Integrating non-communicable disease prevention and control into maternal and child health programmes
BMJ 2023; 381 doi: https://doi.org/10.1136/bmj-2022-071072 (Published 23 May 2023) Cite this as: BMJ 2023;381:e071072Read the full collection
- Suzanne M Simkovich, assistant professor12,
- Megan E Foeller, maternal-fetal health specialist3,
- Özge Tunçalp, scientist4,
- Aris Papageorghiou, professor5,
- William Checkley, professor67
- 1Division of Healthcare Delivery Research, MedStar Health Research Institute, Hyattsville, USA
- 2Division of Pulmonary and Critical Care Medicine, Georgetown University, Washington USA
- 3Department of Obstetrics and Gynaecology, St Alphonsus Regional Medical Center, Boise, USA
- 4UNDP, UNFPA, Unicef, WHO, World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
- 5Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
- 6Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- 7Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, USA
- Correspondence to: W Checkley wcheckl1{at}jhmi.edu
The importance of maternal and child health has long been recognised, and it was made a global priority in the United Nations millennium development goals in 2000.1 Despite progress, reductions in morbidity and mortality have fallen short of established goals. One major gap is the burden of non-communicable diseases (NCDs),23 which are responsible for 19 million deaths in women worldwide each year.4 Traditionally, interventions targeting NCDs in women of reproductive age have been geared around child bearing. Unfortunately, waiting to prevent and treat these diseases until the preconception period is not enough. The harmful effects of NCDs in women of reproductive age can start before pregnancy and, in turn, affect the fetus during gestation.
NCDs in pregnancy are associated with long term complications to the mother and offspring.56789 However, robust efforts to prevent the development of diseases before pregnancy have fallen short.356789 As resources are limited, particularly in low and middle income countries, diseases with a high burden should be prioritised initially. The World Health Organization has identified interventions to prevent hyperglycaemia and hypertension in women as best buys,210 and we suggest these should be the initial priority in prevention of NCDs.
The harms of hyperglycaemia and hypertension in women of reproductive age are well established (box 1). Cost effective and equitable interventions to prevent these conditions are available,1031 but their implementation and uptake has not been fully realised. One reason for this may be that the design of the interventions does not consider the needs and preferences of women of reproductive age.3233 In addition, implementation methods fail to consider the rapidly evolving nuances of individual contexts, especially with regard to use of technology in resource limited settings and the available infrastructure.3233 For example, many of the newly developed interventions such as using artificial intelligence guidance on insulin dosing in diabetes, use mobile devices along with open sourced data and have proved difficult to implement in low and middle income countries for multiple reasons such as lack of linguistic diversity and experience with technology among end users.33 Furthermore, the systems and infrastructure to support these technologies are evolving, and policy and regulation have not necessarily kept pace with these changes.3334
Effects of hypertension and hyperglycaemia on maternal, newborn, and infant health
Hypertension
Hypertension is the leading modifiable risk factor for cardiovascular disease, affecting 32% of women aged 30-79 years worldwide.11 Hypertension can develop from childhood as a result of exposure to risk factors such as secondhand smoke, obesity, and sedentary behaviour.12
The use of oral contraceptives may increase the risk of hypertension, particularly in young women, and these risks and benefits must be carefully balanced.7 Raised blood pressure in women of reproductive age is associated with earlier development of a cardiovascular event, such as stroke, heart attack, or heart failure, later in life.13
Hypertensive disorders of pregnancy including pre-eclampsia, gestational hypertension, chronic hypertension, and chronic hypertension with superimposed pre-eclampsia complicate about 5-10% of pregnancies and are implicated in over 50 000 maternal deaths annually.1415 Related complications include placental abruption, eclampsia, fetal growth restriction, and increased risk of a caesarean delivery.16
Over the long term, hypertension in pregnancy is associated with immune, hormonal, and vascular changes that result in an increased risk of cardiovascular complications, including ischaemic heart disease, myocardial infarction, and end stage kidney disease.1718 For every 13 mm Hg increase in systolic blood pressure in early and late pregnancy, the risk of cardiovascular mortality increases by 20% and 14% respectively over the woman’s lifespan.19
In addition to maternal risks, hypertensive disease of pregnancy is a major contributor to prematurity and related sequalae.2021 Hypertension during pregnancy is associated with a 26% increased all-cause mortality in offspring compared with those not exposed in utero and there is a strong link with fetal growth restriction.22 Preterm birth increases the risk of impaired respiratory and sensory development, feeding difficulties, and longer term developmental delay among other complications.23 Fetal growth restriction is associated with poor childhood growth, impaired neurodevelopment and an increased susceptibility to adult onset diseases.6 One recent study of a large longitudinal cohort of offspring exposed to maternal hypertension showed a higher risk of mortality starting in early adulthood.22
