Hawley-Scale

(WOMENSENEWS)–Two "awareness" days almost bumped into each other last month. World Prematurity Day was Nov. 17, three days after World Diabetes Day on Nov. 14.

There’s potent symbolism there, because the worlds of maternal-child health and chronic disease are going to collide, sooner than we think, and with wide-reaching consequences for global health.

For the past 25 years, global maternal-child health efforts have focused on ensuring adequate nutrition for pregnant women, access to essential medicines, skilled health workers, safe facilities for birthing and treating conditions such as prematurity, which remains the leading cause of newborn death.

As a result, maternal deaths have fallen by almost 45 percent since 1990 and the mortality of those under age 5 has more than halved, according to the World Bank and the World Health Organization.

But that progress is soon going to be threatened by the rapidly rising prevalence of obesity and related chronic diseases, like diabetes, among 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.

In line with this, more and more women are overweight or obese or have an existing chronic disease when they become pregnant. Being overweight and obesity in pregnancy are associated with numerous adverse outcomes; one of which is premature birth.

Obese women have more than double the risk of preterm birth compared to women of normal weight and their risk of extremely preterm birth (giving birth before 28 weeks gestation) may be greater still.

Stillbirths, congenital abnormalities and high birth weight, which itself leads to possible birth injuries and infant death, are also more common among the infants of women who are overweight or obese. For the mothers themselves, there is increased risk of developing diabetes during pregnancy, high blood pressure and the need for Cesarean section deliveries – all of which increase the risk of maternal mortality.

U.S. Doctors Already Adapting

In the United State, obstetrics and gynecology practice is adapting to this new reality. 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 deliveries.

But it is not in the United States that the greatest burden of this problem will be felt.

By far the greatest burden of obesity and related chronic disease is in low- and middle-income countries. In South Africa, for example, up to 70 percent of adult women are overweight or obese; 30 million adults in India are obese; and in China the prevalence of obesity, while still relatively low, has more than doubled in just 20 years.

Many of these are countries going through a public health transition. They are still struggling with infectious diseases and the traditional maternal-child health challenges. But they are also contending with the rapid emergence of chronic diseases.

Low- and middle-income countries often suffer shortages of health professionals so it’s hard for them to support primary care for the population much less the problems of a pregnancy complicated by obesity or diabetes.

The emerging strain casts a shadow over some recent progress.

As women with pregnancies complicated by obesity or diabetes seek specialized medical attention, for instance, it’s easy to imagine that, in response, resources will be tugged away from a community-based, midwife-led model that many countries have pursued.

The health infrastructure in these settings, even within tertiary care, is often poor. Expert anesthesiologists for Cesarean deliveries are needed. So is more surgery space, beds large enough to safely accommodate a 400-pound woman during labor, essential medicines for gestational diabetes and hypertension. All of these can be scarce. Neonatal intensive care facilities are few and far between.

Without doubt, there is still considerable work to do to prevent maternal and child deaths from traditional causes.

But with at least 650 million women in low- and middle-income countries living with obesity or diabetes, the potential consequences for maternal and child health can no longer be ignored.

If we learned anything from the recent Ebola epidemic, it is that global health crises need to be anticipated and acted upon immediately. We can start by recognizing that prematurity and diabetes are not separate issues after all and that rising levels of chronic diseases in pregnancy are likely to represent the next major challenge for global maternal and child health. Early action is going to be imperative if we are going to continue to make important progress toward global goals for maternal and child health.


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