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Title: Diabetes mellitus and hypertension in pregnancy in low and middle income countries, and a case study of the health system in Jamaica
Author: Kanguru, Lovney
ISNI:       0000 0004 5366 7175
Awarding Body: University of Aberdeen
Current Institution: University of Aberdeen
Date of Award: 2015
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Background: Maternal mortality is a major public health problem worldwide, especially in low and middle-income countries (LMIC). The majority of these deaths are due to direct (obstetric) complications. However, almost one third of maternal deaths globally are caused by indirect (non-obstetric) causes, including non-communicable diseases (NCDs) such as diabetes mellitus (DM) and various forms of long-standing hypertension (excluding pre-eclampsia and eclampsia). Much is known about the contribution of the direct causes to overall levels of maternal deaths. However, less is known about the contribution of NCDs to maternal deaths and morbidity, yet these diseases are increasingly being observed in LMIC and among younger populations. Women of childbearing age are particularly vulnerable because of the effects these conditions may have on pregnancies and the unborn baby. Aim: This thesis aims to explore the existing situation of NCDs in pregnancy (DM and hypertension in particular) from a public health perspective and to identify how health systems in LMIC need to respond, so as to more effectively address the growing burden of NCDs. The case study of Jamaica is examined in depth. Rationale: In deciding which NCDs to focus on, consideration was given to the burden and its effect on pregnancy outcomes. The leading NCDs causing death worldwide in women are cardiovascular conditions. Among these conditions, hypertension was chosen because it is the most commonly occurring worldwide. DM was chosen because of its associated link with hypertension, and also because it is among the NCDs with high morbidity worldwide. The focus on Jamaica was because it is an upper middle-income transitioning country that is faced with the problem of NCDs. Jamaica is also among the few LMIC that reports on indirect causes of maternal deaths that includes NCDs. Method: Public health principles were used in this thesis, to: investigate the burden of DM and hypertension; understand related risk factors; and inform development of prevention strategies for addressing the problem. To assess the burden of disease in LMIC, two systematic reviews were conducted: studies 1a and 1b, investigating the epidemiology of DM and hypertension in pregnancy (up to one year post-delivery). Secondary data analyses of lifestyle and maternal mortality surveillance data were conducted to examine the burden of NCDs and their associated risk factors in further depth within the setting of Jamaica (study 2). Building up the case study of Jamaica, key informant interviews (study 3) were conducted to explore the existing health system organisation in relation to maternity care for NCDs and to propose options for the future. Key findings: The first systematic review found that the prevalence of gestational DM among pregnant women ranged from 0.4 to 24.3%. Up to 0.7% of pregnant women had pre-existing DM (types 1 and 2) in LMIC. Mortality and the prevalence of postpartum DM were scarcely reported. In the second systematic review, the prevalence of gestational hypertension ranged from 0.3 to 60% and that of chronic hypertension ranged from 0.2 to 24%. Prevalence of preeclampsia superimposed on chronic hypertension ranged from 0.1% to 20.6%, and that of unspecified hypertension was 4.1%. The percentage of maternal mortality due to gestational hypertension and chronic hypertension ranged from 2.5 to 5.5% and 1.0 to 4.6% respectively. Amongst the papers included in the review, studies reporting on prevalence were not always population-based and varying definitions of the conditions in pregnancy were used. The secondary data analyses revealed that 6.6% of women of reproductive age in Jamaica were diabetic, 24.1% were hypertensive and 62.8% were overweight or obese. Overweight or obesity was identified as a risk factor for DM and hypertension among women of reproductive age. Furthermore, being in employment and of high gravidity and parity were risk factors associated with hypertension and being overweight or obese. Of the maternal deaths examined, 2.0% were due to DM, 20.7% were due to hypertension and 7.9% were associated with overweight or obesity. The commonest comorbidities among women who died due to DM and hypertension were conditions that affected the circulatory or cardiovascular system such as subarachnoid haemorrhage and cardiomyopathies. Most of the overweight or obese women who had died suffered from obstetric complications, which were the underlying causes of their death. Among the three conditions, hypertensive women had the highest proportions of their babies dying undelivered and preterm live births, while diabetic women had the highest proportions of non-viable outcomes. Key informants from Jamaica provided insights as to how their health system is dealing with the growing burden of NCDs in pregnancy. The problem of NCDs in pregnancy is already being addressed in the island through the implementation of relevant policies targeting these conditions. This include policies that affect service delivery such as the introduction of special clinics for women with NCDs during pregnancy and after delivery, upgrading of some types of health facilities to perform obstetric services and the introduction of home visits. In addition, Jamaica introduced the national health fund to promote equity and access to essential medicines for NCDs and has also abolished user fees. The introduction of maternal-foetal medicine consultants to provide specialist inputs to women with NCDs in pregnancy has also been implemented. However, there were gaps in the health system in the care provided for NCDs in pregnancy which included; resource constraints (financial, health workforce and drugs and supplies), obstetrician inertia to change, lack of training of staff, referral and follow up constraints, poor multidisciplinary team approaches, deficiencies in the health management information system (HMIS) and lack of reward or encouragement for combating NCDs. Conclusion: The large variation in prevalence rates of DM and hypertension found in the systematic reviews may be a reflection of variations in geography or populations, case definitions, study approach and data quality. A comprehensive picture of the burden due to these conditions in pregnancy (and up to one year) in LMIC was not possible to obtain from the systematic reviews because of the sparseness of population-based data. Survey and surveillance data in Jamaica allowed further investigation on the epidemiology of NCDs in pregnancy and highlighted that a considerable burden exists, underscoring the necessity for a responsive health system to manage medical conditions in pregnancy. Although health systems interventions are already in place in Jamaica, challenges and gaps still remain. These could be addressed by learning lessons from other countries' approaches to organising care and by drawing from existing frameworks for delivery of care.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: Diabetes in pregnancy ; Hypertension in pregnancy ; Maternal health services