Interventions integrating non-communicable disease prevention and reproductive, maternal, newborn, and child health: A systematic review

Preterm birth, low birth weight, and their co-occurrence among women with preexisting chronic diseases prior to conception: a cross-sectional analysis of postpartum women in a low-resource setting in Ghana

BACKGROUND

The incidence of chronic diseases, which are significant contributors to maternal deaths and adverse new-born outcomes, is increasing among women of reproductive age in northern Ghana. This emerging health issue raises serious concerns about the potential exacerbation of adverse birth outcomes in this setting, given that it is one of the regions in the country with a high incidence of such outcomes. We investigated the risks of preterm birth (PTB), low birth weight (LBW), and concurrent PTB and LBW among women with preexisting chronic conditions prior to conception in the Tamale Metropolis of northern Ghana.

METHODS

A facility-based cross-sectional study was conducted among 420 postpartum women randomly selected from five public health facilities. Information was collected electronically on participants' self-reported experience of chronic conditions, namely, hypertension, diabetes, asthma, heart disease, and sickle cell disease, prior to their most recent pregnancy. Information on gestational age at delivery and birth weight was also collected. Regression modeling was used to quantify the risk of adverse newborn outcomes among women who reported preexisting chronic conditions prior to pregnancy.

RESULTS

Chronic diseases affected 31.2% of our sample. Of these, 28.6% had a single chronic condition, while 2.6% had comorbid chronic conditions. The prevalence of PTB was 24.0% (95% CI: 20.2, 28.4), 27.6% (95% CI: 23.5, 32.1) of the newborns were born LBW, and 17.4% (95% CI: 14.0, 21.3) of the pregnancies resulted in both PTB and LBW. Compared with those without chronic conditions, women with chronic conditions prior to conception had a greater risk of PTB (aOR = 6.78, 95% CI: 3.36, 13.68), LBW (aOR = 5.75, 95% CI: 2.96, 11.18), and the co-occurrence of PTB and LBW (aOR = 7.55, 95% CI: 3.32, 17.18).

CONCLUSIONS

We observed significant rates of PTB, LBW, and the co-occurrence of PTB and LBW among women who were already aware that they had preexisting chronic conditions prior to conception. Our findings highlight a potential gap in the quality of prenatal care provided to these women before delivery. Preconception care may offer an opportunity to address preexisting chronic conditions in women before pregnancy and potentially improve maternal and newborn health outcomes.

Integrated Diagnosis in Africa's Low- and Middle-Income Countries: What Is It, What Works, and for Whom? A Realist Synthesis

Introduction

Integrated diagnosis can improve health outcomes and patient experiences through early diagnosis and identification of cases that could otherwise be overlooked. Although existing research highlight the feasibility of integrated diagnosis across various conditions, a significant evidence gap remains regarding its direct impact on patient experiences and health outcomes. This review explores the conceptualizations of integrated diagnosis by different stakeholders along the healthcare pathway and examines the necessary contexts and mechanisms crucial for its effectiveness.

Methods

This study adopts a realist methodology to explore integrated diagnosis. Using a systematic approach, the research aims to collect, assess, and synthesize existing evidence on integrated diagnosis, guided by a program theory developed through literature review and expert consultations. Primary studies and reviews related to integrated diagnosis, multi-disease testing, or integrated healthcare with a diagnostic focus were sourced from major databases and global health organization websites. The collected evidence was used to construct and refine the evolving theoretical framework.

Results

This study identified three models of integrated diagnosis interventions: individual/human resource integration, facility or mobile-based integration, and technology integration. Successful implementation of these models relies on understanding the values and perceptions of both healthcare workers and patients/clients. This research emphasizes a holistic approach that considers all elements within the health system and underscores their interdependence. Using the WHO health systems framework to contextualise factors, the study positions diagnosis as an integral component of the broader health ecosystem. A key finding of the research is the importance of addressing the barriers and facilitators of integrated diagnosis interventions. This includes policy frameworks, diagnostic tools, funding mechanisms, treatment pathways, and human resource issues. Improving patient experiences requires cultivating positive relationships with healthcare workers ensuring elements such as respect, confidentiality, accessibility, and timeliness of services are prioritised.

Discussion and Conclusion

The diverse conceptualisations of integrated diagnosis highlight the importance of clear definitions for each intervention. This clarity is essential for transferring lessons learned, comparing programs, and effectively measuring results. The success of integrated diagnosis is not a one-size-fits-all scenario; decisions regarding the approach, conditions to be integrated, and timing of integration must be guided by local contexts to ensure sustainable outcomes. The review findings suggest that integrated diagnosis may be suitable at the primary care level in LMICs under specific circumstances. Successful implementation hinges on addressing the perspectives of healthcare workers and patients/clients alike, requiring adequate time, resources, and a well-defined intervention model.

