Unravelling non-communicable diseases among pregnant women in a lower-middle-income country and the feto-maternal outcomes: a descriptive cross-sectional study

Abstract

Objectives

This study aimed to determine the prevalence of non-communicable diseases (NCDs) among pregnant women in Sri Lanka and examine the association between NCDs and maternal and fetal outcomes.

Design

A hospital-based, descriptive cross-sectional study.

Setting

The study was conducted in three tertiary care hospitals in the Western Province and one intermediate obstetrics care facility in the Southern Province of Sri Lanka, encompassing diverse, multiethnic populations, over 3 months.

Participants

Data from 1350 pregnant women were collected from discharged bed head tickets of the postnatal obstetric wards using a standardised checklist.

Primary and secondary outcome measures

The primary outcomes were the prevalence of NCDs. Secondary outcomes included associations between maternal NCDs and adverse fetal outcomes such as preterm births and neonatal complications.

Results

Among the participants, 68.5% (n=926) had one or more NCDs, with anaemia (37.9%), obesity (18.1%), gestational diabetes mellitus (14.9%) and hypertensive disorders (13.6%) being the most prevalent. Women with NCDs were at significantly higher odds of adverse fetal outcomes, including preterm birth (OR=2.3, 95% CI: 1.5 to 3.4), neonatal sepsis (OR=2.5, 95% CI: 1.5 to 4.04) and hypoglycaemia (OR=3.5, 95% CI: 1.2 to 10.0). Maternal complications, including postpartum haemorrhage (3.3%) and placental abruption (0.7%), were also more frequent in this group.

Conclusions

NCDs are highly prevalent among pregnant women in Sri Lanka and are significantly associated with adverse maternal and fetal outcomes. Enhanced screening and management strategies during antenatal care are essential to mitigate risks and improve health outcomes, aligning with global efforts to reduce maternal and neonatal morbidity and mortality.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• A hospital-based, descriptive cross-sectional study was conducted in four public hospitals across two provinces in Sri Lanka with a large sample size of 1350 pregnant women.

• Standardised data collection using a uniform checklist ensured consistency across study sites.

• Diagnoses of non-communicable diseases (NCDs) were based on established clinical criteria (eg, WHO, the International Association of Diabetes and Pregnancy Study Group).

• The results may not accurately reflect the prevalence or impact of NCDs in rural areas of the country.

• The study also did not assess NCD-specific feto-maternal outcomes.

Introduction

Non-communicable diseases (NCDs) have become a growing health concern, with rising prevalence globally.¹ According to WHO, in 2022, it was estimated that 41 million individuals succumbed to NCDs, accounting for 74% of all global deaths. A disproportionate burden of these deaths (77%) occurred in low-income and middle-income countries (LMICs).² NCDs are no longer confined to older populations. Individuals from reproductive age groups, particularly pregnant women, are increasingly susceptible to these conditions.³ NCDs significantly contribute to morbidity and mortality during pregnancy.⁴

The Millennium Development Goals led to a substantial reduction in maternal mortality rates, from 390 000 in 1990 to 275 000 in 2015. The Sustainable Development Goals (SDGs) aim to maintain this progress by reducing the global maternal mortality ratio (MMR) to less than 70 per 100 000 live births by 2030 (SDG 3.1). This objective can be achieved by addressing high-risk pregnancies that significantly contribute to mortality and morbidity.⁵

Indirect maternal deaths are mainly due to pre-existing or pregnancy-aggravated conditions rather than direct obstetric causes. These conditions are exacerbated by the physiological effects of pregnancy.⁶ NCDs are recognised as indirect causes of maternal mortality, accounting for 27.5% of maternal deaths as reported in a WHO systematic review⁷ with diabetes, cardiovascular disease, anaemia and neoplasms being the most common in LMICs.⁸