Hyperglycaemia
Hyperglycaemia caused by type 1 or 2 diabetes or impaired glucose tolerance occurs in 8% of women globally and increases the overall risk of premature death throughout the lifespan.24 There has been a rapid rise in type 2 diabetes because of a higher prevalence of obesity and lack of physical activity.24 Women with diabetes have a 44% increased risk of coronary artery disease, and a 27% increased risk of stroke in addition to strong associations with peripheral artery disease, angina, and dementia.2526
Hyperglycaemia in pregnancy is estimated to affect 17% of live births.27 Death rates in pregnant women with type 1 diabetes are three times higher than those in pregnant women without diabetes.28 During pregnancy, hyperglycaemia increases the risk of caesarean birth and pre-eclampsia.29 Over the longer term, women who have gestational diabetes have a 16-67% risk of developing type 2 diabetes by age 80.30
Hyperglycaemia in pregnancy can increase the risk of macrosomia, shoulder dystocia, birth injury, caesarean delivery, prematurity, neonatal hyperbilirubinaemia, and perinatal mortality.9 Children born to mothers with hyperglycaemia in pregnancy are at increased risk of developing obesity, dysglycaemia, dyslipidaemia, and metabolic syndrome in later life.9 With concurrent in utero exposure to hypertension and hyperglycaemia, offspring have a 57% higher all-cause mortality than those exposed only to hypertension.22
One way to increase uptake of interventions is to integrate human centred design strategies into the implementation process. Human centred design has been used successfully in healthcare organisations to change processes and introduce technology to improve health outcomes.35 However, it has not been widely used in low and middle income countries or included in implementation frameworks.36 Use of open sourced data could also help increase use of preventive interventions for NCDs in young women. This will require training researchers and building capacity in implementation science and data science.
Use of implementation science to target research
Human centred design strategies were originally established in software development with the premise that design of a product or service should focus on the end user. It evaluates people’s interactions with their environment and their efficiency in undertaking tasks,35 attempting to understand what affects people’s choices so that interventions can be adapted to increase uptake. The methods have been effective in healthcare, especially in evaluating the safety and integration of technological interventions.33 Despite the potential benefits, use of human centred design to improve health outcomes is still in its early stages and remains underused in the global public health landscape.34
Use of technology in disease prevention is rapidly growing as infrastructure for mobile devices is expanding, highlighting the need for successful implementation strategies.37 The use of mobile technology in healthcare delivery has been shown to improve clinical outcomes and quality of life in high and low income settings.38 Effective technology based interventions for preventing hypertension and hyperglycaemia include SMS messaging to prompt patients to take their medication, use of artificial intelligence to guide insulin dosing based on reported blood glucose levels, and lifestyle modifying applications that provide dietary recommendations and track physical activity.3839
Although mobile technology interventions for hyperglycaemia are promising, good uptake depends on them meeting the needs and preferences of women of reproductive age, who are the end users. The next step should be developing implementation packages incorporating standardised definitions, frameworks, and human centred design strategies to adapt interventions to enhance health outcomes.3536 These can then be used to tailor and implement interventions to reduce hypertension and hyperglycaemia in women of reproductive age.
Potential of open source databases
Open source data refers to structured data that are freely available online in a format that allows users to re-use, share, and combine with other data. Large databases have traditionally been used in public health for disease surveillance, but there is tremendous promise to analyse them to develop early pattern recognition, refine population specific guidance to deliver precision medical care, build artificial intelligence algorithms to modify care plans, and optimise ergonomics of care delivery. Large datasets are increasingly becoming open source, partly because study funders are requiring data from research studies to be made publicly available. The use of open source data to guide preventive strategies is rapidly evolving, and research efforts to expand this area should be supported.
Open source data are already being used in preventive care to provide personalised management strategies—for example, open sourced automated insulin delivery technologies were used to develop and inform algorithms to guide users of insulin pens and pumps on dosing.394041 A trial in 97 children and adults with type 1 diabetes found that those randomised to open sourced automated insulin delivery systems had glucose levels within target more often than those using an automated sensor augmented insulin pump.42
Non-clinical open source data such as geographical information systems (GIS) also have potential to optimise preventive care (box 2). Open sourced maps and population overlays have been used to identify where to locate resources to reach the greatest population. Such information is particularly valuable in low and middle income countries, as maps may not always be accurate and may not account for smaller roads and inaccessible terrain.
