The Dubai Declaration on Hyperglycemia in Pregnancy

The Preamble:

Whereas

  • The Middle East Region has significantly reduced its maternal mortality ratio (MMR), from 130 in 1990 to 74 per 100,000 live births in 2013, marking a 43% decline. Maternal death, a largely preventable tragedy, continues to be a challenge in some countries in the region, particularly in Yemen, Iraq, Jordan, Palestine, and Syrian Arab Republic.
  • Hemorrhage, hypertension, sepsis and obstructed labor directly account for a large number of these deaths, however a significant proportion of these deaths are also due to indirect causes.
  • Maternal deaths due to medical conditions that are exacerbated by pregnancy (such as obesity, diabetes, hypertension etc.) now account for over 28% of maternal deaths globally. Because of targeted interventions to address direct maternal deaths some countries in Middle East, as in Europe, are witnessing a proportional increase in maternal deaths due to indirect causes. To further reduce maternal mortality efforts will have to be made to address indirect causes.
  • Overweight and obesity is a huge problem among reproductive age women in the Middle East. It is estimated that 85% of women between 20 and 49 years of age are either overweight (57.2%) or obese (27.7%). The problem is particularly acute in the Gulf Co-operation Council (GCC) states. At the same time 10·9% live births in the region are low birth weight (LBW) and 21.7% are small for gestational age (SGA). A significant proportion of LBWs and SGAs in the region are contributed by Yemen, Palestine, and Iraq. Older maternal age and multiparity is also frequent in the Middle East region.
  • Diabetes mellitus is escalating worldwide and the rise is particularly alarming in the Middle East Region. The estimated age adjusted prevalence of diabetes in countries in the Middle East ranges from 5.4% in Yemen to 17.7% in Saudi Arabia. Diabetes already affects over 15 million people in the region and is projected to almost double by 2045. The age adjusted prevalence of diabetes among women in the GCC states ranges between 13% and 19%. There is an equally high burden of pre-diabetes.
  • The age of onset for diabetes and prediabetes is declining and it now increasingly affects people in the reproductive age. People with diabetes or prediabetes, particularly the young and women are often unaware of their condition as they have never been tested before.
  • Hyperglycemia in pregnancy (HIP) is one of the most common medical conditions affecting women during pregnancy. According to the International Diabetes Federation, the age adjusted prevalence of HIP in the Middle East and North Africa region is estimated to be 17.7%. Studies from the GCC states show rates of HIP as high as 35 %.
  • Majority of women with HIP have gestational diabetes (GDM), which develops due to hormonal changes of pregnancy and is confined to the duration of pregnancy
  • Studies from Middle East describe high rates of pregnancy complications in women with hyperglycemia. Hyperglycemia during pregnancy significantly increases risk of pregnancy complications- hypertension, obstructed labor, postpartum hemorrhage, infections, still births, premature delivery, newborn deaths due to respiratory problems, hypoglycemia and birth injuries
  • Risk factors such as overweight and obesity, family history of diabetes, multiparity and increasing maternal age increase the risk for HIP. These risks alone or in combination are almost ubiquitous in the Middle East region, supporting the argument for universal testing of all pregnant women for HIP.
  • Despite the high risk and increased threat, awareness about HIP and its consequences among pregnant women as well as care providers is relatively low in the region.
  • There are no clear cut strategies for testing women for hyperglycemia during pregnancy and diverse ad hoc approaches are in vogue. When protocols and strategies exist they are poorly understood and implemented.
  • Without preventive care, almost half of women with GDM develop type 2 diabetes and a significant proportion develop premature cardiovascular disease, within 10 years of childbirth
  • Children born to women with GDM are at very high risk of obesity, early onset type 2 diabetes and cardiovascular disease, whereby, HIP perpetuates the risk of diabetes into the next generation
  • Addressing HIP helps lower maternal and newborn morbidity and mortality by lowering the risk of pregnancy complications and provides an opportunity to break the chain of intergenerational transmission of diabetes, cardiovascular diseases and metabolic problems.
  • Most women diagnosed with GDM can be adequately managed through proper monitoring and practical nutrition and lifestyle counselling, some may require medical treatment and referral to specialist care.
  • Providing preventive lifestyle care to women post GDM pregnancy reduces risk of future diabetes and cardiovascular disease.
  • Improving preconception counselling of young women and couples of reproductive age, including health evaluation and lifestyle counselling such as practical advice on nutrition and exercise, birth spacing etc., helps prevent pregnancy complications and expensive interventions later on; as well as helps reduce the future risk of developing obesity, type 2 diabetes, and cardiovascular diseases.
  • Focusing attention on HIP is a sustainable and cost effective way of addressing the double disease burden of high maternal and newborn morbidity and mortality and rising rates of obesity, diabetes and cardiovascular diseases; providing an opportunity for addressing two important components of the sustainable development goal 3 (maternal and newborn health and NCDs) with one comprehensive intervention.
  • The United Nations Secretary General in his report on the Prevention and control of non-communicable diseases to the UN General Assembly on 19th May 2011 noted that "the rising prevalence of high blood pressure, diabetes and gestational diabetes is increasing adverse outcomes in pregnancy and maternal health. Improving maternal health and nutrition plays an important role in reducing the future development of such diseases in offspring"
  • The Political Declaration of the High-level Meeting of the UN General Assembly on the Prevention and Control of Non-communicable Diseases held in New York on 19th September 2011

