Humble beginnings and pioneering efforts

Author: Yildiz Arslan

On an annual basis, elevated blood sugar levels during pregnancy pose a significant health risk for around 21 million women and their children worldwide, with the majority residing in low- and middle-income countries (LMICs). According to the International Diabetes Federation, high blood sugar levels (hyperglycaemia in pregnancy or HiP) affect one in six live births globally.

Diagnosing and treating HiP is crucial as it can lead to serious complications during pregnancy and delivery for both mother and child. Further, women with a history of HiP as well as their offspring are at a higher risk of developing type 2 diabetes and other non-communicable diseases (NCDs) later in life. In other words, the high and increasing prevalence of HiP is silently fuelling diabetes in future generations. Integrating HiP screening and follow-up into prenatal and postpartum care can significantly improve health outcomes and quality of life, and impact cost efficiency in healthcare systems.

Women in LMICs face a higher risk of experiencing HiP-related complications due to systemic barriers such as distance to clinics, cost of consultations, or lack of capacity and quality in the health system. The consequences for women experiencing complications are also greater in low-income settings, as their potential inability to work or carry out unpaid care work affects entire families and communities.

This underscores the urgent need for better prevention, screening, and care before, during, and after pregnancy. Since its inception in 2002, the World Diabetes Foundation (WDF) has been working persistently to address this issue.

A disease with long-term consequences

The risks posed by HiP

Elevated blood sugar levels during pregnancy (HiP), including gestational diabetes mellitus (GDM) and pre-existing type 1 or type 2 diabetes (diabetes in pregnancy, DiP), can increase the risk of several complications for both the mother and the baby if not properly managed.

Some of the risks include

• Higher birth weight of the baby, which risks injury to both baby and mother during delivery

• Higher risk of delivering the baby before 37 weeks of pregnancy

• Increased risk of stillbirth

• High blood pressure and damage to organs such as the liver and kidneys

• Babies born to women with diabetes in pregnancy are at a higher risk of developing hypoglycaemia, which can cause seizures, breathing problems, and other complications Increased risk of developing type 2 diabetes later in life

• Higher risk of developing birth defects, such as heart and neural tube defects for the baby.

A window of opportunity for a healthy life-course

Why GDM is so important for WDF

WDF tackles HiP through two strategic tracks: care and prevention. We view GDM as a window of opportunity to improve maternal health and reduce the risk of long-term health issues for both mothers and children. Our focus on GDM seeks to support a healthy life beyond pregnancy and early motherhood for both woman and child.

Mother and baby tend to be in frequent contact with the healthcare system, both before and after birth, providing ample opportunities for health interventions. Additionally, studies show that pregnant women and new mothers are more willing to change their health habits compared to during other life phases.

The prevalence of GDM is increasing globally. In some countries, such as India, the prevalence  is particularly high. The potential individual and societal impact of supporting these mothers and their babies is remarkable. It is a window of opportunity for healthier lives that must not be missed.

Revealing a hidden disease

HiP on the global NCD map

Since 2002, WDF has worked tirelessly to raise awareness of the need to address hyperglycaemia in pregnancy. Through this push, attention to the disease area has increased, but unfortunately GDM remains underprioritised in global health interventions.

WDF's first project on GDM was with Dr V. Seshiah Diabetes Care and Research Institute, where the partner managed to screen 11,000 women in India.

"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 Anil Kapur, WDF's Chair of the Board.

WDF's gestational diabetes initiatives soon gained momentum with large-scale screening projects in China, India, South Africa and across several countries in Latin America. "Women living in urban settings in Chennai, South India diagnosed with gestational diabetes touched 17%, similar data was noted from studies in China," Dr Kapur continues. The results of these studies were instrumental in gaining momentum among policy makers at national and global levels and made it possible to attract additional funding from other donors.

WDF's HiP portfolio includes a total of 105 projects, with 22 ongoing HiP projects and 83 completed. The total contribution to HiP projects to date is 18.9 million USD. Across the 105 projects, 2.8 million women have been screened, 135,000 doctors, nurses and other healthcare providers have been trained in HiP care, and around 1.7 million women have received counselling or training in GDM care, nutrition, and healthy living.

To understand the impact of these numbers, we must explore what positive changes our GDM-related partnership projects have enabled. This impact deep dive will focus on India, one of the countries where GDM is hitting the hardest, showcasing how our support has had an impact at organisational, personal and policy levels in the country.  

Shared purpose and camaraderie in India

The impact of WDF’s collaboration with Jhpiego

India is facing a growing epidemic of NCDs, with 6 million deaths annually from heart and lung diseases, stroke, cancer, and diabetes. India accounts for 1 in 7 adults living with diabetes globally, with an estimated 74 million people living with the disease in 2021.

India has the largest cohort of pregnant women in the world, with an estimated 30 million pregnancies and 27 million live births annually. GDM affects as many as 5 million women – that is one in six pregnancies - every year. The overall prevalence of GDM is estimated to be 10 to 14%. Jhpiego, a global health non-profit organisation, and WDF have been working together since 2018 to integrate GDM screening, diagnosis, and care into public antenatal care services in two states in Central India: Madhya Pradesh and Maharashtra.

