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 Table of Contents  
PERSPECTIVE
Year : 2020  |  Volume : 5  |  Issue : 2  |  Page : 96-98

Noncommunicable diseases and maternal health in face of the coronavirus disease 2019 response


1 Department of Epidemiology, University of Alabama at Birmingham, School of Public Health, Birmingham, Alabama, USA
2 Former Executive Director, WHO, New York, USA

Date of Submission25-May-2020
Date of Decision06-Jun-2020
Date of Acceptance11-Jun-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Dr. Jennifer Prince Kingsley
Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_29_20

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  Abstract 


Maternal health and Non-communicable Disease (NCD) are closely linked. NCDs in pregnancy lead to serious complications during pregnancy and delivery and in newborns. The management and treatment of pregnant women with NCDs have been compromised by the coronavirus disease 2019 (COVID-19) pandemic, which has brought to the forefront the deficiencies in the healthcare systems globally. Measures such as lockdowns, social distancing, and transportation restrictions impact maternal healthcare by disrupting access and continuity of care for NCDs and to preventive and health promotion services. In parallel, it negatively impacts the global progress made in decreasing the maternal and neonatal mortality rates (MMR and NMR) in the lower and middle-income countries. There is an urgent need to incorporate maternal health with a focus on high-risk pregnancies into the response measures for COVID-19 and in the planning of preparedness of future pandemics if the Sustainable Development Goals targets for MMR and NMR are to achieve by 2030.

Keywords: Coronavirus disease 2019, noncommunicable diseases, pregnancy


How to cite this article:
Kingsley JP, Sathiakumar N, Bolaji B, Kumaresan J. Noncommunicable diseases and maternal health in face of the coronavirus disease 2019 response. Int J Non-Commun Dis 2020;5:96-8

How to cite this URL:
Kingsley JP, Sathiakumar N, Bolaji B, Kumaresan J. Noncommunicable diseases and maternal health in face of the coronavirus disease 2019 response. Int J Non-Commun Dis [serial online] 2020 [cited 2020 Oct 26];5:96-8. Available from: https://www.ijncd.org/text.asp?2020/5/2/96/288250




  Pregnancy and Noncommunicable Diseases Top


Maternal mortality rate (MMR) is a general indicator of the overall development of a country and the strength of its health and infrastructure. The MMR in 2017 was 462/100,000 live births in low-income countries versus 11/100,000 live births in high-income countries reflecting the inequalities in access to quality health services and socioeconomic status in these countries.[1] The cause of maternal death in the perinatal period is moving from direct obstetric causes, such as postpartum hemorrhage, obstructed labor, and sepsis, to indirect causes, such as previous existing diseases or diseases developed during pregnancy, and is aggravated by the physiologic effects of pregnancy.[2] These indirect causes include noncommunicable diseases (NCDs) such as diabetes, hypertension, anemia, cancer, and obesity. Further, through the mechanism of intrauterine programming, the burden of NCDs during pregnancy is extended to an increased risk of NCDs in subsequent generations.[3] NCDs kill 35 million people each year with more than half (18 million) among women in their reproductive years. Having an NCD places the pregnant woman in the high-risk pregnancy category. Two NCDs that are typically screened and monitored during pregnancy are hyperglycemia in pregnancy (HIP) and hypertensive disorders of pregnancy (HDP).

HIP may be due to gestational diabetes mellitus (GDM) – a mild degree of hyperglycemia present only during pregnancy; or diabetes in pregnancy (DIP) – the more serious form (Type 1 or 2) persisting beyond the birth.[4] The global prevalence of GDM in women (20–49 years) was 16.9% or 21.4 million live births in 2013, with 16% of these cases estimated to be due to DIP; more than 90% of cases of GDM occurred in low- and middle-income countries (LMICs).[4] Mothers with HIP are at increased risk of preeclampsia, gestational hypertension, hydramnios, and cesarean section [5],[6] Adverse effects in infants include fetal macrosomia, hypoglycemia, and hyperinsulinemia at birth and shoulder dystocia associated with obstructed labor.[4] DIP carries additional risks of maternal mortality and of fetal malformations, fetal loss, and perinatal and neonatal mortality.[6] The mainstay of treatment for both GDM and DIP is insulin as it does not cross the placenta. Fasting and postprandial self-monitoring of blood glucose is recommended daily in both GDM and DIP to achieve optimal glucose levels. For those with no self-monitoring capabilities, poorly controlled hyperglycemia, or severe hyperglycemia, frequent monitoring and quality care at a hospital are mandatory.