Example of use of geographical information systems for healthcare delivery
We evaluated the accessibility of resources to diagnose and treat severe pneumonia in children using a geographical information system (GIS) and found that only 43-69% of the population lived within 30 minutes’ travel time of a health facility equipped to care for severe pneumonia in selected rural areas in Guatemala, India, Peru, and Rwanda.43 Use of GIS to identify locations for setting up pulse oximetry shortened travel time by 18 minutes across sites.43
Similar strategies could be implemented to position resources for the management of hypertension and hyperglycaemia. The US Centers for Disease Control and Prevention has set up the chronic disease GIS exchange with resources to support GIS use for chronic disease management.44 For example, Hawaii Primary Care Association, the Hawaii Public Health Institute, and the Hawaii State Department of Health used GIS mapping to identify new locations in remote communities with a high prevalence of high blood pressure to increase access to healthy foods (personal communication).
RETURN TO TEXTThe use of open sourced data for the prevention of hypertension and hyperglycaemia is just beginning, and initial solutions using this technology have shown promise. However, availability of open source data from proprietary sources is set to increase, and determining the optimal way to use these sources should be a priority. Regulation and policy around the safe and ethical use of data in open sourced databases will be essential to ensure protection of privacy while sharing data freely.
Training the next generation
Research to strengthen strategies for implementation and care delivery clearly needs prioritisation. This is challenging as implementation science has not been part of training for many researchers. Understanding of the psychological principles of human centred design is important to determine how to structure evaluations and implementation.3545 Furthermore, training in informatics is also necessary to optimise care and care delivery using open source data.
Intensive educational programmes in implementation are being designed and supported by funders, such as the Global Alliance for Chronic Diseases. However, more efforts are needed, particularly related to NCDs.46 Global programmes for standardisation of open sourced data include the observational health data sciences and informatics programme, which brings together global researchers in academia, industry, and government. Research training programmes in low and middle income countries are also on the horizon, such as the Irish non-governmental online education provider iHeed, the World Health Organization Academy, and TDR’s massive open online course on implementation.4748
Greater awareness of implementation research methods, in particular human centred design and novel informatics, need to be brought to the forefront so that implementation assessments go beyond academia and are more likely to produce real life impact. Successful development and use of implementation strategies and frameworks occurs through partnerships between researchers, implementers, and policy makers with a common goal of strengthening health by prioritising people, processes, and technologies.49
There is still much work to be done to close the gap in preventable morbidity and mortality in women and children from hypertension and hyperglycaemia. A multifaceted approach that uses technology, integrates human centred design strategies, and builds local capacity is necessary to bring interventions from bench to bedside and combat the growing burden of NCDs in women and children worldwide.
Key messages
Effective strategies to prevent hypertension and hyperglycaemia in young women are not universally implemented or used
Using human centred design strategies as a part of the implementation process for interventions can accommodate the needs of end users and incorporate rapidly changing technology
Open sourced data should be used to optimise healthcare delivery and identify patient care needs
Strengthening training programmes and capacity building in implementation science, human centred design, and data science are critical to move research from bench to bedside
Footnotes
Contributors and sources:SMS is a physician scientist who focuses on developing and implementing interventions to improve health of communities in low and high resource settings. MF is a maternal-fetal medicine specialist with experience in implementation science in the global context, particularly during pregnancy and the postpartum period. OT is a physician and epidemiologist with expertise on maternal and perinatal health, managing WHO’s research and guideline portfolio for antenatal and maternal care. WC is a physician scientist who has led multiple trials of interventions directed at mitigating non-communicable diseases in low and middle income countries. AP is a maternal fetal medicine specialist who has led research projects focused on maternal, fetal, and perinatal health with a specific interest in the use of artificial intelligence in pregnancy imaging and screening. WC has focused his studies on the development of interventions from conception through later ages. All authors contributed to drafting this manuscript, with SMS taking the lead role of writing the manuscript, and all authors providing intellectual input to improve the manuscript, as well as reading and approving the final version. WC is the guarantor.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is part of a series commissioned by The BMJ based on a proposal from the World Health Organization. The BMJ retained full editorial control over external peer review, editing, and publication. WHO paid the open access fees.
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