University of Groningen
Pregnancy complications
Fitria, Najmiatul
DOI:
10.33612/diss.167808473
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Publication date: 2021
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Fitria, N. (2021). Pregnancy complications: health economics of screening and prevention. University of Groningen. https://doi.org/10.33612/diss.167808473
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The Division for Sustainable Development (DSD) in the United Nations Department of Economic and Social Affairs (UNDESA) seeks to provide leadership and generate action in promoting and coordinating the implementation of development goals, including the Sustainable Development Goals (SDGs). Notably, SDG 3 aims to ensure healthy lives and promote well-being for all at all ages. Among its targets are reducing the global maternal mortality ratio to less than 70 per 100,000 live births, reducing by one-third premature mortality from non-communicable diseases through prevention and treatment, achieving universal health coverage, including access to quality essential health-care services and access to safe, effective, quality and affordable medications (1)
Maternal and Child health management in Indonesia
Indonesia is a vast archipelago. The significance of the timely transport of patients to an emergency health facility is, therefore, inescapable and eminently challenging. Maternal and neonatal mortality rates differ extensively among Indonesia’s provinces and districts. They are sparsely populated and unable to afford rapidly accessible care for the whole population (2). In this reverence, Indonesia may always be at a shortcoming in meeting the SDGs when compared with smaller countries with more inclusive land communication. Despite decades of political appeals and programmatic support, a large number of births in Indonesia still take place at home. Over 90% of non-hospital deliveries take place in the woman’s (64%) or midwife’s (28%) home (3-5). Most home births in Indonesia are attended by midwives or traditional birth attendants. These birth attendants frequently lack the skills and experience needed to save lives in the face of obstetrical emergencies (4,6). The distribution of midwifery provision in rural areas is limited as about 10% of villages do not have a midwife but a nurse as a midwifery provider (5). There is a deficit in midwife density in remote villages compared with urban areas (4,7)
Current health services for pregnant women in Indonesia include measurements of the height, blood pressure, upper arm circumference and height of the uterus, fetal positioning, fetal presentation, and fetal heart rate calculation, tetanus toxoid immunization status, primary laboratory tests (blood type, Hb and urine), blood tests (such as HIV, syphilis, and malaria in endemic areas), counseling on pregnancy care and prevention of congenital abnormalities and treatment in case of abnormalities (8-10).
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The implementation of health information systems in Indonesia is still in the early stages due to the limitations of facility-based data sources (11). These limitations may appear from the incomplete coverage and management of the system, or the uncritical use of limited data sources. A national insurance program covers pregnancy, delivery, and childbirth, but it does not yet serve all families (10). Hospitals criticize that the decentralized system requires them to provide services, but with insufficient funds or for low fees (7). Families served by public health facilities that are supposed to offer services at no cost find that payment is needed, but the necessary treatment is delayed (11). The new system targeting poor women utilizing the National Health Insurance (JKN) is an essential step in helping to reduce these obstacles. However, it may not be generous enough to protect all people who are considered vulnerable (8).
The burden of hyperglycemia in Indonesia
While maternal health has increased in Indonesia over the past decades, it still falls short of the Sustainable Development Goals. Accumulated evidence has shown that hyperglycemia during pregnancy not only increases perinatal morbidity and mortality in mothers and children but also increases the manifestation of disease later in life. For example, women with GDM have a higher incidence of preeclampsia (PE), cesarean deliveries, and birth trauma. Higher levels of Fasting Blood Glucose (FBG), as in Diabetes In Pregnancy (DIP), are associated with a higher burden in terms of maternal (C-Section and maternal death) and neonatal outcomes (preterm birth, small for gestational age, neonatal death)(12,13) . Close monitoring of the women at-risk population, regarding treatment, is needed to ensure its effect on maternal-neonatal outcomes. This comprehensive action is necessary to reduce the burden of pregnancy complications, inclusive assessing the cost-effectiveness of screening.
Prospective hyperglycemia prevention strategies for Indonesia
The necessary actions for successful hyperglycemia prevention strategies in Indonesia include planning and preparation before pregnancy, lifestyle modification, medical therapy, and postpartum follow-up.
