Millions of women each year are diagnosed with pregnancy complications like gestational diabetes and pregnancy hypertension (a precursor to pre-eclampsia). Research shows women who experience these conditions during one pregnancy are at very high risk of the same and additional problems in subsequent pregnancies, as well as type 2 diabetes, hypertension, and cardiovascular disease later in life.
As the WDF reflects on 20 years of improving lives together, two leading GDM and public health experts, Dr Anil Kapur and Dr Hema Divakar, discuss the struggles to highlight the rising prevalence of hyperglycaemia in pregnancy, develop diagnostic protocols and then raise awareness, introduce universal screening for pregnant women and tackle questions of gender and power dynamics affecting maternal health.
Dr Kapur has been associated with the Foundation since inception. As an internal medicine specialist, he has written several books on diabetes, coordinated ground-breaking studies and published more than 120 medical papers in Indian and international journals. Dr Divakar is an accomplished Ob-Gyn specialist and runs the Divakar speciality hospital in Bangalore, India. She has established new benchmarks and standards in maternal health and is currently the Federation of Obstetric and Gynaecological Societies of India (FOGSI) ambassador to the International Federation of Gynaecology and Obstetrics (FIGO), the international organisation of Ob-Gyns; and chairs its Committee on maternal health and wellbeing.
Putting gestational diabetes on the map
“Our health is greatly influenced and to a large extent determined by our life in our mother's womb; what our mother eats, what kind of health she has is very important determinant,” Dr Anil Kapur, WDF chairman says. One of the slogans that emerged from the WDF-sponsored United Nations expert meeting on Diabetes, Women, and Development in New York in 2008, he notes, was ‘Women’s health is a nation’s wealth’.
One of WDF’s first initiatives was a project in India that studied diabetes in pregnancy, screening 11,000 women. “We needed to understand the prevalence of diabetes during pregnancy and also use the opportunity to start initiatives with the public health system to try and address the testing of women during pregnancy,” Dr Kapur says.
WDF’s gestational diabetes initiatives soon gained momentum, with large-scale screening projects in China, India, Latin America, and South Africa. Some of the data coming in was alarming. “Urban women in Chennai, South India diagnosed with gestational diabetes touched 17%, similar data was noted from studies in China” Dr Kapur says. He realised that India and China would be crucial in turning the tide on gestational diabetes globally.
WDF soon joined forces with the International Federation of Gynaecology and Obstetrics (FIGO). At a conference organised by the Federation of Obstetric and Gynaecological Societies of India (FOGSI), Dr Kapur met Dr Hema Divakar, then president of the organisation. This was the beginning of a friendship and partnership dedicated to putting gestational diabetes on the global agenda.
Alarming prevalence of gestational diabetes
Describing the results of the WDF’s first study of 11,000 women in India as an “eye-opener”, Dr Divakar says the research brought the extent of the problem to light.
“Obstetricians are the frontline health care providers for women, and they knew nothing specific about gestational diabetes so that was a huge challenge in itself. Then the question was how do we build their capacity? So, for the very first time in the world - with the help of the WDF and other partners -we brought in a certification course for Ob-Gyns because they not only need to test but they also need to know how to manage the disease.”
Creative, sustainable and pragmatic solutions were required. In India alone, there are about 30 million pregnancies per year, and 5 million women diagnosed with hyperglycaemia while pregnant - but only 1,000 diabetologists, Dr Divakar says.
“We ourselves have to build the capacity of our own speciality, who are dealing with women across their lifespan,” Dr Divakar says. Part of this was adopting solutions suitable for low- and middle-income countries (LMICs). This includes single step testing which, although a struggle at first, is now accepted by the Indian government and internationally. Another innovation is a non-fasting blood sugar testing, as some pregnant women travel more than 200 miles to reach health facilities.
Dr Kapur agrees that the testing protocols for diagnosis of gestational diabetes in LMICs pose a tremendous challenge, as much of the evidence was for high-income countries where women have fewer pregnancies and easier access to health facilities. WDF and its partners had to find pragmatic solutions to suit local contexts.
Working towards a global understanding
In September 2016, 300 South Asian maternal health leaders gathered in Sri Lanka to build on the knowledge and experience gathered in India and elsewhere. They signed the Colombo Declaration, pledging to support efforts to ensure universal screening among pregnant women for hyperglycaemia, accept single-step testing and address the link between maternal health and NCDs.
Dr Kapur and Dr Divakar stood side by side along with other leaders in the area, as the Sri Lankan Health Minister signed the declaration during the ceremonial signing the declaration. The declaration became a springboard for similar declarations for Africa, the Middle East, and Latin America and ultimately a Global Declaration from FIGO, Dr Kapur says.
The achievement of the Colombo Declaration, Dr Divakar says, was “decluttering the thinking around gestational diabetes and the testing methods as well as showing how important the issue really is for future generations’ health.”
A lever for more integrated healthcare
Dr Divakar (right) marking India’s first GDM Awareness Day in 2019. Photo courtesy of Divakar Speciality Hospital
The question for Dr Divakar was what to do with the newfound support and awareness. “Who will bring the declaration from bench to bedside? That is where the WDF funding for the FOGSI and FIGO implementation initiative was key. We need to collaborate across fields. So, let's at least get moving with the first step of testing and the other implementable management care that we can do both in the short term and in the long term,” she says.
Dr Divakar is seeing a change in mindset and in the health system. In India, which held the first annual GDM Awareness Day on 10 March 2019, clinicians now screen all pregnant women as per the ministry of health national guideline on gestational diabetes.
“It's been a long journey, but we still have a very long way to go,” she acknowledges.
Addressing gender inequality is key to improving maternal health
Universal screening is only the first hurdle. Treating and caring for hyperglycaemia represents a massive array of next steps for clinicians, Dr Divakar says, and many are not empowered to give dietary or lifestyle advice.
Another challenge is how to continue supporting women who have had high-risk pregnancies post-delivery, Dr Kapur says. Women with gestational diabetes have a higher risk profile of being diagnosed with type 2 diabetes and cardiovascular diseases later in life.
Dr Kapur and Dr Divakar agree that gender inequality complicates prevention and care post-delivery. In India and other LMICs, pregnant women are often accompanied to health centres by a male relative, for the sake of the unborn child. However, they cannot maintain regular check-ups after the birth without their husband’s or mother-in-law’s permission, which is often not granted or just because of the additional workload of caring for a child and lack of time prevents women from focussing on self-care.
“It is important for medical professionals to see maternal health from a holistic, societal perspective,” Dr Kapur notes. Dr Divakar sees education and economic empowerment as crucial to improving gender equality, maternal health and reproductive rights.
While a huge challenge, gestational diabetes also offers a chance to innovate and to break down barriers, Dr Kapur says.
“From a WDF perspective, it provides us the opportunity to build partnerships. Health systems traditionally work in silos, where you have communicable diseases, non-communicable diseases, and maternal and child health separately. So gestational diabetes provides us the opportunity to create the advocacy that we need to integrate systems at the primary care level.”