Non-communicable diseases and their impact on maternal health – is there more to the story and how can we combat the uprising?

By Maisha Syed - BSc Biology (QMUL), MSc Global Health and Development (UCL)

Non-communicable diseases and their impact on maternal health – is there more to the story and how can we combat the uprising?

Non-communicable diseases and their impact on maternal health – is there more to the story and how can we combat the uprising?

 

By Maisha Syed – BSc Biology (QMUL), MSc Global Health and Development (UCL)

Currently, non-communicable diseases (NCDs) account for approximately 71% of deaths worldwide. NCDs are diseases that are chronic disorders such as diabetes, cancers and respiratory conditions like asthma. They are often resultant of a mix of both genetic and environmental factors. Out of the yearly NCD deaths, 77% of them sadly occur in low- and middle-income countries (LMICs), such as Bangladesh (WHO, 2021). In 2016, in Bangladesh alone, almost 70% of deaths were due to NCDs amongst the general population (WHO, 2018). To add to the problem, many NCDs, in particular diabetes and hypertension, have been shown to negatively impact maternal health and pregnancy outcomes (Kapur, 2015). Intrauterine programming, which refers to the effects of womb conditions on a developing foetus, under such maternal conditions can lead to the retention and expression of degenerative health pre-dispositions in future generations due to increased genetic risk (Fowden, Giussani & Forhead, 2006, Kapur, 2015). If this issue is not addressed, this vicious cycle is likely to continue and hinder Bangladesh from achieving MDGs 4 (reducing child mortality) and 5 (improve maternal health) and SDG 3 (good health and well-being)(UN, 2015b, UN, 2015a).

Moreover, the newborn and foetal complications that arise from pregnant women with NCDs and related risk factors are also severe. For example, pregnant mothers who are obese have an increased risk of stillbirths and congenital malformations amongst other obstetric and neonatal complications (Akil & Ahmad, 2011, Kapur, 2015). Plus, these mothers will be more likely to develop gestational diabetes mellitus, which is a risk factor for developing type 2 diabetes in both the later life of the mother and child (Damm et al., 2016, Song et al., 2018). Additionally, being overweight or obese during pregnancy not only increases the risk of developing diabetes, hypertension and cardiovascular disease, but also increases the risk of pre-eclampsia and postpartum haemorrhage, which are two of the most common causes of maternal mortality in Bangladesh (Khatun et al., 2012, Kapur, 2015, Roy & Shengelia, 2016).

This highlights the importance in not just tackling the more direct causes of maternal and newborn morbidity and mortality, but also the more indirect factors and determinants, attributed to NCDs. Im one study it was found that approximately 35% of the causes leading to maternal mortality are indirect, meaning they stemmed from pre-existing conditions as opposed to direct birthing complications. This highlights the importance of putting a greater focus on preventative approach in respect to tackling the indirect causes of maternal mortality attributed by NCDs. In fact, as time has passed, the field of maternal health has seen various changes, both positive and negative. Due to the improvement of maternal healthcare overtime, the number of maternal mortalities attributable to direct causes have reduced. However, this decrease has unfortunately brought with it an increase in the number of maternal deaths due to indirect causes. This phenomenon is prevalent today and is termed the “obstetric transition” (Souza et al., 2014, Hussein, 2017). The rise in NCDs and related conditions is fitting with the “Epidemiological Transition”(Omran, 2005). In this theory, Omran outlines four stages of transition that previously were the major risk factors for mortality across the world, from famine to degenerative diseases. Since then, it has been suggested that obesity and lack of activity might be the fifth stage of transition amongst the human population (Gaziano, 2010).