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Health economic evaluation
Health economic evaluations are increasingly common nowadays in public health and medical care research, as they can provide comprehensive insights for both practical and efficient health-care for decision-makers (14). Due to an increasing amount of potential interventions to improve health outcomes in contrast to scarce resources (for example, people, time, facilities, equipment, knowledge, and human resources), it is necessary to have a full assessment on how to allocate these resources efficiently.
Three main types of economic evaluations are cost-minimization analysis (CMA), cost-effectiveness analysis (CEA), and cost-utility analysis (CUA). CMA only applies to interventions that have been proven equal or are expected to be equivalent in their effectiveness. On the other hand, CUA and CEA are the types of economic evaluations that value the effectiveness or consequences of interventions in terms of clinical events or health outcome measures. CEA uses natural effects, or physical units such as life-years gained to measure the effectiveness of health interventions.
Furthermore, CUA uses the quality of life as an outcome measure, commonly expressed in terms of quality-adjusted life-year (QALY) or disability-adjusted life year (DALY). Both in CEA and CUA, an incremental cost-effectiveness ratio (ICER) is used as a summary measure expressing the economic value of an intervention compared to its comparator. The ICER is defined by dividing the difference in cost between intervention and comparator by the difference in their effect (14).
Micronutrient supplementation during pregnancy.
Micronutrient deficiencies are common among women in low-middle income countries. Several studies suggest that micronutrients decreases the risk of maternal-neonatal mortality and improves maternal-neonatal health outcomes (15). Deficiencies in multiple micronutrients result from inadequate dietary intake like vitamins and minerals from vegetables, animal proteins, and also fortified foods (16). Supplementing pregnant women with multiple micronutrients (MMN), including iron-folic acid, is a potentially effective intervention to improve maternal and child health. These multiple micronutrients contain vitamin A, B complex, D, E, Zinc, Calcium, copper, magnesium, selenium, and iodine (15,16).
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Probiotic supplementation in pregnant women.
Several studies have shown that probiotics could recover glycemic control and alleviate some of the adverse effects of type 2 diabetes (17,18). However, whether the effects are generalizable to gestational diabetes mellitus (GDM) is still undetermined. Supplementation with probiotics seems to reduce the risk of newborn hyperbilirubinemia and improve glycemic control, blood lipid profile, and inflammation and oxidative stress in pregnant women with GDM (17,19). Also, in pregnant women with hyperglycemia, probiotic supplementation for six to eight weeks resulted in a significant decrease in insulin resistance (20). So, the use of probiotic supplements seems promising and will be hopeful as a potential therapy to help in the management of hyperglycemia metabolism. However, given the heterogeneity in the existing studies (17,18,20,21), further studies are assured to address the limitations of existing evidence and better inform the management of hyperglycemia in pregnancy (19). Further high-quality studies with longer duration are needed to determine the safety, optimal dosage, and quintessential bacterial composition of prebiotics before their routine use can be recommended in this group of patients (17).
Objectives and outline of the thesis
As the continuum of pregnancy care is comprehensive, this thesis covers a small part of this topic. The aims of this thesis are:
1. To assess the epidemiological and economic impact of screening issues in pregnancy;
2. To evaluate the cost-effectiveness of strategies to improve health in pregnancy.
This thesis is arranged in two sections. The first part is on screening issues during pregnancy, and the second is on the nutritional issues during pregnancy.
Thesis outline:
Chapter 1 Introduction
Section 1 Screening issues during pregnancy
This section describes the types of increased blood glucose among pregnant women, the burden of increased blood glucose, and cost-effective ways to manage the condition.
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Chapter 2 The burden of hyperglycemia first detected in pregnancy among Indonesian women.
This chapter explores the association of hyperglycemia first detected in pregnancy (HFDP) with fetal and maternal outcomes in 3536 high-risk women referred to two West Sumatera hospitals between 2014 and 2015. As a secondary objective, I explored the influence of the timing of the oral glucose tolerance test (OGTT) screening on these associations. This study shows the high mortality rate of mothers suffering from hyperglycemia. Also, the tendency of hyperglycemic women to give birth to preterm children is indicative of poor awareness of maternal services, including glucose screening . Information given in this study could be used as a basis to develop practical approaches to complications associated with hyperglycemia in pregnancy in both mothers and their offspring. Chapter 3 Cost-effectiveness of controlling gestational diabetes mellitus: A
systematic review.