HDP is categorized into pregnancy-induced hypertension (PIH) – after 20 weeks of gestation or in the first 24 h postpartum and with no proteinuria; preeclampsia – hypertension with proteinuria; and chronic or essential hypertension – preexisting hypertension with or without preeclampsia.[7] Based on the review of data from forty countries, the overall estimates for preeclampsia and eclampsia were 4.6% (95% uncertainty range, 2.7–8.2) and 1.4% (95% uncertainty range, 1.0–2.0), respectively.[8] Preeclampsia is the most serious form of HDP and, if untreated, results in eclampsia. The hemolysis, elevated liver enzymes, and low platelet count syndrome is the most serious complication, accounting for most maternal deaths associated with hypertension. Intrauterine growth retardation and premature delivery are major threats to the fetus. Women diagnosed with HDP require monitoring of the kidney and liver function from using blood samples and urinalysis for proteinuria. Fetal monitoring is conducted through ultrasonographic evaluation, nonstress test, and biophysical profile. Monitoring is done weekly in mothers with PIH and twice weekly in those with preeclampsia.

Pregnancies complicated with NCDs pose a high risk to mothers and newborns, due to the inherent biological risks.[9] High-risk pregnancies require more frequent monitoring and quality care for delivery and newborn care than normal pregnancies.


  Pregnancy, Noncommunicable Disease, and Coronavirus Disease 2019 Top


As per the Centers for Disease Control and Prevention, “Pregnant women experience immunologic and physiologic changes which might make them more susceptible to viral respiratory infections, including coronavirus disease 2019 (COVID-19).”[10] Although current data do not show that pregnant women are more likely to get COVID-19 infection than the general population, their vulnerability to COVID-19 cannot be ruled out. However, having an NCD will potentially increase their susceptibility; data from different countries reveal that people with underlying NCDs and/or an NCD risk factor such as obesity are extremely vulnerable to COVID-19, resulting in severe disease and death.[11],[12] The implications on pregnancies complicated by NCDs and COVID-19 infection will be evident as the pandemic evolves.


  Impact of Coronavirus Disease 2019 Response on Pregnant Women With Noncommunicable Disease Top


The COVID-19 pandemic and global response measures have exacerbated the inequalities within societies; those with very low to low socioeconomic status and women living in rural areas are affected the most.[13] Before the COVID-19 pandemic, quality and timely maternal healthcare services were unavailable or inaccessible to large proportions of populations in LMICs. The COVID-19 response has further compromised these services.

To meet the extreme demand of COVID-19 care, HICs adopted strategies such as canceling elective surgeries and other services deemed to be “nonessential” and switched to virtual care when and where feasible. Maternity and other wards have been reallotted to treat COVID-19 patients. In the LMICs with fewer resources and limited intensive care capacity, governments implemented and enforced rigorous national lockdowns including suspension of all public transportation to limit the spread of infection. Consequently, maternal health and other routine services were suspended with staff and equipment diverted to COVID-19 care. Disruptions in the supply chain limited the availability of essential medications. Lockdowns, economic loss, and transportation disrupted patient access to care. Constrained health services and access to care have resulted in delays in the screening, monitoring, and management of NCDs in pregnancy. Without proper management, NCDs increase the morbidity and avoidable maternal deaths.


  Merging High-Risk Pregnancy Care Into Coronavirus Disease 2019 Response Top


The United Nations Sustainable Development Goals (SDGs) target 3 for 2030 aims to reduce the global MMR to no more than 70 maternal deaths per 100,000 live births, with no country having an MMR >140/100,000 live births, and to reduce the neonatal mortality rate (NMR) to no more than 12 infant deaths per 1000 live births.[14] In 2019, SDG 3 along with the other SDG targets was found to be off track with 90% of maternal deaths occurring in LMICs.[15]