To tackle the rising cases of NCDs amongst pregnant women, the underlying risk factors have to established and targeted. For diabetes, cardiovascular diseases and hypertension, although there is a genetic aspect, the majority of preventative care can be carried out through healthy life-style choices, for example, daily exercise and eating more whole foods. This has been long proven. For example, one study followed a group of approximately 85,000 women for sixteen years and recorded their daily lifestyle habits such as food, smoking status, and exercise pattern. These women all started the study with no known diabetes or heart disease, but by the end almost 4% had developed type 2 diabetes. The study found that, by comparing to a low-risk cohort, the development of type 2 diabetes was highly correlated with healthier food choices, regular exercise, not smoking and limited alcohol consumption (Hu et al., 2001). However, when putting this into the context of women in LMICs such as Bangladesh, the social fabric and lifestyle is fundamentally different to those in higher-income countries. The disparity is further warped when we consider women of different socio-economic status and those living in rural slums compared to urban houses. It’s only when we delve into the details and upstream factors for “simple” elements like choice of food and exercise, do we realise how important the social determinants of health are in dictating the health outcomes of these women (Liburdet al., 2005, Walker, Strom Williams & Egede, 2016). Namely, the way foods are cooked or bought (home cooked, fast food or village grown) and the way physical activity is carried out (desk job vs labourer or famer), differ greatly. Furthermore, LMICs have been found to have higher prevalence of NCDs such as diabetes mellitus (Zheng, Ley & Hu, 2018).

So, what can we do?

A more holistic approach needs to be taken to address rising NCDs and their impact on maternal health effectively. Frameworks that take a life-course standpoint are one potential method to combatting this issue. This style of framework takes into account how health outcomes, good and bad, can build-up over the course of an individual’s lifetime based on things such as occupation, education and family dynamics (Marmot, 2010). By taking these details into account, each country and each community can attempt to understand the upstream causational factors behind the rise in NCDs, then try to initiate preventative measures at different stages in the life course to stop this increase. For example, attempting to teach young girls of reproductive age about how obesity can lead to gynaecological problems and NCDs like diabetes mellitus, which in turn will make pregnancies difficult and may be damaging to their offspring, could be beneficial. Making such education part of the national curriculum would be one way forward. Similarly, it would be useful to ensure that each community has local centres or forums where the benefits of healthy eating and exercise are discussed with all ages, within the context of the area. In the case of Bangladesh for example, in a rural village the benefits of freshly harvested produce and/or cattle and dairy products can be emphasised. Whereas in an urban setting, the importance of more home-cooked meals with produce from grocery stores or markets as opposed to fast food should be highlighted.  Likewise for exercise, the often labour-intensive work of those in rural villages should account for a lot of their physical activity, alongside leisure such as pond swimming or fishing. In urban settings, the use of gyms or walking to work rather than using transport would be initiatives to boost. These examples are not exhaustive, and more work needs to be done to tailor the advice and interventions to each individual within a community, given their socio-economic background and so resources available to them. Hopefully, with the introduction of such frameworks as part of the healthcare system in LMICs such as Bangladesh, the ability to combat the rise in NCDs and their impact on LMICs will improve.

References

AKIL, L. & AHMAD, H. A. 2011. Relationships between obesity and cardiovascular diseases in four southern states and Colorado. J Health Care Poor Underserved, 22(4 Suppl), pp. 61-72.

DAMM, P., HOUSHMAND-OEREGAARD, A., KELSTRUP, L., LAUENBORG, J., MATHIESEN, E. R. & CLAUSEN, T. D. 2016. Gestational diabetes mellitus and long-term consequences for mother and offspring: a view from Denmark. Diabetologia, 59(7), pp. 1396-1399.

FOWDEN, A. L., GIUSSANI, D. A. & FORHEAD, A. J. 2006. Intrauterine Programming of Physiological Systems: Causes and Consequences. Physiology, 21, pp. 29-37.

GAZIANO, J. M. 2010. Fifth phase of the epidemiologic transition: the age of obesity and inactivity. JAMA, 303(3), pp. 275-6.

HU, F. B., MANSON, J. E., STAMPFER, M. J., COLDITZ, G., LIU, S., SOLOMON, C. G. & WILLETT, W. C. 2001. DIET, LIFESTYLE, AND THE RISK OF TYPE 2 DIABETES MELLITUS IN WOMEN. NEJM, 345(11), pp. 790-797.

HUSSEIN, J. 2017. Non-communicable diseases during pregnancy in low and middle income countries. Obstet Med,10(1), pp. 26-29.

KAPUR, A. 2015. Links between maternal health and NCDs. Best Pract Res Clin Obstet Gynaecol, 29(1), pp. 32-42.

KHATUN, F., RASHEED, S., MORAN, A. C., ALAM, A. M., SHOMIK, M. S., SULTANA, M., CHOUDHURY, N., IQBAL, M. & BHUIYA, A. 2012. Causes of neonatal and maternal deaths in Dhaka slums: implications for service delivery. BMC Public Health, 12pp. 84.