NCDs encountered during pregnancy span a spectrum of acute, chronic, transient and permanent conditions, including hypertensive disorders, hyperglycaemia in pregnancy (gestational diabetes and type II diabetes), anaemia, obesity, thyroid dysfunction, cardiovascular diseases, rheumatological diseases and chronic respiratory conditions such as bronchial asthma.⁹

These conditions are closely associated with adverse maternal and fetal outcomes.^{10 11} For example, gestational diabetes and maternal obesity increase risks of macrosomia, preterm delivery and neonatal hypoglycaemia.¹² Similarly, hypertensive disorders during pregnancy heighten the risk of placental abruption, pre-eclampsia and postpartum haemorrhage. These complications carry both immediate and long-term health consequences, reinforcing the importance of early detection and management.¹³ In this study, pregnancy-specific conditions such as gestational diabetes mellitus (GDM) and gestational hypertension (GHT) were included due to their strong association with long-term metabolic and cardiovascular risks in mothers.

Despite the growing burden, data on the prevalence and types of pre-existing NCDs in pregnancy are limited in the Sri Lankan setting. This study aims to determine the prevalence of NCDs in four large healthcare institutions across two provinces in Sri Lanka. This information will facilitate effective resource allocation and the development of targeted public health interventions to reduce the prevalence of NCDs among pregnant women. Understanding the influence of age and parity on the progression of NCDs supports the creation of targeted, age-appropriate healthcare strategies and enhances patient education, particularly for women planning pregnancies later in life or with higher parity.

Studying NCD-associated fetal outcomes is crucial for improving neonatal care in healthcare settings where high-risk pregnancies are being managed. Assessment of maternal outcomes will provide valuable insights to improve postnatal care, ensuring that women with NCDs receive proper follow-up to prevent long-term health complications. Ultimately, achieving these objectives will align with SDG 3.1 (reducing maternal mortality) and SDG 3.2 (ending preventable neonatal deaths).

Methods

Study design and setting

This hospital-based descriptive study was conducted over 3 months (April–June 2023) at three tertiary care hospitals in the Western Province and one intermediate obstetrics care facility in the Southern Province of Sri Lanka. Western Province has the largest population in Sri Lanka, with diverse ethnic groups. The selected tertiary care hospitals include Colombo South Teaching Hospital, De Soysa Hospital for Women and Colombo North Teaching Hospital. The fourth hospital selected for the study was a base hospital located in the Southern Province.

Data collection

Data from 1350 pregnant women were collected from discharged bed head tickets (BHTs) of the postnatal obstetric wards using a standardised checklist. Individual patient data, such as name and address, were not collected. Information collected included age category, parity, pre-pregnancy body mass index (BMI), underlying NCDs during current pregnancy and treatments taken, obstetric history, including previous NCDs and outcome of babies, and investigation results (haemoglobin and red cell indices). BHTs missing any of these key details were excluded.

The NCDs included cardiovascular disorders, hypertensive disorders in pregnancy, endocrine disorders, including pre-existing diabetes mellitus and GDM and thyroid disorders, neurological disorders, psychiatric disorders, haematological disorders, gastrointestinal disorders (peptic ulcer disease and gastro-oesophageal reflux disease), chronic liver disease, chronic respiratory diseases and rheumatological diseases, including systemic lupus erythematosus and cancer. Although gestational diabetes and GHT are pregnancy-specific conditions, they were included due to their established association with long-term risks for type 2 diabetes and chronic hypertension, respectively. These conditions, though not classified as NCDs under standard WHO definitions, were considered within the study scope due to their prognostic value and clinical relevance to both immediate pregnancy outcomes and future maternal health.

Maternal outcome data were documented, including mode of delivery (spontaneous vaginal delivery, assisted vaginal delivery, caesarean section), mode of induction of labour and complications like placental abruption and postpartum haemorrhage. Fetal outcomes were reported as live births, stillbirths and preterm deliveries. For live births, the gestational age, birth weight, 5 min Apgar score, presence of birth trauma, neonatal hyperbilirubinaemia and need for respiratory support were recorded. There were no potential sources of bias.

