Latin American & Caribbean Declaration On Hyperglycemia in Pregnancy, 2017
The Latin American & Caribbean Declaration On Hyperglycemia in Pregnancy
The Preamble:
Whereas
- Latin America and the Caribbean are among developing regions with relatively low maternal mortality (MMR in 2013 of 77 and 190 per 100000 in in Latin America the Caribbean respectively).
- Between 1990 and 2014, maternal mortality declined by 56 per cent and 36 per cent in Latin America and the Caribbean respectively, despite the fact that there are countries that increased their ratio and others where it is still unacceptable.
- In the region of Latin America and the Caribbean, direct causes of maternal death still prevail; however, a growing trend of maternal deaths is observed, like other parts of the world, due to medical conditions exacerbated by pregnancy (such as HIV, Malaria, Diabetes, Obesity, etc.) which at present means a level of more than 28% of total maternal deaths (indirect maternal mortality).
- This requires increased efforts to identify, prevent and treat these conditions to further reduce MMR rates.
- Overweight and obesity is an important problem among women of reproductive age in Latin America and Caribbean where an estimated 70% of women between 20 and 49 years are either overweight or obese.
- Infant and under 5 mortality in the region declined 67% from 54/1000 live births in 1990 to 18/1000 live births in 2015.
- The overall prevalence of large for gestational age (LGA) and small for gestational age (SGA) newborns in Latin America and the Caribbean is reported to be 16.5% and 6.3%, respectively. The highest rate of LGA was reported by Mexico (21.9%).
- Rates of premature deliveries range from 5 to 14% and rates of caesarian deliveries from 30 to 60% in some select countries.
- Diabetes mellitus is escalating worldwide and prevalence of diabetes among all age groups in also increasing in Latin America and Caribbean where it already affects an estimated 42 million people and is projected to increase to 66 million people by 2040. There is an equally high burden of pre-diabetes - approximately 56 million are estimated to have prediabetes which is likely to increase to about 96 million by 2040.
- More than half of people with diabetes and a majority of people with prediabetes remain undiagnosed and unaware; particularly the young and women, as they have never been tested given that diabetes is mistakenly believed to only affect the elderly.
- The age of onset for diabetes and prediabetes is declining globally and now affects many young people in the reproductive age. At the same time, age at child birth is rising and older, overweight primi-gravida may be particularly vulnerable and yet unaware of their diabetes status.
- Hyperglycemia in pregnancy (HIP) is one of the most common medical conditions affecting women during pregnancy. According to the International Diabetes Federation, an estimated 12% of live births in Latin America and Caribbean may be impacted by hyperglycemia during pregnancy.
- Highly diverse testing strategies are used in Latin America and the Caribbean, including single or two step testing, different doses of glucose and different blood glucose cut-offs for GDM diagnosis.
- 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.
- HIP significantly increases risk of pregnancy complications- hypertension, obstructed labor, postpartum hemorrhage, infections, still births, premature delivery, both large and small for gestational age babies, congenital anomalies, 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 develop premature cardiovascular disease, within 10 years of childbirth.
- Children born to women with HIP 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.
- 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 their risk for future diabetes and cardiovascular disease.
- While several risk factors such as overweight and obesity and increasing maternal age increase the risk for HIP, in practice, only slightly over half of the women with GDM have these risk factors, supporting the contention that identification of women who have GDM requires testing all pregnant women.
- Despite evidence of both immediate and long term benefits (health and economic, diagnosis and management of GDM and providing post-partum preventive care, concerns continue to be expressed that universal testing and (consequently) increased diagnosis of GDM would place additional logistical and economic challenges to healthcare systems, as OGTTs are time-consuming and incur more costs; and women with GDM will require care by nutritionists and diabetes nurse specialists.
- 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 weight management, 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 reducing maternal and newborn morbidity and rising rates of obesity, diabetes and cardiovascular diseases; as well as, offering 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 Noncommunicable 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.
- A Pan American Health Organization (PAHO) conference on hyperglycemia and pregnancy in the Americas held in September 2015 in Lima, Peru recommended holding activities to raise awareness throughout the Region of the Americas regarding the importance of programs for the prevention and control of hyperglycemia in pregnancy; promote greater capacity for the prevention and control of GDM, including the adoption, review, and implementation of clinical practice guidelines; begin compiling health system data or enhance data collection and improve access to care. It also recommended holding national meetings in which specific needs and future plans are discussed with stakeholders, policy-makers, the scientific community, civil society, and health care providers and to disseminate the call for action in all Member States, emphasizing the importance of controlling hyperglycemia in pregnancy: a necessary investment for ensuring a healthy future for the population of the Americas.
We, the undersigned, as leaders and representatives of professional medical organisations, public health agencies research institutions, governments, affected communities, civil society and private industry, living and working in Latin America and the Caribbean,
Hereby Declare
That maternal obesity and HIP 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 and in the 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 and worsen the ongoing diabetes and obesity 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 obesity, diabetes, hypertension, CVD and stroke. That we resolve to address the challenges posed by the rising rates of hyperglycemia in pregnancy and maternal obesity and to convert them into opportunities for improved health outcome for mothers and the future generation of our 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, obesity and diabetes as a public health priority.
To accelerate the implementation of the FIGO GDM initiative in Latin America and Caribbean, including by pursuing supportive policy actions and mobilizing resources for its implementation. without detriment to actions to prevent direct maternal deaths, urging governments to increase their efforts and budgets to prevent and intervene in chronic non-communicable diseases.
To support efforts to increase public awareness about hyperglycemia in pregnancy and its impact on maternal and child health, encourage preconception counseling, antenatal care and post-natal follow up.
To favour the adoption and implementation of FIGO recommendations on Maternal Nutrition, where applicable, to address the nutritional needs of girls and women in order to prevent and manage present or future complications. Adopt the life-cycle approach by considering perinatal health within the context of women's overall health and with particular emphasis on adolescent nutrition and preconception as well as maternal and postpartum health.
To promote and celebrate a National GDM Awareness Day as an instrument to bring public attention and raise awareness of the problem.
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.
Although FIGO recommends universal diagnosis with a one-step test, it still has to be accepted that each country adopts this recommendation to their local needs based on their health economics. Anyway, we hope that in future all countries will accept the universal recommendation of FIGO.
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 in different parts of Latin America and Caribbean.
Cancun, Mexico | November 2017
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 International Diabetes Federation IDF Diabetes Atlas 7th Edition
Report by the Secretary-General on the prevention and control of non-communicable diseases (A/66/83)
General Assembly Resolution on Prevention and control of non-communicable diseases (A/RES/64/265)
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