Understanding integrated service delivery: a scoping review of models for noncommunicable disease and mental health interventions in low-and-middle income countries

BACKGROUND

Noncommunicable diseases (NCDs) and mental health conditions represent a growing proportion of disease burden in low- and middle-income countries (LMICs). While past efforts have identified interventions to be delivered across health system levels to address this burden, the challenge remains of how to deliver heterogenous interventions in resource-constrained settings. One possible solution is the Integration of interventions within existing care delivery models. This study reviews and summarizes published literature on models of integrated NCD and mental health care in LMICs.

METHODS

We searched Pubmed, African Index Medicus and reference lists to conduct a scoping review of studies describing an integrated model of NCD or neuropsychiatric conditions (NPs) implemented in a LMIC. Conditions of interest were grouped into common and severe NCDs and NPs. We identified domains of interest and types of service integration, conducting a narrative synthesis of study types. Studies were screened and characteristics were extracted for all relevant studies. Results are reported using PRISMA-ScR.

RESULTS

Our search yielded 5004 studies, we included 219 models of integration from 188 studies. Most studies were conducted in middle-income countries, with the majority in sub-Saharan Africa. Health services were offered across all health system levels, with most models implemented at health centers. Common NCDs (including type 2 diabetes and hypertension) were most frequently addressed by these models, followed by common NPs (including depression and anxiety). Conditions and/or services were often integrated into existing primary healthcare, HIV, maternal and child health programs. Services provided for conditions of interest varied and frequency of these services differed across health system levels. Many models demonstrated decentralization of services to lower health system levels, and task shifting to lower cadre providers.

CONCLUSIONS

While integrated service design is a promising method to achieve ambitious global goals, little is known about what works, when, and why. This review characterizing care integration programs is an initial step toward developing a structured study of care integration.

A realist review of interventions targeting maternal health in low- and middle-income countries

Maternal mortality is disproportionately higher in low- and middle-income countries compared to other parts of the world. International research efforts are reflective of the urgency to improve global maternal outcomes. The existing literature of maternal health interventions in low- and middle-income countries targets a variety of populations and intervention types. However, there is a notable lack of systemic reviews that examine the wider contextual and mechanistic factors that have contributed to the outcomes produced by interventions. This article aims to use realist synthesis design to identify and examine the relationships between the contexts, mechanisms and outcomes of maternal health interventions conducted in low- and middle-income countries. This will inform evidence-based practice for future maternal health interventions. In May 2022, we searched four electronic databases for systematic reviews of maternal health interventions in low- and middle-income countries published in the last 5 years. We used open and axial coding of contexts, mechanisms and outcomes to develop an explanatory framework for intervention effectiveness. After eligibility screening and full-text analysis, 44 papers were included. The majority of effective interventions reported good healthcare system contexts, especially the importance of infrastructural capacity to implement and sustain the intervention. Most intervention designs used increasing knowledge and awareness at an individual and healthcare-provider level to produce intended outcomes. The majority of outcomes reported related to uptake of healthcare services by women. All mechanism themes had a relationship with this outcome. Health system infrastructure must be considered in interventions to ensure effective implementation and sustainability. Healthcare-seeking behaviours are embedded within social and cultural norms, environmental conditions, family influences and provider attitudes. Therefore, effective engagement with communities and families is important to create new norms surrounding pregnancy and delivery. Future research should explore community mobilization and involvement to enable tailored interventions with optimal contextual fit.

Non-communicable diseases and maternal health: a scoping review

BACKGROUND

Non-communicable diseases [NCDs] are leading causes of ill health among women of reproductive age and an increasingly important cause of maternal morbidity and mortality worldwide. Reliable data on NCDs is necessary for accurate measurement and response. However, inconsistent definitions of NCDs make reliable data collection challenging. We aimed to map the current global literature to understand how NCDs are defined, operationalized and discussed during pregnancy, childbirth and the postnatal period.  METHODS: For this scoping review, we conducted a comprehensive global literature search for NCDs and maternal health covering the years 2000 to 2020 in eleven electronic databases, five regional WHO databases and an exhaustive grey literature search without language restrictions. We used a charting approach to synthesize and interpret the data.  RESULTS: Only seven of the 172 included sources defined NCDs. NCDs are often defined as chronic but with varying temporality. There is a broad spectrum of conditions that is included under NCDs including pregnancy-specific conditions and infectious diseases. The most commonly included conditions are hypertension, diabetes, epilepsy, asthma, mental health conditions and malignancy. Most publications are from academic institutions in high-income countries [HICs] and focus on the pre-conception period and pregnancy. Publications from HICs discuss NCDs in the context of pre-conception care, medications, contraception, health disparities and quality of care. In contrast, publications focused on low- and middle-income countries discuss NCDs in the context of NCD prevention. They take a life cycle approach and advocate for integration of NCD and maternal health services.