Failure to prioritize maternal health during the COVID-19 pandemic would reverse the gains made in MMR and NMR in the past. The economic losses due to COVID-19 will create additional setbacks for progress due to massive investments in dire recovery measures. Achieving the SDG target 3 will require continued investment in maternal health research and policy at the global level and very focused action at the country level.[16] Governments should guide national and local responses with specific strategies incorporating the unique needs of vulnerable and marginalized population subgroups. Some considerations include prioritizing maternal and neonatal care as “essential;” preventing diversion of staff and resources away from maternal health services; ensuring continuity in the supply of essential medications; eliminating barriers for access to care; and supporting NCDs patients, their families, and their caregivers. The management of NCDs in pregnant women is key in preserving the health of future generations. Hence, a well-formulated and well-executed plan for the prevention and control of NCDs in pregnancy is crucial in the ongoing pandemic and in preparedness for future public health threats. It will also contribute to the action plan for tackling the immense global burden of NCDs, similar in magnitude to the burden of COVID-19.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Trends in Maternal Mortality: 2000-2017 – Estimates by WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Fund. World Health Organization; 2017.  Back to cited text no. 1
    
2.
World Health Organization. The WHO Application of ICD-10 to Deaths during Pregnancy, Childbirth and Puerperium: ICD MM. World Health Organization Report. Geneva, Switzerland: World Health Organization; 2012.  Back to cited text no. 2
    
3.
Kapur A, Links Between Maternal Health and NCDs. Best Pract Res Clin Obstet Gynaecol 2015;29:32-42.  Back to cited text no. 3
    
4.
Guariguata L, Linnenkamp U, Beagley J, Whiting DR, Cho NH. Global estimates of the prevalence of hyperglycaemia in pregnancy. Diabetes Res Clin Pract 2014;103:176-85.  Back to cited text no. 4
    
5.
World Health Organization (WHO) recommendation on the diagnosis of gestational diabetes in pregnancy. Available from: https://extranet.who.int/rhl/topics/preconception-pregnancy-childbirth-and-postpartum-care/antenatal-care/who-recommendation-diagnosis-gestational-diabetes-pregnancy. [Last accessed on 2020 Mar 08].  Back to cited text no. 5
    
6.
Wang Z, Kanguru L, Hussein J, Fitzmaurice A, Ritchie K. Incidence of adverse outcomes associated with gestational diabetes mellitus in low- and middle-income countries. Int J Gynaecol Obstet 2013;121:14-9.  Back to cited text no. 6
    
7.
Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000;183:S1-22.  Back to cited text no. 7
    
8.
Abalos E, Cuesta C, Grosso AL, Chou D, Say L. Global and regional estimates of preeclampsia and eclampsia: A systematic review. Eur J Obstet Gynecol Reprod Biol 2013;170:1-7.  Back to cited text no. 8
    
9.
Hussein J. Non-communicable diseases during pregnancy in low and middle income countries. Obstet Med 2017;10:26-9.  Back to cited text no. 9
    
10.
Centers for Control and Prevention, Risk of COVID-19 during Pregnancy. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions. [Last cited on 2020 May 17].  Back to cited text no. 10
    
11.
World Health Organization. Information Note on COVID-19 and NCDs. World Health Organization; 2020. Available from: https://www.who.int/publications/m/item/covid-19-and-ncds. [Last cited on 2020 May 17].  Back to cited text no. 11
    
12.
Lighter J, Phillips M, Hochman S, Sterling S, Johnson D, Francois F, et al. Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission. Clin Infect Dis 2020. pii: ciaa415.  Back to cited text no. 12
    
13.
Bong CL, Brasher C, Chikumba E, McDougall R, Mellin-Olsen J, Enright A. The COVID-19 pandemic: Effects on low and middle-income countries. Anesth Analg 2020;131:86-92.  Back to cited text no. 13
    
14.
United Nations. Goal 3: Ensure Healthy Lives and Promote Well-Being for All at All Ages. Available from: http://www.un.org/sustainable development/health/. [Last cited on 2020 May 20].  Back to cited text no. 14
    
15.
16.
United Nations. The Sustainable Development Goals Report 2016. New York. Available from: http://unstats.un.org/sdgs/report/2016/The%20Sustainable%20Development%20Goals%20Report%202016.pdf. [Last cited on 2020 May 20].  Back to cited text no. 16
    




 

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