PMNCH Knowledge Summaries: #15 - Non-communicable diseases
Publisher: The Partnership for Maternal, Newborn and Child Health
Publication date: 2011
Language: English only
Note: Full text and all graphs, tables and references for each Knowledge Summary are available only on the PDF version.
Women and children in low- and middle-income countries often bear a triple burden of ill-health related to pregnancy and childbirth, to communicable diseases and to non-communicable diseases (NCDs), mainly cardiovascular disease, cancer, chronic respiratory disease and diabetes. This burden is exacerbated by high healthcare costs and productivity losses that push households into a vicious cycle of poverty, loss of income, debt and ill-health, and adversely affects national economies. NCDs increasingly affect women and children across the reproductive, maternal, newborn and child health (RMNCH) continuum. Tobacco use and exposure to secondhand smoke, unhealthy diet, physical inactivity and harmful use of alcohol are the four main risk factors for NCDs. The RMNCH continuum of care provides several opportunities to prevent, diagnose and treat NCDs. The UN Secretary-General’s Global Strategy for Women’s and Children’s Health recommends that healthcare for NCDs be provided as part of an integrated approach to promote women’s and children’s health.
NCD-related burden is increasing in low-income countries
Most premature deaths in low-income countries are caused by infectious diseases, maternal and perinatal conditions and nutritional deficiencies. Adding to this burden, there is now a higher proportion of premature NCD-related deaths in low- and middle-income countries than in high-income countries. Nearly 80% of all NCD-related deaths in 2008 occurred in low- and middle- income countries, and a third of these deaths were in people less than 60 years old.1 In 2004, there were more NCD-related deaths among women aged 15 to 44 years in Africa than in high-income countries.
There are some NCDs that specifically affect women, adolescent girls and children. For example, breast cancer is the leading cause of cancer death among women worldwide, causing an estimated 458,400 deaths in women in 2008, despite the availability of methods for early detection and treatment. Of the 1.4 million new cases of breast cancer identified in 2008, about half were in low- and middle-income countries. Certain types of human papillomavirus (HPV), a sexually transmitted infection, lead to the development of pre-cancer and cancer of the cervix. 88% of the 275,000 women who died from cervical cancer in 2008 were in low- and middle-income countries. Children can develop chronic conditions such as asthma, diabetes and congenital heart abnormalities. Each year 8 million children are born with birth defects, including heart defects.
NCDs can impose high costs on households and economies
Healthcare costs often have to be borne by households. In India, of the 4% of the Gross Domestic Product spent on healthcare in 2008, public expenditure was 1.1%.9 The rest was from private sources of which 80% were out-of-pocket payments. People with NCDs incurred nearly twice the treatment expenses compared to other health problems. Paying for healthcare for NCDs can push households into a vicious cycle of poverty, loss of income, debt and ill-health. Related productivity losses adversely affect national economies and projected increases in NCD incidence in low-income countries could be catastrophic. By 2020, low-income countries in Africa, South East Asia and the Eastern Mediterranean region could see a 20% increase in NCD-related deaths, as their populations age.
NCD risk factors across the RMNCH continuum
There are a number of known risk factors for NCDs. Age, gender and family history are non-modifiable risk factors for NCDs. The four main modifiable risk factors for the four major NCDs are tobacco use and exposure to secondhand smoke, unhealthy diet, physical inactivity and harmful use of alcohol. If these risk factors were prevented, an estimated 75% of premature heart disease, stroke and diabetes, and 40% of cancer could be prevented globally. Many behaviors related to NCD risk factors are initiated during adolescence. The low socio-economic, legal and political status of many women and children increases their exposure and vulnerability to NCD risk factors11 across the RMNCH continuum. There are also projected increases in urbanization, which leads to lifestyle changes that increase the risks of developing NCDs.
Tobacco use, exposure to secondhand smoke and indoor air pollution
Tobacco use, including cigarettes, Bidis (hand-rolled tobacco leaves), snuff and chewing tobacco, during pregnancy adversely impacts fetal health. Smoking during pregnancy is increasing in low- to middle-income countries. Smoking, exposure to secondhand smoke and indoor air pollution during pregnancy increases risk of pregnancy complications, including fetal deaths, low birth-weight and premature delivery. Exposure to indoor air pollution from wood and solid fuel smoke from cooking is a widespread risk factor among women and children in low-income countries and is a contributing factor to childhood pneumonia, which causes 18% of all deaths in children under the age of five.