Permission to access patient records was obtained from each hospital’s administrative authority and the relevant consultants of postnatal obstetric wards.

Definitions

The NCDs were defined based on established diagnostic criteria. Standard 1999 WHO diagnostic criteria (FBS>126 mg/dL or 75 g OGTT 2-hour value>200 mg/dL) for non-pregnant adults were used for the diagnosis of pre-gestational diabetes mellitus (T2DM).¹⁴ The International Association of Diabetes and Pregnancy Study Group criteria based on the Hyperglycaemia and Adverse Pregnancy Outcome study (FBS>92 mg/dL, 75 g OGTT 1 hour value>180 mg/dL, 75 g OGTT 2 hour value>153 mg/dL) was used to diagnose GDM.¹⁵

Chronic hypertension was defined as blood pressure≥140/90 mm Hg before 20 weeks of gestation or a prior diagnosis of hypertension. GHT refers to new-onset hypertension≥140/90 mm Hg after 20 weeks of gestation.¹⁶ Anaemia in pregnancy was defined as a haemoglobin concentration<11 g/dL, according to WHO criteria. Obesity was classified based on a pre-pregnancy BMI≥30 kg/m².¹⁷

Hypothyroidism was defined as elevated Thyroid-stimulating hormone (TSH) levels above the trimester-specific upper reference range (2.5 mIU/L in the first trimester and 3.0 mIU/L in the second and third trimesters) and low free T4 level or previously diagnosed women on treatment. Hyperthyroidism was defined as the lower limit of TSH as 0.1 mlU/L in the first trimester, 0.2 mlU/L in the second trimester and 0.3 mlU/L in the third trimester or if diagnosed before pregnancy.¹⁸

Cardiovascular diseases included documented congenital heart defects, valvular abnormalities, ischaemic heart disease and arrhythmias. Psychiatric disorders of any type diagnosed before or during pregnancy, including depression, anxiety, schizophrenia or bipolar disorder as recorded in patient files, were included.

Data analysis

Quantitative data were systematically collected, entered, validated and analysed. Statistical analysis was performed to determine the prevalence of pregnancy-related or aggravated conditions, prevalence of NCDs and both maternal and fetal outcomes. The Wilson score interval was used for calculating the 95% CIs for proportions. The Z test was used to assess the statistical significance of the differences between proportions, with a predetermined significance level of 5%. ORs with 95% CIs were calculated to estimate the risks associated with adverse fetal outcomes.

Patient and public involvement

This study did not involve direct patient or public participation.

Results

Among a total of 1350 pregnant women, 42.1% (568) were primigravida and 57.9% (n=782) were multigravida. The mean age of participants was 28.9 years (SD±5.5). 23 women (1.7%) were teenagers (<18 years), and 12.9% were aged≥35 years.

Among all participants, nearly 69% (n=926; 95% CI: 66.0 to 71.1) had one or more NCDs and 8.4% of all women had three or more NCDs. Among the 568 primigravida women, 65.8% (95% CI: 61.8 to 69.7) had one or more NCDs. 56.5% of teen primigravida women had one or more NCDs. In the elderly age group (35 years or more), those in their first pregnancy, 78.9% had one or more NCDs, while those in their third pregnancy or more, 79.4% had at least one NCD (table 1).

Table 1. Age parity standardisation on the prevalence of non-communicable diseases.