LIBURD, L. C., JACK, L., JR., WILLIAMS, S. & TUCKER, P. 2005. Intervening on the social determinants of cardiovascular disease and diabetes. Am J Prev Med, 29(5 Suppl 1), pp. 18-24.

MARMOT, M. 2010. Fair Society, Healthy Lives. The Marmot Review. Strategic Review of Health Inequalities in England Post 2010, London.

OMRAN, A. R. 2005. The Epidemiologic Transition: A Theory of the Epidemiology of Population Change. The Milbank Quaterly, 83(4), pp. 731-757.

ROY, A. & SHENGELIA, L. 2016. An Analysis on Maternal Healthcare Situation in Bangladesh: A Review. Diversity and Equality in Health and Care, 13(5), pp. 360-364.

SONG, C., LYU, Y., LI, C., LIU, P., LI, J., MA, R. C. & YANG, X. 2018. Long-term risk of diabetes in women at varying durations after gestational diabetes: a systematic review and meta-analysis with more than 2 million women. Obes Rev, 19(3), pp. 421-429.

SOUZA, J. P., TUNCALP, O., VOGEL, J. P., BOHREN, M., WIDMER, M., OLADAPO, O. T., SAY, L., GULMEZOGLU, A. M. & TEMMERMAN, M. 2014. Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG,121 Suppl 1pp. 1-4.

  1. 2015a. The 17 Goals [online]. Available from: https://sdgs.un.org/goals [Accessed Tue 20 Apr 2021].
  2. 2015b. We can end poverty Millenium Development Goals and Beyone 2015 [online]. Available from: https://www.un.org/millenniumgoals/ [Accessed Tue 20 Apr 2021].

WALKER, R. J., STROM WILLIAMS, J. & EGEDE, L. E. 2016. Influence of Race, Ethnicity and Social Determinants of Health on Diabetes Outcomes. Am J Med Sci, 351(4), pp. 366-73.

WHO. 2018. Bangladesh | World Health Orgainization – Noncommunicable Diseases (NCD) Country Profiles.

WHO. 2021. Noncommunicable diseases [online]. WHO. Available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases [Accessed Tue 20 Apr 2021].

ZHENG, Y., LEY, S. H. & HU, F. B. 2018. Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nat Rev Endocrinol, 14(2), pp. 88-98.

 

Non-communicable diseases and their impact on maternal health – is there more to the story and how can we combat the uprising?

 

By Maisha Syed – BSc Biology (QMUL), MSc Global Health and Development (UCL)

Currently, non-communicable diseases (NCDs) account for approximately 71% of deaths worldwide. NCDs are diseases that are chronic disorders such as diabetes, cancers and respiratory conditions like asthma. They are often resultant of a mix of both genetic and environmental factors. Out of the yearly NCD deaths, 77% of them sadly occur in low- and middle-income countries (LMICs), such as Bangladesh (WHO, 2021). In 2016, in Bangladesh alone, almost 70% of deaths were due to NCDs amongst the general population (WHO, 2018). To add to the problem, many NCDs, in particular diabetes and hypertension, have been shown to negatively impact maternal health and pregnancy outcomes (Kapur, 2015). Intrauterine programming, which refers to the effects of womb conditions on a developing foetus, under such maternal conditions can lead to the retention and expression of degenerative health pre-dispositions in future generations due to increased genetic risk (Fowden, Giussani & Forhead, 2006, Kapur, 2015). If this issue is not addressed, this vicious cycle is likely to continue and hinder Bangladesh from achieving MDGs 4 (reducing child mortality) and 5 (improve maternal health) and SDG 3 (good health and well-being)(UN, 2015b, UN, 2015a).

Moreover, the newborn and foetal complications that arise from pregnant women with NCDs and related risk factors are also severe. For example, pregnant mothers who are obese have an increased risk of stillbirths and congenital malformations amongst other obstetric and neonatal complications (Akil & Ahmad, 2011, Kapur, 2015). Plus, these mothers will be more likely to develop gestational diabetes mellitus, which is a risk factor for developing type 2 diabetes in both the later life of the mother and child (Damm et al., 2016, Song et al., 2018). Additionally, being overweight or obese during pregnancy not only increases the risk of developing diabetes, hypertension and cardiovascular disease, but also increases the risk of pre-eclampsia and postpartum haemorrhage, which are two of the most common causes of maternal mortality in Bangladesh (Khatun et al., 2012, Kapur, 2015, Roy & Shengelia, 2016).

