Published as part of a series on PMNCH.
In sub-Saharan Africa each day, 550 women and 2,800 newborns die from preventable complications related to pregnancy, childbirth, and other causes. An additional 2,900 women experience a stillbirth. Childbirth is the riskiest time for women and their babies, and diabetes is one of the most important risk factors for complications. The theme of World Health Day this year is “Beat Diabetes.” As the global community unites to increase awareness about the shocking rise in diabetes, we must not overlook the staggering burden and consequences of diabetes for pregnant women and their babies.
The scale of the impact of diabetes should not be underestimated. Globally, approximately 1 in 7 live births are affected by diabetes, mostly gestational diabetes. The numbers are steadily rising, and countries with higher numbers of births have correspondingly more women with gestational diabetes. For example, Nigeria has the third highest number of births and the third highest number of women with diabetes, with over 711,000 cases identified in 2015.
The risks from unmanaged diabetes to both mother and baby are broad, complicated and potentially fatal. Women with unmanaged diabetes are at greater risk of developing pregnancy-induced hypertension, pre-eclampsia, antepartum hemorrhage, premature rupture of membrane, and cesarean delivery. For a baby, there is increased risk of being born large-for-gestational-age, congenital anomalies, and prematurity. The increased risk of an obstructed labor can result in death of the mother and the baby or birth injury for the infant. The risk of stillbirth is also much greater. A recent analysis from The Lancet Ending Preventable Stillbirth Series estimated that over 92,000 stillbirths are attributable to pre-existing maternal diabetes in sub-Saharan Africa.
The dangers are not confined to pregnancy and childbirth as gestational diabetes has long-term health impact. More than half of affected women and their babies are at higher risk of developing type 2 diabetes. Their babies will also have a higher likelihood of being overweight or obese.
It is therefore critical that mothers are diagnosed during pregnancy and that they have regular postpartum follow-up for identification and treatment of complications. Ideally, every pregnancy should be appropriately screened for diabetes as part of standard antenatal care practices; however this is not the case in many low and middle income countries where over 90% of cases occur. Evidence shows that well-trained and skilled midwives could deliver most sexual, reproductive, maternal and newborn health services, including working in collaboration with other health professionals to screen and manage women with diabetes.
Improving quality and equitable care during pregnancy and childbirth – including diagnosis and treatment for diabetes – will be essential to address in the new era of the Sustainable Development Goals and the Global Strategy for Women’s, Children’s, and Adolescents’ Health. In sub-Saharan Africa, newborn mortality has decreased by only 38% since 1990 – compared with 60% for children aged 1–59 months. If the present rate of decline continues, it will be over a century before an African newborn baby has the same survival probability as one born in Europe or North America. Estimated progress for stillbirth prevention is even bleaker – at the current rate, it will be over 160 years before the average pregnant woman in sub-Saharan Africa has the same chance of her baby being born alive as women in a high-income countries today.
The inequity in access to quality and affordable care in Africa requires deliberate efforts to accelerate action. Governments and global partners have taken concrete action in recent years by developing strategies for improving maternal and newborn health, including most notably Every Newborn: an action plan for ending preventable deaths launched in 2014 and endorsed at the World Health Assembly, and Strategies for Ending Preventable Maternal Mortality launched in 2015. These strategies outline key actions needed to end preventable maternal and newborn mortality and stillbirths within a generation.
Many countries have taken forward the call to action and have developed newborn-specific action plans or sharpened RMNCAH national health strategies to align with the global recommendations including actions to increase the health work force. Since 2014, more than 50 new commitments for newborn health have been made towards Every Woman Every Child, a movement that puts into action the Global Strategy for Women’s, Children’s, and Adolescents’ Health, as well as establishes initiatives and partnerships to support delivery on these commitments.
To ensure the provision of quality antenatal care for all women and care at childbirth for all women and babies, the World Health Organization has developed a set of quality-of-care standards that recognise the broad range of health systems factors required to support reliable implementation of evidence-based care. They are now preparing implementation guidance – providing countries with a roadmap for implementation and scale up of quality care.
The evidence for action is overwhelming. If high-quality care is received during pregnancy and childbirth, the result would yield a quadruple return on investment by preventing maternal and newborn deaths and stillbirths, plus improving child development and other health outcomes, such as a reduced risk of diabetes later in life. To beat diabetes and its array of related complications, we have to start by improving care during pregnancy and at childbirth. Only then will we ensure a healthy start for every mother, every newborn, everywhere.