Non-communicable diseases	Parity 1			Parity 2		Parity 3
	<18 years (n=23)	19–34 years (n=507)	≥35 years (n=38)	19–34 years (n=379)	≥35 years (n=48)	19–34 years (n=229)	≥35 years (n=126)
None
N (%)	10 (43.5%)	176 (34.7%)	8 (21.1%)	128 (33.8%)	11 (22.9%)	65 (28.4%)	26 (20.6%)
95% CI	25.7 to 63.2	30.7 to 38.9	11.1 to 36.4	29.2 to 38.7	13.3 to 36.5	23.0 to 34.6	14.5 to 28.5
1
N (%)	10 (43.5%)	211 (41.6%)	11 (28.9%)	147 (38.8%)	18 (37.5%)	84 (36.7%)	54 (42.9%)
95% CI	25.7 to 63.2	37.4 to 45.9	17.0 to 44.7	34.0 to 43.8	25.2 to 51.6	30.7 to 43.1	34.6 to 51.5
2
N (%)	1 (4.3%)	83 (16.4%)	12 (31.6%)	84 (22.2%)	11 (22.9%)	55 (24.0%)	32 (25.4%)
95% CI	1.1 to 29.2	13.4 to 19.9	19.1 to 47.5	18.3 to 26.7	13.3 to 36.5	18.9 to 29.9	18.6 to 33.7
≥3
N (%)	2 (8.7%)	37 (7.3%)	7 (18.4%)	20 (5.3%)	8 (16.7%)	25 (10.9%)	14 (11.1%)
95% CI	2.4 to 26.8	5.3 to 9.9	9.2 to 33.4	3.5 to 8.0	8.7 to 29.6	7.4 to 15.6	6.7 to 17.8

Among those who had NCDs, 0.3% were teen pregnancies, and nearly 18% were over 35 years old. Among the women between the ages of 18 and 34 years, 59.2% (590) had one or more NCDs (figure 1).

Figure 1. Prevalence of non-communicable diseases (NCDs) among pregnant women.

Table 2 compares the prevalence of specific NCDs among primigravida and multigravida women. The most common NCD in the participant group is anaemia (37.9%, n=511), followed by obesity (18%), GDM (14.9%) and hypertension in pregnancy (13.6%). An array of heart diseases was identified among 4.2% (n=57) of participants. 31 pregnant women (2.3%) had psychiatric conditions. A significant difference was seen between the proportions in primi and multigravida for hyperglycaemic conditions, bronchial asthma and obesity (p<0.05).

Table 2. Prevalence of specific non-communicable diseases among multigravida and primigravida women.

	Total (%)	Primigravida (n=568) (%)	Multigravida (n=782) (%)	Z test; p value
All non-communicable diseases	926 (68.5)	374 (65.8)	552 (70.6)	1.8; 0.06
Type 2 diabetes mellitus	40 (3.0)	7 (1.2)	33 (4.2)	3.2; 0.001
Gestational diabetes mellitus	201 (14.9)	69 (12.1)	132 (16.9)	2.4; 0.02
Chronic hypertension	34 (2.5)	14 (2.5)	20 (2.6)	0.11; 0.9
Gestational hypertension	150 (11.1)	58 (10.2)	92 (11.8)	0.9; 0.34
Bronchial asthma	103 (7.6)	57 (10.0)	46 (5.9)	2.8; 0.004
Anaemia	511 (37.9)	205 (36.1)	306 (39.1)	1.1; 0.2
Hypothyroidism	50 (3.7)	23 (4.0)	27 (3.5)	0.57; 0.57
Hyperthyroidism	03 (0.2)	2 (0.4)	1 (0.1)	0.86; 0.39
Heart disease	57 (4.2)	26 (4.6)	31 (4.0)	0.55; 0.58
Epilepsy	15 (1.1)	8 (1.4)	7 (0.9)	0.88; 0.37
Obesity	245 (18.1)	79 (13.9)	166 (21.2)	3.4; 0.001
Cancer	05 (0.4)	2 (0.4)	3 (0.4)	0.09; 0.9
Psychiatric conditions	31 (2.3)	12 (2.1)	19 (2.4)	0.38; 0.7

According to figure 2, all NCDs show an increased prevalence in the subsequent pregnancy. A statistically significant increase was observed in the number of women acquiring additional NCDs in their subsequent pregnancies. This pattern was most prominent for anaemia, obesity, hypertensive disorders, heart disease and mental health conditions (p=0.001).