This highlights the importance in not just tackling the more direct causes of maternal and newborn morbidity and mortality, but also the more indirect factors and determinants, attributed to NCDs. Im one study it was found that approximately 35% of the causes leading to maternal mortality are indirect, meaning they stemmed from pre-existing conditions as opposed to direct birthing complications. This highlights the importance of putting a greater focus on preventative approach in respect to tackling the indirect causes of maternal mortality attributed by NCDs. In fact, as time has passed, the field of maternal health has seen various changes, both positive and negative. Due to the improvement of maternal healthcare overtime, the number of maternal mortalities attributable to direct causes have reduced. However, this decrease has unfortunately brought with it an increase in the number of maternal deaths due to indirect causes. This phenomenon is prevalent today and is termed the “obstetric transition” (Souza et al., 2014, Hussein, 2017). The rise in NCDs and related conditions is fitting with the “Epidemiological Transition”(Omran, 2005). In this theory, Omran outlines four stages of transition that previously were the major risk factors for mortality across the world, from famine to degenerative diseases. Since then, it has been suggested that obesity and lack of activity might be the fifth stage of transition amongst the human population (Gaziano, 2010).

To tackle the rising cases of NCDs amongst pregnant women, the underlying risk factors have to established and targeted. For diabetes, cardiovascular diseases and hypertension, although there is a genetic aspect, the majority of preventative care can be carried out through healthy life-style choices, for example, daily exercise and eating more whole foods. This has been long proven. For example, one study followed a group of approximately 85,000 women for sixteen years and recorded their daily lifestyle habits such as food, smoking status, and exercise pattern. These women all started the study with no known diabetes or heart disease, but by the end almost 4% had developed type 2 diabetes. The study found that, by comparing to a low-risk cohort, the development of type 2 diabetes was highly correlated with healthier food choices, regular exercise, not smoking and limited alcohol consumption (Hu et al., 2001). However, when putting this into the context of women in LMICs such as Bangladesh, the social fabric and lifestyle is fundamentally different to those in higher-income countries. The disparity is further warped when we consider women of different socio-economic status and those living in rural slums compared to urban houses. It’s only when we delve into the details and upstream factors for “simple” elements like choice of food and exercise, do we realise how important the social determinants of health are in dictating the health outcomes of these women (Liburdet al., 2005, Walker, Strom Williams & Egede, 2016). Namely, the way foods are cooked or bought (home cooked, fast food or village grown) and the way physical activity is carried out (desk job vs labourer or famer), differ greatly. Furthermore, LMICs have been found to have higher prevalence of NCDs such as diabetes mellitus (Zheng, Ley & Hu, 2018).

So, what can we do?

A more holistic approach needs to be taken to address rising NCDs and their impact on maternal health effectively. Frameworks that take a life-course standpoint are one potential method to combatting this issue. This style of framework takes into account how health outcomes, good and bad, can build-up over the course of an individual’s lifetime based on things such as occupation, education and family dynamics (Marmot, 2010). By taking these details into account, each country and each community can attempt to understand the upstream causational factors behind the rise in NCDs, then try to initiate preventative measures at different stages in the life course to stop this increase. For example, attempting to teach young girls of reproductive age about how obesity can lead to gynaecological problems and NCDs like diabetes mellitus, which in turn will make pregnancies difficult and may be damaging to their offspring, could be beneficial. Making such education part of the national curriculum would be one way forward. Similarly, it would be useful to ensure that each community has local centres or forums where the benefits of healthy eating and exercise are discussed with all ages, within the context of the area. In the case of Bangladesh for example, in a rural village the benefits of freshly harvested produce and/or cattle and dairy products can be emphasised. Whereas in an urban setting, the importance of more home-cooked meals with produce from grocery stores or markets as opposed to fast food should be highlighted.  Likewise for exercise, the often labour-intensive work of those in rural villages should account for a lot of their physical activity, alongside leisure such as pond swimming or fishing. In urban settings, the use of gyms or walking to work rather than using transport would be initiatives to boost. These examples are not exhaustive, and more work needs to be done to tailor the advice and interventions to each individual within a community, given their socio-economic background and so resources available to them. Hopefully, with the introduction of such frameworks as part of the healthcare system in LMICs such as Bangladesh, the ability to combat the rise in NCDs and their impact on LMICs will improve.