Notes with concern that maternal and child health is inextricably linked with non-communicable diseases and their risk factors, specifically such as prenatal malnutrition and low birth weight create a predisposition to obesity, high blood pressure, heart disease and diabetes later in life, and that pregnancy conditions, such as maternal obesity and gestational diabetes, are associated with similar risks in both the mother and her offspring

Advocates for the inclusion of non-communicable disease prevention and control within sexual and reproductive health and maternal and child health programs, especially at the primary health-care level, as well as other programs, as appropriate, and also integrate interventions in these areas into non-communicable disease prevention programs

We, the undersigned, leaders and representatives of professional medical organizations, public health agencies, research and academic institutions, governments, affected communities, civil society and private industry, living and working in the Middle East Region,

Hereby Declare

  • That the high rates of diabetes, prediabetes and obesity in the Middle Eastare both a contributor to and consequence of HIP and therefore HIP has become a significant public health challenge impacting maternal, newborn and child health and the future burden of type 2 diabetes and cardio metabolic disorders in our region.
  • That until and unless urgent action is taken to systematically address the issue, it has the potential to undo the gains in maternal and newborn health achieved over the past decade and worsen the ongoing diabetes and NCD epidemic.
  • That focusing on HIP provides a unique opportunity to integrate services, to lower traditional maternal and perinatal morbidity and mortality indicators and address transgenerational prevention of NCDs such as diabetes, hypertension, cardiovascular diseases and stroke.
  • That we resolve to address the twin challenges posed by the rising rates of HIP and inadequate maternal care service, and through our concerted action convert them into opportunities for improved future population health in the region. And to this effect,

We, Hereby Agree

  • To undertake actions in our various capacities to support efforts to address the link between maternal health and diabetes as a public health priority
  • To accelerate the implementation of the FIGO GDM initiative. (http://www.ijgo.org/issue/S0020-7292(15)X0015-4) in the Middle East Region, including by pursuing supportive policy actions and mobilizing resources for its implementation.
  • To seek to adopt and implement the FIGO Adolescent, Preconception and Maternal Nutrition recommendations in the Middle East where applicable, in order to address the nutritional needs of girls and women in order to both prevent and manage current or future complications.
  • To adopt the life course approach- considering perinatal health within the context of women’s overall health and placing a particular emphasis on adolescent and preconception nutrition as well as maternal and postpartum health. http://obgyn.onlinelibrary.wiley.com/hub/issue/10.1002/ijgo.2015.131.is…)
  • To support efforts to increase public awareness about HIP and its impact on maternal and child health, encourage preconception counselling, antenatal care and post-natal follow up.
  • To promote and celebrate a National Hyperglycemia in Pregnancy Awareness Day in our respective countries and the region, as an instrument to bring public attention and raise awareness.
  • To develop, support and carry out research to more clearly define the burden and to develop and scale up implementation of contextually relevant protocols to improve testing, diagnosis, monitoring and management of HIP; as well as, the ability to engage, counsel and track the mother-child pair over the long term and improve collaboration and efficacy in existing programs, keeping in mind the health care delivery realities of countries in the region.
  • To advocate for access to uninterrupted diagnostic supplies, medications and trained manpower for diagnosis and appropriate management for HIP at all levels of care at affordable costs keeping the pregnant women's convenience in mind.
  • To ensure all pregnant women attending health facilities in the region are tested for hyperglycemia using a single-step procedure by offering simple, cost effective, feasible and timely diagnostic tests as advocated by FIGO, keeping in mind the constraints in resources, accessibility to care and other barriers in our individual countries.
  • To support and encourage task shifting, role based training to build capacity for prevention, early diagnosis, and treatment of HIP and continued engagement with the high risk mother child pair over a prolonged time period.