Figure 2. Prevalence of an increase or a decrease in non-communicable diseases (NCDs) in multigravida women (n=782).

Feto-maternal outcome

Out of a total of 1350 pregnancies, 1337 were live births, while 12 (0.89%) were stillbirths, with one miscarriage. Regarding the mode of delivery, 758 (56.1%) births were by spontaneous vaginal delivery, while 560 (41.5%) accounted for lower segment caesarean sections. Out of the caesarean births, the majority were intrapartum (emergency) caesarean sections with a total of 297 (53.0%), while the rest were planned caesarean sections. Vacuum deliveries accounted for 22 (1.6%) births, while 6 (0.4%) mothers had forceps deliveries.

A total of 176 (13%) births were preterm deliveries, of which 107 (7.9%), 29 (2.1%), 32 (2.4%) and 8 (0.6%) were respectively late preterm, moderate preterm, very preterm and extremely preterm babies.

Out of a total of 1338 live births, the mean birth weight was 2837.8 (± 540.5) g, among which 281 (21%) babies had a low birth weight of less than 2500 g. Among those with low birth weight, 25 babies had very low birth weight (1000–1499 g) and 19 babies had extremely low birth weight (<1000 g). 11 (0.8%) babies were macrosomic (>4000 g).

Fetal outcomes were studied based on the need for respiratory support, presence of birth trauma and other adverse outcomes, including neonatal sepsis, neonatal hyperbilirubinaemia and neonatal hypoglycaemia.

As shown in table 3, approximately 15% of births were complicated by the need for respiratory support after birth, followed by neonatal sepsis (9.4%) and neonatal hyperbilirubinaemia (9.7%). Stillbirth accounted for 0.88% of the pregnancies. Among women with one or more NCDs, the odds of these complications were significantly higher, with exploratory ORs as follows: respiratory support (OR=1.8, 95% CI: 1.3 to 2.6), sepsis (OR=2.5, 95% CI: 1.5 to 4.04), hypoglycaemia (OR=3.5, 95% CI: 1.2 to 10.0) and preterm birth (OR=2.3, 95% CI: 1.5 to 3.4). Stillbirths were not significantly associated with maternal NCDs (OR=1.4, 95% CI: 0.4 to 5.1).

Table 3. Adverse fetal outcomes.

Adverse fetal outcomes	Total	% among total births	% among live births	With one or more non-communicable diseases (%)	No non-communicable diseases	OR (95% CI)
Stillbirth	12	0.88	0.89	9 (75.0)	3 (25.0)	1.4 (0.4 to 5.1)
Respiratory support	202	14.96	14.55	159 (78.7)	43 (21.3)	1.8 (1.3 to 2.6)
Sepsis	127	9.40	9.15	106 (83.5)	21 (16.5)	2.5 (1.5 to 4.04)
Hyperbilirubinaemia	131	9.70	9.43	102 (77.9)	29 (22.1)	1.7 (1.1 to 2.6)
Hypoglycaemia	34	2.51	2.44	30 (88.2)	4 (11.8)	3.5 (1.2 to 10.0)
Preterm birth	176	13.03	12.68	144 (81.8)	32 (18.2)	2.3 (1.5 to 3.4)
Any fetal outcome	406	30.07	29.25	313 (77.1)	93 (22.9)	1.8 (1.4 to 2.4)

The maternal adverse outcomes studied were placental abruption, postpartum haemorrhage and death. 44 (3.3%) births resulted in postpartum haemorrhage, 9 (0.7%) births in placental abruption and only 1 birth resulted in maternal death.

Out of total births, 220 (16.3%) resulted in adverse maternal outcomes, which was either a preterm delivery, Post Partum Haemorrhage (PPH), abruption or death. Among those who had an adverse maternal outcome, 169 (76.8%) had one or more NCDs, and 51 (23.2%) did not have any NCDs, which was found to be a statistically significant factor (p=0.001).

