The Colombo Declaration On Hyperglycemia in Pregnancy - South Asia

The Preamble:

Whereas

South Asia significantly reduced its maternal mortality ratio (MMR), from 550 in 1990 to 190 per 100,000 live births in 2013, marking a decline of 65%; maternal deaths, a largely preventable tragedy, continue to be a challenge in South Asia, accounting for 24% of global maternal deaths
Hemorrhage, hypertension, sepsis and obstructed labor directly account for a large number of these deaths, a significant proportion of deaths are due to indirect causes. Some of the indirect causes such as hyperglycemia in pregnancy (HIP) also contribute to increasing the risk for the direct causes
With decline in direct maternal deaths because of targeted interventions, efforts to further reduce maternal mortality will have to be refocused on reduction of indirect causes
Diabetes mellitus is escalating worldwide; it already affects over 85 million people in South Asia and is projected to affect over 150 million people by 2040. There is an equally high burden of pre-diabetes - approximately 45 million are estimated to have pre- diabetes
Eight low and middle-income countries that account for over half the global live births, also contribute to more than half of the global diabetes burden; Bangladesh, India and Pakistan among them, also fare poorly on the issue of maternal and child health The Colombo Declaration On Hyperglycemia in Pregnancy - South Asia [2]
The age of onset for diabetes and prediabetes is declining, particularly in South Asia, and now affects many young people in the reproductive age
The majority of people with diabetes, particularly the young and women are unaware of their condition as they have never been tested
Hyperglycemia in pregnancy (HIP) is one of the most common medical condition affecting women during pregnancy - an estimated 25% of live births in South Asia are impacted by hyperglycemia during pregnancy
The 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
South Asian women are considered to have the greatest vulnerability for GDM, yet routine testing of all pregnant women for hyperglycemia is not done
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
Without preventive care, almost half of women with GDM develop type 2 diabetes and a significant proportion develops 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 has been shown to reduce risk of future diabetes and cardiovascular disease [3]
Modeling studies based on data from South Asia show that in the long term, investments made in testing, diagnosis and management of GDM and providing post-partum preventive care are highly cost-effective
Evidence shows that improving preconception counselling of young women of reproductive age and couples, including health evaluation and lifestyle counselling such as practical advice on nutrition and exercise, helps prevent pregnancy complications and expensive interventions later on, as well as help reduce the future risk of developing obesity, type 2 diabetes, and cardiovascular diseases
Focusing attention on GDM 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 [4]

We, the undersigned, as leaders and representatives of professional medical organizations, public health agencies and research institutions, governments, affected communities, civil society and private industry, living and working in South Asia,

Hereby Declare That

hyperglycemia in pregnancy is a significant public health challenge impacting maternal, newborn and child health and the future burden of type 2 diabetes and cardio metabolic disorders globally, but in particular, South Asia.

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 and worsen the ongoing diabetes epidemic.

That focusing on HIP provides a unique opportunity to integrate services, to lower traditional maternal and peri natal morbidity and mortality indicators and address inter-generational prevention of NCDs such as diabetes, hypertension, CVD and stroke

That we resolve to address the challenges posed by the rising rates of hyperglycemia in pregnancy and maternal care delivery and to convert them into opportunities for improved health of the future generation of South Asians

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 in South Asia, including by pursuing supportive policy actions and mobilizing resources for its implementation.

To support efforts to increase public awareness about hyperglycemia in pregnancy and its impact on maternal and child health, encourage preconception counselling, antenatal care and post-natal follow up.

To promote and celebrate a National GDM Awareness Day as an instrument to bring public attention and raise awareness of the problem [5]

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 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 in South Asia attending health facilities are tested for hyperglycemia using a single-step procedure. Keeping in mind the resource constraints, accessibility and other barriers, to offer simple, cost effective, feasible and timely diagnostic tests as advocated by FIGO GDM Initiative (such as the DIPSI test adapted in India).

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.

To help develop, support and carry out a robust research agenda that fuels both the discovery of new tools and procedures to improve point of care diagnostics, monitoring and management of HIP and the ability to engage, counsel and track the mother-child pair over the long term; as well as carry out operational research to improve collaboration and efficacy in existing programs, keeping in mind the health care delivery realities of South Asia.

Colombo Sri Lanka 8th September 2016

View and download the declaration as a PDF.