  • To make all efforts to support post-partum follow up and engagement of the high risk mother child pair post-GDM pregnancy, linked to the child's vaccination program, by engaging and collaborating with other health care professionals.

Resources

The International Federation of Gynaecology and Obstetrics (FIGO) Initiative on Gestational Diabetes Mellitus: A Pragmatic Guide for Diagnosis, Management, and Care. International Journal of Gynaecology and Obstetrics 131 S3 (2015) S173–S211

Hanson MA, Bardsley A, De-Regil LM, Moore SE, Oken E, Poston L, Ma RC, McAuliffe FM, Maleta K, Purandare CN, Yajnik CS, Rushwan H, Morris JL. The International Federation of Gynecology and Obstetrics (FIGO) recommendations on adolescent, preconception, and maternal nutrition: “Think Nutrition First”. Int J Gynaecol Obstet. 2015 Oct;131 Suppl 4:S213-53.

International Diabetes Federation IDF Diabetes Atlas 7th Edition http://www.diabetesatlas.org/

Report by the Secretary-General on the prevention and control of non-communicable diseases (A/66/83) http://www.ghd-net.org/sites/default/files/UN%20SecretaryGeneral's%20Report%20on%20NCDs.pdf

General Assembly Resolution on Prevention and control of non-communicable diseases (A/RES/64/265) http://www.un.org/en/ga/president/65/issues/A-RES-65-238.pdf

Levels & Trends in Child Mortality Report 2015 - Estimates Developed by the UN Interagency Group for Child Mortality Estimation https://www.unicef.org/publications/files/Child_Mortality_Report_2015_Web_9_Sept_15.pdf

Trends in Maternal Mortality: 1990 to 2013 - Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality2013/en/

Global Health Observatory Data. Maternal mortality country profiles. http://www.who.int/gho/maternal_health/countries/en/

Maternal newborn & child survival. The 2015 Report- A Decade of Tracking Progress for Maternal, Newborn and Child Survival.   

World Health Organisation (WHO), Global status report on noncommunicable diseases 2014. Available at: http://apps.who.int/iris/bitstream/10665/148114/1/9789241564854_eng.pdf?ua=1

Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell R, Uauy R, and the Maternal and Child Nutrition Study Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet , 2013; 382 , Issue 9890 , 427 – 451. http://dx.doi.org/10.1016/S0140-6736(13)60937-X

Alshaikh MK, Filippidis FT, Al-Omar HA, Rawaf S, Majeed A, Salmasi AM.The ticking time bomb in lifestyle-related diseases among women in the Gulf Cooperation Council countries; review of systematic reviews. BMC Public Health. 2017 Jun 2;17(1):536. doi: 10.1186/s12889-017-4331-7.

Wahabi H, Fayed A, Esmaeil S, Mamdouh H, Kotb R. Prevalence and Complications of Pregestational and Gestational Diabetes in Saudi Women: Analysis from Riyadh Mother and Baby Cohort Study (RAHMA). Biomed Res Int. 2017;2017: 6878263. doi: 10.1155/2017/6878263

Al-Rubeaan K, Al-Manaa HA, Khoja TA, Ahmad NA, Al-Sharqawi AH, Siddiqui K, Alnaqeb D, Aburisheh KH, Youssef AM, Al-Batel A, Alotaibi MS, Al-Gamdi AA. Epidemiology of abnormal glucose metabolism in a country facing its epidemic: SAUDIDM study. J.Diabetes. 2015 Sep;7(5):622-32. doi: 10.1111/1753-0407.12224. Epub 2014 Dec 1.