Given the cross-sectional nature of the study, the associations observed between NCDs and adverse feto-maternal outcomes do not imply causation, and this has been acknowledged as a limitation of the study.

Discussion

Our study reveals a substantial burden of NCDs among pregnant women, with nearly 68.5% of participants affected by at least one NCD (figure 1). The most prevalent conditions identified were anaemia (37.9%), obesity (18.1%), hyperglycaemia in pregnancy (17.9%) and GHT (11.1%). These findings align with regional trends but highlight an intensified challenge in Sri Lanka. All these NCDs show a statistically significant increase during index pregnancy compared with the previous pregnancy (figure 2).

Comparatively, studies from neighbouring South Asian countries, such as Nepal and Bangladesh, report lower prevalence rates of similar NCDs among women of reproductive age (18–49 years). For instance, Nepal reports a prevalence rate of 39%, while Bangladesh reports a prevalence rate of 34.55%.^{19 20} However, India’s National Family Health Survey reports a prevalence of 77% for anaemia, obesity, diabetes, hypertension and thyroid disease.²¹ These differences may be attributed to variations in healthcare infrastructure, dietary practices and socioeconomic factors, suggesting a unique and pressing need for targeted healthcare strategies within Sri Lanka.

The prevalence of NCDs is significantly influenced by age and parity, with an increased risk among women of advanced maternal age and those with higher parity (table 1). Specifically, we observed higher rates of NCDs, such as GDM and hypertensive disorders, among women over 35. This trend is noteworthy as it reflects the global shift towards delayed pregnancies, often associated with the increased use of assisted reproductive technologies (ARTs).²² As described by Lang et al, ARTs are associated with higher rates of primiparity, GHT, pre-eclampsia, preterm birth and caesarean sections.²³ These findings emphasise the necessity for enhanced screening protocols and antenatal care practices, particularly for advanced maternal age primigravidas in Sri Lanka.

Anaemia was the most prevalent NCD in our cohort, suggesting both nutritional and systemic barriers to effective management. This corresponds with national data, where anaemia was the most prevalent NCD among pregnant women in Sri Lanka from 2017 to 2021.²⁴ However, there has been a decline in the number of diagnosed cases of anaemia and case rate from 2019. Hospital-based antenatal clinics have also shown a significant improvement in screening for anaemia among registered expectant women from 33.4% (2020) to 89.3% (2021).²⁵ Despite national improvements, gaps remain—likely worsened by COVID-19-related healthcare disruptions.

Maternal anaemia is significantly associated with preterm birth, low birth weight, perinatal and neonatal mortality in LMICs.²⁶ Our study suggests a potential correlation between these disruptions and the elevated rates of anaemia, possibly reflecting limited access to essential antenatal care services in rural regions during this period. Addressing this disparity through targeted nutritional support and consistent screening in antenatal clinics, especially in underserved areas, could substantially reduce the risks of anaemia-related complications and improve overall maternal and fetal health outcomes.

Similarly, the increased prevalence of GDM and obesity observed in our study points to a critical need for early detection and management strategies. While nearly 82.1% of pregnant women in Sri Lanka undergo BMI screening at their first antenatal visit, preventive strategies like dietary counselling and physical activity remain underused.

Globally, GDM affects approximately 7% of pregnancies, varying between 1% and 14% depending on the population studied and the diagnostic criteria used.²⁷ The prevalence of GDM in India is 13% as per the Diabetes in Pregnancy Study of India diagnostic criteria.²⁸ In our study, the prevalence of GDM and T2DM was 14.9% and 3.0%, respectively (table 2). Higher prevalence in contrast with worldwide trends can be primarily attributed to Asian ethnicity and higher rates of overweight in our population.^{29 30}

Sri Lankan data from 2021 revealed that GDM was the predominant form of hyperglycaemia in pregnancy, accounting for 6.23% of cases, with 1.48% showing chronic diabetes. 0.31% of cases of GDM progressed into diabetes mellitus during the postpartum period.²⁵ Furthermore, women with GDM in their index pregnancy were 10.6 times more likely to develop diabetes within 10 years compared with women without GDM.³¹ Interpregnancy care should be considered a continuum of postpartum care, providing an opportunity to optimise health status before a subsequent pregnancy. This can be achieved through health counselling, postpartum glucose monitoring, weight management and pharmacological management of hyperglycaemia. These interventions may ensure long-term favourable health outcomes.