References

AKIL, L. & AHMAD, H. A. 2011. Relationships between obesity and cardiovascular diseases in four southern states and Colorado. J Health Care Poor Underserved, 22(4 Suppl), pp. 61-72.

DAMM, P., HOUSHMAND-OEREGAARD, A., KELSTRUP, L., LAUENBORG, J., MATHIESEN, E. R. & CLAUSEN, T. D. 2016. Gestational diabetes mellitus and long-term consequences for mother and offspring: a view from Denmark. Diabetologia, 59(7), pp. 1396-1399.

FOWDEN, A. L., GIUSSANI, D. A. & FORHEAD, A. J. 2006. Intrauterine Programming of Physiological Systems: Causes and Consequences. Physiology, 21, pp. 29-37.

GAZIANO, J. M. 2010. Fifth phase of the epidemiologic transition: the age of obesity and inactivity. JAMA, 303(3), pp. 275-6.

HU, F. B., MANSON, J. E., STAMPFER, M. J., COLDITZ, G., LIU, S., SOLOMON, C. G. & WILLETT, W. C. 2001. DIET, LIFESTYLE, AND THE RISK OF TYPE 2 DIABETES MELLITUS IN WOMEN. NEJM, 345(11), pp. 790-797.

HUSSEIN, J. 2017. Non-communicable diseases during pregnancy in low and middle income countries. Obstet Med,10(1), pp. 26-29.

KAPUR, A. 2015. Links between maternal health and NCDs. Best Pract Res Clin Obstet Gynaecol, 29(1), pp. 32-42.

KHATUN, F., RASHEED, S., MORAN, A. C., ALAM, A. M., SHOMIK, M. S., SULTANA, M., CHOUDHURY, N., IQBAL, M. & BHUIYA, A. 2012. Causes of neonatal and maternal deaths in Dhaka slums: implications for service delivery. BMC Public Health, 12pp. 84.

LIBURD, L. C., JACK, L., JR., WILLIAMS, S. & TUCKER, P. 2005. Intervening on the social determinants of cardiovascular disease and diabetes. Am J Prev Med, 29(5 Suppl 1), pp. 18-24.

MARMOT, M. 2010. Fair Society, Healthy Lives. The Marmot Review. Strategic Review of Health Inequalities in England Post 2010, London.

OMRAN, A. R. 2005. The Epidemiologic Transition: A Theory of the Epidemiology of Population Change. The Milbank Quaterly, 83(4), pp. 731-757.

ROY, A. & SHENGELIA, L. 2016. An Analysis on Maternal Healthcare Situation in Bangladesh: A Review. Diversity and Equality in Health and Care, 13(5), pp. 360-364.

SONG, C., LYU, Y., LI, C., LIU, P., LI, J., MA, R. C. & YANG, X. 2018. Long-term risk of diabetes in women at varying durations after gestational diabetes: a systematic review and meta-analysis with more than 2 million women. Obes Rev, 19(3), pp. 421-429.

SOUZA, J. P., TUNCALP, O., VOGEL, J. P., BOHREN, M., WIDMER, M., OLADAPO, O. T., SAY, L., GULMEZOGLU, A. M. & TEMMERMAN, M. 2014. Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG,121 Suppl 1pp. 1-4.

  1. 2015a. The 17 Goals [online]. Available from: https://sdgs.un.org/goals [Accessed Tue 20 Apr 2021].
  2. 2015b. We can end poverty Millenium Development Goals and Beyone 2015 [online]. Available from: https://www.un.org/millenniumgoals/ [Accessed Tue 20 Apr 2021].

WALKER, R. J., STROM WILLIAMS, J. & EGEDE, L. E. 2016. Influence of Race, Ethnicity and Social Determinants of Health on Diabetes Outcomes. Am J Med Sci, 351(4), pp. 366-73.

WHO. 2018. Bangladesh | World Health Orgainization – Noncommunicable Diseases (NCD) Country Profiles.

WHO. 2021. Noncommunicable diseases [online]. WHO. Available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases [Accessed Tue 20 Apr 2021].

ZHENG, Y., LEY, S. H. & HU, F. B. 2018. Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nat Rev Endocrinol, 14(2), pp. 88-98.

 

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