Taking on this massive need for screening and care requires a stepwise approach. Jhpiego and WDF focused on improving access and providing technical support at various levels in project phases that were scaled over time. The first phase focused on providing extensive support to selected districts in the Madhya Pradesh state, equipping clinics and staff to provide screening and care for GDM. Technical advice was also given at institutional level to develop a roadmap for state-wide scale-up enrolling 533 clinics. The second phase of the project targeted the two states with full-scale implementation in Madhya Pradesh and two districts in Maharashtra. The number of clinics has increased to improve access to GDM screening and care in 2,469 public health facilities, with more than 110,000 pregnant women screened to date. 

The policy impact of Jhpiego’s WDF-supported work

• Approval of government budgets for implementing GDM testing and management guidelines in Madhya Pradesh and Maharashtra

• Issuing directives for inclusion of GDM in the Prime Minister’s Safe Motherhood Assurance (PMSMA) programme

• Initiative by state government for scale-up of GDM in Madhya Pradesh and Maharashtra, and initiation of GDM services in Bihar, Rajasthan, and Uttar Pradesh states

• GDM is included in national and state governments' monitoring, evaluation, and review mechanisms.

Impact on healthcare workers and facilities

• Capacity building efforts increased the knowledge and confidence of frontline healthcare workers and community volunteers to work with pregnant women to prevent and treat HiP

• This has, in cascade, led to the generation of awareness about GDM in the community and the availability of GDM services closest to the communities.

When asked about the change that Jhpiego as an organisation has undergone after becoming a WDF partner, their Programme Manager Ms. Pooja Sharma is very clear: “Jhpiego is being recognised by national and state governments as well as by professional bodies such as FOGSI (Federation of Obstetricians and Gynaecologists in India) and DIPSI (Diabetes in Pregnancy Study Group of India) as a strong technical partner in GDM services”. She continues, “Without WDF’s funding, technical support to other state governments for GDM services initiation would not have been possible”.

The partnership with Jhpiego exemplifies two important tactics, which are used in many of the countries in which the WDF engages:

1. a phased approach which is scaled over time, building capacity, and enabling sustainable health system strengthening,

2. and joining forces with strong organisations and local NCD champions, who can lead the implementation with local knowledge and networks.

Madhya Pradesh and Maharashtra have populations of more than 72 million and 112 million, respectively. Working with state-level government authorities to develop and roll out a GDM road map with the potential to enhance access and quality of care for pregnant women throughout the two states takes time, resources, and long-term trusted partnerships. Yet, the partnership between WDF, Jhpiego and the health authorities in Madhya Pradesh and Maharashtra shows that we are on the right track with providing women in the two states with opportunities for enjoying a healthy pregnancy and reducing the risk of diabetes and other NCDs later in life - both for them and their babies.

WDF’s reach in India

• 20 projects with GDM components with 12 different partners since 2004

• 1.5 million women screened for HiP

• 57,000 nurses, doctors and other healthcare providers trained in GDM and DiP care

• 1.1 million women have received counselling and training in GDM care and prevention

A meaningful and pragmatic approach with great potential

The partnership between WDF and Jhpiego in the Indian states Madhya Pradesh and Maharashtra started humbly, focusing on a few districts. The partnership has grown into a pioneering endeavour that has had a noticeable impact, with government budgets approved for implementing GDM testing and management guidelines, and GDM included in national and state governments' monitoring, evaluation, and review mechanisms. The capacity building efforts have increased the knowledge and confidence of frontline workers and community volunteers to work with pregnant women to prevent and treat HiP.

The prevalence of GDM in LMICs is on the rise, and to meet the growing need, WDF must join forces with strong organisations and local diabetes champions who can lead the implementation with local knowledge and networks. The risks posed by HiP have dire consequences for women in low-income settings, and WDF's focus on reducing the risk of long-term health issues for both mothers and children is thus both meaningful and pragmatic.

In early 2024, the WDF Board of Directors agreed to support the United Nations lead agency for maternal health, the United Nations Population Fund (UNFPA), with a grant to unfold and describe in detail how HiP/GDM may be integrated in its work. This support to UNFPA represents a potential game changer in the guidance provided to LMIC health authorities. Together with upcoming new guidance from World Health Organisation (WHO) on pregnancy and NCDs – a process which WDF also follows and engages in – WDF hopes that GDM care and prevention become standardised recommended action in pre- and post-partum care in all LMICs. A policy change of that magnitude has the potential to impact millions of women and their children living in vulnerable settings.

WDF's efforts to address hyperglycaemia in pregnancy have already contributed to strengthening screening and care for 4.5 million women and their children in LMICs since 2002. Our focus on HiP exemplifies our general approach to building strong and resilient healthcare systems: We make the most of the windows of opportunity that present to ensure healthier lives for the most underserved populations in the world.