Unhealthy diet and physical inactivity
Many low- and middle- income countries have a large burden of under-nutrition. Undernutrition during pregnancy increases the risk of intrauterine growth retardation in the babies, which will increase children’s risk of obesity and developing NCDs, such as cardiovascular diseases and type 11 diabetes later in life. Undernutrition in mothers is also associated with low birth-weight and pre-term births, which increases the risk of infant deaths. In addition, rates of overweight and obesity are increasing. Overweight and obesity in women increase the risk of Gestational Diabetes (GDM) (a form of diabetes with onset during pregnancy), pre-eclampsia, pregnancy-induced hypertension, large babies, induced labor, caesarean sections19 and stillbirths.20 GDM is estimated to develop in one in 25 pregnancies and is associated with perinatal complications.
Harmful use of alcohol
ƒAlthough 55% of women globally have never consumed alcohol, it is of growing concern that there are high risk patterns of drinking among women who have consumed alcohol in the past year in many low- and middle-income countries. Consuming alcohol during pregnancy may lead to fetal death or premature delivery. Fetal alcohol syndrome, which can occur in a baby whose mother consumed alcohol during pregancy, is associated with heart abnormalites.
Because addressing NCDs requires a focus on a range of conditions, reducing the burden of NCDs is challenging, particularly for health systems with limited capacity. Evidence shows that NCDs are largely preventable and can be treated and controlled. The Global Strategy for Women’s and Children’s Health recommends that healthcare for NCDs be provided as part of an integrated approach to promote women’s and children’s health.
Integrating care for RMNCH and NCDs
The RMNCH continuum of care offers critical entry points for women and children who may not otherwise have access to healthcare services. Nearly 80% of pregnant women in low- and middle-income countries have at least one antenatal visit23 and children get a series of immunizations - this provides a crucial opportunity for providing integrated services.
Preventative care and health promotion interventions throughout the RMNCH continuum of care can promote sexual health, good nutrition, and physical activity and prevent tobacco use, exposure to secondhand smoke and indoor air pollution and harmful use of alcohol. Interventions addressing alcohol use among adolescents should prevent the use of alcohol among this population. The HPV vaccine can prevent up to 70% incidence of cervical cancer. Pre-conception planning can reduce maternal and newborn health risks for NCDs, particularly for women with diabetes.
In antenatal care, assessment, counselling and management can help prevent and reduce tobacco use in women as well as exposure to secondhand smoke and alcohol use and prevent sexually transmitted diseases and related birth defects.25 A comprehensive, universally available antenatalcare package which includes detection and management of diabetes in pregnancy can help reduce stillbirths by up to 45%, and also prevent maternal and newborn deaths.
As part of post-natal care, congenital heart disease in babies can be screened and treated immediately, preventing newborn deaths and chronic heart conditions.
Strengthening health systems to diagnose, manage and monitor NCDs in women and children
A skilled workforce, affordable interventions, effective referral systems and public awareness and engagement are needed in many low- and middle-income countries to provide care for RMNCH as well as chronic diseases. National health information systems need to be strengthened to get accurate data on NCDs. In Africa, around 80% of people with diabetes are undiagnosed. In many low- and middle-income countries, screening coverage for cancer is usually low. A review of cervical cancer screening programs in 57 countries suggests low-cost screening such as pelvic exams or visual inspection with acetic acid are possible when women contact obstetric services. Integrating NCD-related information with other data on the health of women, children and other household members can help design programs that address the needs of vulnerable and high-risk groups in a more comprehensive manner.
Population-based policies and programs are needed
Population-based programs and policies are required to effectively prevent NCDs and can be implemented with relatively modest resources. For example, interventions to control tobacco and alcohol use include raising taxes and regulating advertising, packaging and labelling of cigarettes and tobacco products. Interventions such as promoting and supporting exclusive breastfeeding for the first six months of life and appropriate complementary feeding can reduce NCD risk factors and prevent NCDs.1 Smoke free laws and clean cookstoves can protect women and children from harmful effects of secondhand smoke and indoor air pollution. Policies on food marketing communications can protect children against the impact of marketing of foods and non-alcoholic beverages high in saturated fats, trans-fatty acids, free sugars or salt. School health programs to promote healthy dietary practices and physical activity benefit girls in particular and help prevent overweight and obesity in the long- term.32 School programs on safe-sex behavior have been successful in improving knowledge on the topic.
To reach the Millennium Development Goals (MDGs) 4 and 5, accelerated progress is required. NCDs can impede progress towards the MDGs and severely affect women’s and children’s health worldwide. Increasing exposure to NCD risk factors affects not only women’s and children’s health, but also increases the vulnerability of future generations to ill-health. The RMNCH continuum of care provides many opportunities to integrate NCD services. These synergies can be strengthened by forging links between the 2010 UN Secretary-General’s Global Strategy for Women’s and Children’s Health and the UN High-level Summit on NCDs in September 2011.