At the end of 2018, the International Federation of Gynaecology and Obstetrics (FIGO) signed the FIGO Global Declaration on Hyperglycemia (high blood sugar) in Pregnancy (HIP). The declaration was a culmination of two years work in order to send a clear message to the world that urgent attention and action is required in order to tackle one of the most common medical conditions seen during pregnancy. And unfortunately, it is on the rise.
The rise in HIP (and its end result – diabetes) is not a first world problem. Although obesity in the western world contributes to rising HIP rates, HIP rates are climbing globally. Women themselves who were born with a low birth weight or who were stunted, as seen in the global south, also have a higher risk of HIP despite having a normal BMI. Eight low and middle income countries account for more than half of the global disease burden. HIP places additional stress on health systems in these countries through increased demand and greater economic costs. It is thought that costs associated with diabetes in pregnancy goes up to 37% from 23% compared to a woman without morbidity.
1 in 6 women around the world have some form of HIP, which can lead to diabetes in pregnancy. This has poor outcomes for both mother and child, including raised blood pressure, large and small for gestational age babies, obstructed labor, postpartum haemorrhage, birth injuries, fetal defects (particularly to the heart), still birth and neonatal respiratory problems. In addition, gender amplifies the effect of diabetes on women’s health as it affects health seeking behavior. Women do not attend health facilities until they really need to, and by that time it is too late to prevent a condition that is extremely preventable.
It is vital that HIP is addressed as not only does it cause acute problems during pregnancy and in labor, long term health problems can develop in mother and newborn. Mothers are at greater risk of diabetes and cardiovascular disease later in life, and newborns are at risk of developing cardiovascular disease and metabolic problems in adulthood. Full blown diabetes is not a prerequisite for the acute adverse pregnancy outcomes stated above. There is now evidence to suggest that there is an association between adverse outcomes and maternal glucose within the nondiabetic range.
Pregnancy offers a unique opportunity to break the cycle, which is why FIGO calls for greater attention.
In addition to the Global Declaration, there needs to be greater innovation in this space to help prevent HIP and gestational diabetes. Various research and funding has been poured into the diabetes space to help non-pregnant diabetics monitor their diet and sugars better. However, a special focus is needed in pregnant women. The epidemiology we have around gestational diabetes is likely to be underestimated, and so there is a huge need. Stringent monitoring can be hugely beneficial to not only the mother and fetus, but also to the wider health system. For example, a gestational diabetes app (GDm-Health) devised in the UK which enabled pregnant women to track their blood glucose levels and stay in touch with their healthcare team, showed a reduction in caesarean sections and was cost saving. It also enabled focused care through prioritizing high risk women when triaged in the health system. The National Institute for Health and Care Excellence (NICE), the health technology assessment body in the UK has even appraised the app, showing novel system benefit through improved communication, reducing the workload for healthcare professionals, and reducing the number of outpatient appointments. Smartphone apps can help with monitoring during gestational diabetes. However, further innovation is required to focus on preventing diabetes and tackling HIP during early stages. Innovation in this area will not only to optimize the health of mothers and newborns, but can improve the health of future generations and efficiency of health systems.
Now as a next step, we ask what could be done to lower the costs of the implementation of the E-MOTIVE bundle? The most obvious answer is to consider displacing the tens of thousands of disposable plastic drapes with a purpose-built reusable device.
Fortunately one of the obstetricians involved in the E-MOTIVE study, Dr. Justus Hofmeyr, had been innovating around this very issue, designing a tray with wells that could fit under a woman’s buttocks, collect and accurately measure the. blood. This tray, theMaternaWellTraywas conceived as a device that could be sterilized and reused, and is manufactured in South Africa by Umoya.
The Pumani bubbleCPAP was designed to meet this need for Malawi and is now widely available through Maternova. We had a few questions about post-research phases of the Pumani bubbleCPAP which we posed to Jocelyn Brown, inventor of the Pumani bubbleCPAP, and Molly McCabe, Director of Product Management.