Pregnancy as an Opportunity to the Obstetricians to Improve Long-Term Maternal Health

Pregnancy presents a unique window of opportunity in the life of the women to improve her long-term health by allowing her to visit a doctor for antenatal care many times during the pregnancy [1]. Though many metabolic problems like adolescent polycystic ovarian disease, diabetes and infertility can send a woman to a gynaecologist much before pregnancy, the visits are not always positive, pressing, consistent and encouraging to the women like the antenatal visits. During pregnancy due to the expanding family and changed goal of the couple towards the child, parents are open to counselling and more self-care. This rapport with the doctor can continue throughout life, if the doctor also extends a helping hand. Post-pregnancy interventions for appropriate weight of the mother, breastfeeding and lactational tips and tricks, and optimal nutrition prevent the development of chronic non-communicable diseases. Screening for postpartum anaemia, hypothyroidism and blood sugars at the end of six weeks along with contraception counselling if not already undertaken will help the woman to be confident about her future health.

It is known that pregnancy associated complications such as gestational diabetes, Vitamin D deficiency, hypothyroidism and pregnancy-induced hypertension are associated with higher risk for type 2 diabetes mellitus and cardiovascular disease, respectively, at a later stage in life. Recurrent miscarriage, stillbirth, spontaneous preterm birth, and placental abruption are all associated with increased risk for cardiovascular disease. The load placed by the pregnancy on the physiology of the compromised woman mimics the old age non-communicable diseases that the woman is going to face. Hence it is prudent both for the Gynaecologist and the woman herself along with her family to take notice of the condition and work towards eliminating the high risks or intervene appropriately for control.

Malnutrition and obesity underlie most of the pregnancy complications and if continued they are seen to lead to long-term chronic diseases also. It is estimated that one-third of the world's population suffers from malnutrition, whether it be thinness or obesity or micronutrient deficiencies. India is no different. Suboptimal nutrition, obesity, anaemia, small for gestational age foetus, macrosomia are seen very commonly by Obstetricians. The only soothing factor is that they can be controlled with appropriate lifestyle interventions at a young age. The timing of interventions are proportional to disease control [2].

The antenatal visits and post-pregnancy period presents a unique positive opportunity to intervene and improve future maternal health and family health. The six weeks postpartum follow-up can investigate such patients, offer contraceptive advice and also investigate the husband if need be. With regular further follow-up, pregnancy complications faced by the women can be reviewed and management plans to ensure that women can avail of early identification and intervention of chronic diseases such as glucose intolerance and type 2 diabetes, and cardiovascular diseases such as hypertension, ischæmic heart disease, and stroke.

The antenatal and postpartum visit presents an opportunity to review a woman's recent pregnancy and plan for care for the entire family going forward. Many healthcare systems have robust neonatal and child follow-up programmes and these could be utilised to also consider maternal health status at the same visit. Regular weight check-up, blood pressure monitoring and investigations for hypothyroidism can be done even in paediatric clinic. A pregnancy passport could facilitate planning of optimal care and screening, following pregnancy complications. This has been developed by some centres and the FIGO Committee on Impact of Pregnancy on Long-term Health plans to develop a pregnancy passport that could be used globally.

Exclusive breastfeeding is a very early post-pregnancy intervention that has significant positive impacts on maternal and child health. In addition to immediately reducing postpartum haemorrhage, encouraging normal uterine involution, promoting maternal and child bonding, and preventing neonatal infectious diseases, emerging data now support its role in reducing risk of type 2 diabetes and even cardiovascular disease to the mother. Longer lifetime breastfeeding can reduce lifetime risk of cardiovascular disease—the most common cause of death in young women in India. Women with higher body mass index need additional emotional and psychological support to continue lactation and health care systems should be aware of these requirements, if required lactational consultants can be used for help [3, 4].

Many healthcare providers feel ill-equipped to accurately counsel women about health nutrition or shortage of time to speak in detail to the woman in a busy clinic. The FIGO Nutrition Checklist has been developed as an easy tool to facilitate these discussions. This checklist has been validated against a robust dietary assessment tool—the Food Frequency Questionnaire—and has been found easy to use in many settings in Europe, India, Hong Kong, and South Africa. The FIGO Nutrition Checklist is now available online via the FIGO website and can be adapted for local dietary practices. M-health accessible from women's smart phones can also be a useful resource for nutrition advice [5, 6].

Care of women with obesity at any age should be tailored to the lifestyle of the woman, be culturally appropriate, and involve a multidisciplinary team. In remote areas, where crowded clinics make multidisciplinary consultations a challenge, one day of the week could be devoted for such consultations. Gestational diabetes identifies women with a 50% chance of developing type 2 diabetes in later life and is the best-known association between pregnancy complications and health in later life. To date, lifestyle and pharmacological interventions have been shown to reduce the risk of later type 2 diabetes. Hence this should be utilised to the best possible level [7].

FIGO is committed to improve women's health across the life course and the FIGO Committee on Impact of Pregnancy on Long-term Health will continue to advocate for improved women's health by:

• Promoting breastfeeding in all settings, by promoting first breastfeed within 1 h of life and by continuing to support women to breastfeed to 6 months of age.

• Promoting the postnatal visit as a key intervention time to review pregnancy complications and to scope out care requirements to reduce women's risk of chronic disease.

• Developing and disseminating FIGO clinical guidance, best practice advice, and toolkits to improve healthcare systems—to think nutrition and weight first at every contact [8].

• Reaching out to all stakeholders involved in the care of women throughout the life course to increase their engagement with and understanding of FIGO's messages, guidelines, and available tools (member societies, front-line healthcare professionals, partner nongovernment organisations, women and their families).

FOGSI in its turn has labelled 2023 as the year of “Badlav” which means change in Hindi. It denotes the change required in doctors thinking about Obstetrics as a separate entity from the general health of the women. The work of an Obstetrician is not over when the patient has delivered. In fact, it has just began. Contraception, immunisation, screening for non-communicable diseases, screening for infectious diseases, screening for malignancies, the list is very very long.

“Mothers are not dying because of diseases we cannot prevent or treat. They are still dying because societies have yet to make the decision that their lives are worth saving.” This observation made by Mohammed Fathallahin in 1997, and sadly even today it remains a glaring, inconvenient truth.