Globally, approximately 10% of pregnancies are complicated by hypertensive disorders.³² An Indian study revealed that 11% of pregnancies were affected by hypertension-related disorders.²⁹ Our study observed a 9.3% prevalence, aligning with global and regional statistics (table 2). These disorders, including both GHT and chronic hypertension, continue to pose significant challenges, with significant implications for long-term maternal health. Consistent with global studies, our study also identified a similar association between hypertensive disorders and adverse pregnancy outcomes, necessitating the importance of tailored antenatal and postpartum care. International guidelines recommend postpartum blood pressure monitoring and the use of low-dose aspirin in subsequent pregnancies as preventive measures for women with a history of hypertensive disorders.³⁰ This approach can help mitigate future cardiovascular risk and support women in maintaining a healthy post-pregnancy lifestyle.

Among the psychiatric conditions associated with pregnancy, depression and anxiety were the most prevalent. A recent review indicates that the prevalence of perinatal depression and anxiety in Asian women is 20%.³³ The first Sri Lankan study on antenatal depression reported a prevalence of 16.2% among women at 24–36 weeks of gestation.³⁴ Our study identified depressive disorder in 1% and schizophrenia in 0.33% of participants. However, a qualitative study done in the Southern Province of Sri Lanka recognised that healthcare workers at the community level lacked proper guidance in recognising antenatal mental health issues and therefore raises the need for standardised diagnostic tools.³⁵

The study highlights the impact of maternal NCDs on neonatal outcomes. Neonates born to women with NCDs were at a substantially higher risk of adverse neonatal events such as the need for respiratory support, neonatal sepsis, hypoglycaemia and preterm birth. Overall, 30% (n=406) of births resulted in adverse fetal outcomes, with statistically significant ORs for all adverse outcomes except stillbirths.

In contrast to our study, a hospital-based prospective Indian study of 894 participants⁴ reported significantly higher incidence of stillbirths and maternal deaths, 5.7% (n=57) and 6 (0.7%), respectively. Our study population showed less incidence of stillbirths and maternal deaths: 0.88% (n=12) and 0.074% (n=1), respectively. These results align with declining stillbirth rate trends in Sri Lanka, where the average annual decline was 4.65% from 2007 to 2013.³⁶ In 2022, Sri Lanka’s stillbirth rate was 6.2 per 1000 live births, and the MMR was 33 per 100 000 live births.³⁷ Notably, Sri Lanka has the lowest MMR in Southeast Asia.³⁸

Our findings indicate that respiratory support was required for approximately 15% of live births, and this need was significantly higher among infants born to women with NCDs. This aligns with research suggesting that conditions like gestational diabetes and maternal hypertension are associated with respiratory distress, likely due to the intrauterine impact of maternal metabolic imbalances and compromised placental function.^{10 39}

Furthermore, neonatal sepsis and hyperbilirubinaemia were observed in 9.4% and 9.7% of live births, respectively, with a significantly higher risk among infants born to women with NCDs. Maternal anaemia has been associated with an increased risk of neonatal sepsis and low birth weight, underscoring the necessity for improved antenatal nutrition and infection prevention strategies.

Neonatal hypoglycaemia, seen in 2.5% of births, was also more common among neonates born to women with NCDs. Hypoglycaemia is frequently linked to maternal hyperglycaemia and may have long-term neurodevelopmental effects if untreated. Therefore, screening and managing maternal glycaemic control are essential to prevent neonatal metabolic complications.

