dode MA, Campos MA, et al. Gestational diabetes and pregnancy outcomes – a systematic review of the World Health Organization (WHO) and the International Association of Diabetes in Pregnancy Study Groups (IADPSG) diagnostic criteria. BMC Pregnancy and Childbirth. 2012;12:23. DOI: 10.1186/1471-2393-12-23.
- Seely EW, Ecker J. Chronic hypertension in pregnancy. Circulation. 2014;129:1254-1261. DOI: 10.1161/CIRCULATIONAHA.113.003904.
- The United Nations Children’s Fund. Tracking progress in maternal and child survival case study report 2013 [Internet]. UNICEF; c2013 [cited 2016 Nov 28]. Available from: https://www.unicef.org/ pacificislands/14_-_02-2014_Fiji_Case_Study_For_Delivery_to_UNICEF_8-29-2013_conversion_(1).pdf.
- The World Bank. Reproductive health at a glance: Papua New Guinea, 2011 [Internet]. The World Bank; 2011 Apr [cited 2016 Nov 28]. Available from: http://siteresources. worldbank.org/INTPRH/Resources/376374-1303736328719/PNGhealth42211web.pdf.
- The United Nations Children’s Fund. Solomon Islands: maternal, newborn, and child survival [Internet]. UNICEF; 2008 Nov [cited 2016 Nov 28]. Available from: https://www.unicef.org/eapro/Solomon_Islands_Eng.pdf.
- Welty TK, Bulterys M, Welty ER, Tih PM, Ndikintum G, Nkuoh G, et al. Integrating prevention of mother-to-child HIV transmission into routine antenatal care: the key to program expansion in Cameroon. Journal of Acquired Immune Deficiency Syndrome. 2005;40(4):486-493. DOI: 1097/01.qai.0000163196.36199.89.
- Van der Merwe K, Chersich MF, Tachnau K, Umurungi Y, Conradie F, Coovadia A. Integration of antiretroviral treatment within antenatal care in Gauteng province, South Africa. Journal of Acquired Immune Deficiency Syndrome. 2006;43(5):577-581. DOI: 1097/01.qai.0000243099.72770.d2.
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