CONCLUSION

Standardising the definition and improving the articulation of care for NCDs in the maternal health setting would help to improve data collection and facilitate monitoring. It would inform the development of improved care for NCDs at the intersection with maternal health as well as through a woman's life course. Such an approach could lead to significant policy and programmatic changes with the potential corresponding impact on resource allocation.

Palmitic Acid Impedes Extravillous Trophoblast Activity by Increasing MRP1 Expression and Function

Normal function of placental extravillous trophoblasts (EVTs), which are responsible for uteroplacental vascular remodeling, is critical for adequate delivery of oxygen and nutrients to the developing fetus and normal fetal programming. Proliferation and invasion of spiral arteries by EVTs depends upon adequate levels of folate. Multidrug resistance-associated protein 1 (MRP1), which is an efflux transporter, is known to remove folate from these cells. We hypothesized that palmitic acid increases MRP1-mediated folate removal from EVTs, thereby interfering with EVTs' role in early placental vascular remodeling. HTR-8/SVneo and Swan-71 cells, first trimester human EVTs, were grown in the absence or presence of 0.5 mM and 0.7 mM palmitic acid, respectively, for 72 h. Palmitic acid increased ABCC1 gene expression and MRP1 protein expression in both cell lines. The rate of folate efflux from the cells into the media increased with a decrease in migration and invasion functions in the cultured cells. Treatment with N-acetylcysteine (NAC) prevented the palmitic acid-mediated upregulation of MRP1 and restored invasion and migration in the EVTs. Finally, in an ABCC1 knockout subline of Swan-71 cells, there was a significant increase in invasion and migration functions. The novel finding in this study that palmitic acid increases MRP1-mediated folate efflux provides a missing link that helps to explain how maternal consumption of saturated fatty acids compromises the in utero environment.

Resistance Training as a Countermeasure for Key Non-communicable Diseases in Low-Resource Settings: A Review

Background: Non-communicable diseases (NCDs) are responsible for 60% of global deaths. Of these NCD-attributable deaths, about 80% are in low- to middle-income countries (LMICs). The role of exercise in major NCDs is evident; however, popular and cost-effective aerobic modes of exercise, such as walking, consistently do not meet minimum intensity guidelines for health improvement. Interestingly, low-cost resistance training (using callisthenics, Pilates, elastic tubing, etc.) has proven equally effective to conventional resistance training using weight machines in improving several health parameters related to NCDs, although their effectiveness in LMICs is not as well documented as in high-income countries (HICs). Objectives: This review aimed to examine low-cost approaches of resistance training to health promotion, NCD risk reduction, and NCD rehabilitation/management to mitigate the epidemic of NCDs in lower-resource settings. Methods: An electronic search was performed on the following databases from inception until December 2019: PubMed/Medline, Sport Discuss, Embase, Science Direct, Current Contents, CISTI Source, Google Scholar, Cochrane Library, Cochrane Database of Systematic Reviews, CINAHL EBM Reviews, and international e-catalogues. Results: Data on resistance training provision cost in low-resource settings indicates that it is not reasonable to use this mode of training in low-resource settings in the same way as it is used in high-resource ones. This review summarized some strategies which can be employed to ensure the delivery of all core resistance training components in low-resource settings. The data suggests that resistance training be adapted for delivery in non-clinical settings in LMICs. Conclusions: Program design variables of resistance training are similar in low- and well-resourced settings. However, only individuals with low-risk will be able to perform exercise without adverse consequences in home-based settings. Health care practitioners in LMICs should take an active role in promoting resistance training when promoting health, reducing NCD risk, and NCD rehabilitation.

Nutritional Surveillance for the Best Start in Life, Promoting Health for Neonates, Infants and Children

This Special Issue aims to examine the crucial role of nutritional status starting from pregnancy in modulating fetal, neonatal and infant growth and metabolic pathways, with potential long-term impacts on adult health. Poor maternal nutritional conditions in the earliest stages of life during fetal development and early life may induce both short-term and longer lasting effects; in particular, an increased risk of noncommunicable diseases (NCDs) and other chronic diseases such as obesity, which itself is a major risk factor for NCDs, is observed over the lifespan. Poor maternal nutrition affects the fetal developmental schedule, leading to irreversible changes and slowdown in growth. The fetus limits its size to conserve the little energy available for cardiac functions and neuronal development. The organism will retain memory of the early insult, and the adaptive response will result in pathology later on. Epigenetics may contribute to disease manifestation affecting developmental programming. After birth, even though there is a limited evidence base suggesting a relationship between breastfeeding, timing and type of foods used in weaning with disease later in life, nutritional surveillance is also mandatory in infants in the first year of life. We will explore the latest findings on nutrition in early life and term and preterm babies, as well as the role of malnutrition in the short- and long-term impact over the lifespan. Focusing on nutritional interventions represents part of an integrated life-cycle approach to prevent communicable and non-communicable diseases.