Date Published: September 25, 2018
Publisher: Public Library of Science
Author(s): James G. Beeson, Caroline S. E. Homer, Christopher Morgan, Clara Menendez
Abstract: In a Guest Editorial, James Beeson and colleagues discuss the contribution of nonobstetric morbidity to mortality during and around pregnancy and what needs to be done to address this global health challenge.
Partial Text: Infectious diseases (such as HIV, malaria, tuberculosis, and sexually transmitted infections [STIs]) together with NCDs that are increasingly common in LMICs as a result of demographic, socioeconomic, and environmental changes (cardiovascular disease, diabetes, anemia, micronutrient deficiencies, hypertension, and mental health challenges) each account for substantial morbidity in pregnancy; however, the burden of their combination is less well recognized, and the impacts are not well understood. Some co-occurring morbidities have been well described, such as coinfection with HIV, malaria, or tuberculosis. Curable STIs (syphilis, gonorrhea, chlamydia, trichomonas, and others) likely infect about 40% of pregnant women in sub-Saharan Africa , with negative implications for the health of mother and baby. Infectious plus noninfectious multimorbidity is also important, such as malaria with anemia from nutritional deficiencies and tuberculosis with diabetes [1,5]. In LMIC settings, typically most pregnant women are anemic and have significant nutritional deficiencies [1,5], which may have impact on infections and NCDs . Other multimorbidities are likely to have major impacts but are poorly understood. There is a major knowledge gap for many important co-occurring diseases and risk factors, especially the interaction of macro- and micronutrient deficiencies with infections and other conditions. In addition, poor maternal mental health has short- and long-term adverse effects on mothers and babies and has a likely impact on the whole family .
Addressing the burden of multimorbidity requires innovation and investment to drive the development of new tools, interventions, and strategies. We have listed the main priorities for research and innovation across levels of healthcare in Box 1. Greater research and innovation are urgently needed to identify common contributing factors and adversely synergistic interactions. Given the increasing burden of NCDs, there is a strong need to understand the interactions between different NCDs, as well as between infections and NCDs, among pregnant women. Clinical research is needed to test the potential of integrated interventions against common comorbidities (e.g., malaria and STIs, including HIV). Testing of interventions should be accompanied by improved surveillance and reporting of multimorbidities and a better understanding of the causes of maternal mortality, especially indirect deaths.
Multimorbidity calls for new or enhanced models of care, as well as the application of new technologies and interventions. Innovative diagnostics and systems research will enable broader screening of pregnant women for diseases or risk factors, especially diseases that are frequently asymptomatic and have major impacts, such as curable STIs, poor nutrition, HIV, malaria, and others. Multimorbidity also demands more integrated service delivery, providing quality care that addresses the full spectrum of health needs of each woman; however, current evidence on how best to integrate pregnancy interventions into primary healthcare or public health programs, such as immunization programs, is insufficient to guide policy . Also critical is integration through to postnatal care, which currently has unacceptably low coverage in LMICs and is typically provided through models that pay little attention to maternal multimorbidity . Postnatal visits and even infant immunization visits represent key opportunities for further screening and follow-up of maternal conditions identified in pregnancy and childbirth.
The burden of multimorbidity in pregnancy, combined with global epidemiological changes in disease patterns and resource and health system constraints, poses challenges that can best be addressed by accelerating sustainable improvements in maternal health. Renewed and strengthened focus, research and innovation, and investment and partnerships to address this challenge are urgently needed.