Preterm birth, accounting for 13% of the total deliveries in our study, was significantly associated with maternal NCDs. Given that preterm birth often correlates with maternal hypertensive disorders and diabetes, effective management of these conditions could reduce preterm risks and improve neonatal outcomes.

In terms of maternal postnatal outcomes, 16.3% of NCD-affected pregnancies resulted in adverse maternal outcomes like postpartum haemorrhage and placental abruption. A retrospective cohort study in Pakistan⁴⁰ revealed a higher rate of caesarean section among women with NCDs (67.3%) compared with 41.5% in our study. Most caesarean deliveries in our study involved women with T2DM and hypertension, while thyroid disorders had no significant effect on the mode of delivery.

Our study also highlights the increase in the frequency of NCDs in subsequent pregnancies among multigravida women. This trend underscores the cumulative impact of unmanaged or emerging health issues in women with multiple pregnancies. Given the observed impact of maternal NCDs on neonatal and postnatal health, it is essential to establish comprehensive care strategies. Reproductive health programmes should be integrated with national NCD programmes to facilitate early detection, diagnosis and optimisation of management of these patients. It may be effective to have antenatal clinics dedicated to medical disorders with easy access to multidisciplinary inputs.

Barker’s hypothesis proposes that suboptimal maternal nutrition during intrauterine life and early childhood increases the likelihood of NCDs in the offspring. Chronic maternal malnutrition in LMICs is closely linked to child malnutrition. Therefore, improving the nutritional status of women of reproductive age is a crucial element of public health preventive strategies. It will reduce the burden of NCDs on future generations.⁴¹

The life-course approach to prevent NCDs is a strategy that emphasises the importance of addressing risk factors and promoting health throughout the lifespan, from early childhood to old age. It recognises that the risk of developing NCDs, such as cardiovascular diseases, diabetes and cancers, is influenced by a complex interplay of factors over an individual’s lifetime, including genetics, early life experiences, lifestyle choices and environmental exposures.⁴²

WHO SDG 3.1 aims to reduce the global MMR to less than 70 per 100 000 live births, with no country exceeding the global average by 2030, while SDG 3.2 aims to end preventable deaths of newborns with all countries aiming to reduce neonatal mortality to at least 12 per 1000 live births. In 2020, nearly 95% of all maternal deaths occurred in low-income and lower-middle-income countries.⁴³ Therefore, it is high time to intensify the preventive strategies at the regional, national and community levels in our part of the world.

Strengths and limitations

This study provides an in-depth analysis of the prevalence of NCDs among pregnant women and their associated feto-maternal outcomes in a multiethnic setting. The study population included patients from both tertiary and secondary care centres. However, it is important to note that these results may not accurately reflect the prevalence or impact of NCDs in rural areas in the country. The study population consisted of patients with more complicated pregnancies that necessitate specialised care at tertiary centres. Another limitation is the cross-sectional design of the study, which precludes the establishment of causal relationships between NCDs and the observed feto-maternal outcomes. The study also did not assess NCD-specific feto-maternal outcomes.

Conclusions

The burden of NCDs during pregnancy is high. Early detection and proper medical management of different entities are of utmost importance to minimise adverse feto-maternal outcomes.

Whether in high-income or lower-middle-income countries, NCDs are the leading causes of death for women. Recognition of these conditions in women during pregnancy is crucial. The life-course approach is a cost-effective way of identifying NCDs in pregnancy and postpartum periods. Improvement of antenatal care facilities for early detection of NCDs before pregnancy and in the interpregnancy period is of utmost importance. This will be of national importance while Sri Lanka and other countries aim to achieve SDGs 3.1 and 3.2, which aim to reduce maternal and neonatal mortality by 2030 while also enhancing health equity for women.

Data availability statement

Data are available upon reasonable request.