This chapter provides, utilizing a literature review, an overview of the existing evidence on the cost-effectiveness of identification and treatment of GDM, starting from data extraction and study selection from the database into the quality of reporting and risk of bias assessment.
Section 2 Nutritional issues during pregnancy
During pregnancy, women need supplementation to cover their own needs and for the development of the foetus. Iron folic acid is the most commonly used supplementation in pregnancy nowadays. In this section I evaluate the use of multiple micronutrients (MMN) consisting of (30mg iron (ferrous fumarate), 400µg folic acid, 800µg retinol (retinyl acetate), 200IU vitamin D (ergocalciferol), 10mg vitamin E (alpha-tocopherol acetate), 70mg ascorbic acid, 1.4mg vitamin B1 (thiamine mononitrate), 18mg niacin (niacinamide), 1.9mg vitamin B6 (pyridoxine), 2.6µg vitamin B12 (cyanocobalamin), 15mg zinc (zinc gluconate), 2 mg copper, 65µg selenium, and 150µg iodine. In addition, I investigate the potential of the indigenous probiotic dadiah from West Sumatera
Chapter 4 Cost-effectiveness analysis of multiple micronutrients comparing iron-folic acid in reducing maternal-neonatal death in anemic pregnant women.
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This chapter describes a model-based cost-effectiveness analysis of multiple micronutrients (MMN) compared to iron-folic acid (IFA). Maternal outcomes are expressed as disability-adjusted life years (DALYs) averted, maternal-perinatal mortality, and preterm birth.
Chapter 5 Microbiota community structure in traditional fermented milk dadiah in Indonesia: Insights from high-throughput 16S rRNA gene sequencing.
In this chapter, I describe Dadiah as an Indonesian traditional fermented milk (yogurt-like product) that is consumed in West Sumatra, Indonesia (22). This fermented product contains lactic acid bacteria that produce nisin as probiotics which could improve glycemic control. Several studies show that probiotics also could be able to reduce newborn’s hyperbilirubinemia and improve glycemic control, blood lipid profile, and oxidative stress in pregnant women with GDM (20,21).
Chapter 6 General discussion.
This chapter summarizes and discusses the overall results of this thesis, including the main findings, implementations, and recommendations for future research.
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(8) Ministry of Health Republic of Indonesia. PMK No.27/ 2014. Petunjuk Teknis Sistem Indonesian Case Base Groups (INA-CBGs). 2014.
(9) Ministry of Health Republic of Indonesia. PMK No. 59/2014. Standar Tarif Pelayanan Kesehatan Dalam Penyelenggaraan Program Jaminan Kesehatan. 2014.
(10) Ministry of Health Republic of Indonesia. PMK No 97/2014. Pelayanan Kesehatan Masa Sebelum Hamil, Masa Hamil, Persalinan, dan Masa Sesudah Melahirkan, Penyelenggaraan Pelayanan Kontrasepsi, Serta Pelayanan Kesehatan Seksual. 2014.
(11) National Research Council 2013 editor. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future (2013). Washington, DC: The National Academies Press. https://doi. org/10.17226/18437.; 2013.
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Supplement in Pregnant Women with Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Diabetes Res 2019 Sep 5;2019:5364730.
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(21) Zheng J, Feng Q, Zheng S, Xiao X. The effects of probiotics supplementation on metabolic health in pregnant women: An evidence based meta-analysis. PLoS One 2018 May 21;13(5):e0197771.
(22) Sukma. A, Toh. H, Nguyen. T.T.T, Fitria. N, Mimura. I, Kaneko. R, Arakawa. K, Morita. H. Microbiota community structure in traditional fermented milk dadiah in Indonesia: Insights from high-throughput 16S rRNA gene sequencing. Milk Science International 2017;71:1-3.
