Key Takeaways
- The joint clinical practice guideline on diabetes and pregnancy from the Endocrine Society and the European Society of Endocrinology has significant equity gaps, particularly in its applicability to low- and middle-income countries (LMICs).
- The guideline’s recommendations largely reflect high-income health systems, with limited attention to resource-constrained settings where most women with hyperglycaemia in pregnancy (HIP) live.
- Foundational elements such as reliable insulin supply, structured education, and simplified glucose monitoring are essential for equitable scale-up of technology in LMICs.
- A complementary global consensus supplement is needed to adapt diabetes-in-pregnancy care pathways for LMICs, ensuring that advances in diabetes technology translate into improved maternal and perinatal outcomes for women everywhere.
Introduction to the Issue
The recent commentary published in the International Journal of Gynecology & Obstetrics (IJGO) highlights a critical concern regarding the joint clinical practice guideline on diabetes and pregnancy from the Endocrine Society and the European Society of Endocrinology. While the guideline provides a comprehensive framework for managing pre-existing diabetes from preconception to the postpartum period, it falls short in addressing the needs of women in low- and middle-income countries (LMICs). The guideline’s emphasis on technology-enabled care, including continuous glucose monitoring and hybrid closed-loop systems, may not be feasible or accessible in resource-constrained settings, where the majority of women with hyperglycaemia in pregnancy (HIP) live.
The Burden of Hyperglycaemia in Pregnancy
Globally, nearly one in six pregnancies is affected by HIP, with over 90% of births occurring in LMICs. This staggering statistic underscores the need for implementation strategies tailored to resource-constrained health systems. However, the joint guideline largely neglects this reality, limiting its applicability and potential impact in these contexts. The consequence is a significant equity gap, where women in LMICs may not have access to the same level of care as those in high-income countries. This disparity can have severe consequences, including poor maternal and perinatal outcomes, and highlights the need for a more nuanced approach to addressing HIP in diverse settings.
The Need for Context-Appropriate Adoption
Rather than opposing the use of diabetes technologies, the commentary advocates for context-appropriate adoption. This approach recognizes that the implementation of advanced technologies must be tailored to the specific needs and resources of each setting. In LMICs, foundational elements such as reliable insulin supply, structured education, simplified glucose monitoring, task-sharing models, and integrated antenatal care pathways are essential steps that can enable equitable scale-up of technology over time. By prioritizing these fundamental components, healthcare systems in LMICs can build a solid foundation for the future adoption of more advanced technologies, ultimately improving maternal and perinatal outcomes.
A Call to Action
The authors of the commentary call for a complementary global consensus supplement, led by the International Federation of Gynecology and Obstetrics (FIGO) and partners, to adapt diabetes-in-pregnancy care pathways for LMICs. This supplement would provide guidance on how to implement the joint guideline in resource-constrained settings, taking into account the unique challenges and opportunities of these contexts. By embedding equity within guideline design, the global health community can ensure that advances in diabetes technology translate into improved maternal and perinatal outcomes for women everywhere. This requires a collaborative effort, involving stakeholders from diverse backgrounds and settings, to develop context-appropriate solutions that address the complex needs of women with HIP in LMICs.
Conclusion and Future Directions
In conclusion, the joint clinical practice guideline on diabetes and pregnancy from the Endocrine Society and the European Society of Endocrinology is an important step forward in addressing the complex needs of women with pre-existing diabetes. However, its limited applicability to LMICs underscores the need for a more nuanced approach to addressing HIP in diverse settings. By prioritizing foundational elements, advocating for context-appropriate adoption, and developing a complementary global consensus supplement, the global health community can work towards a more equitable and effective response to HIP. Ultimately, this requires a commitment to embedding equity within guideline design, ensuring that advances in diabetes technology benefit women everywhere, regardless of their geographical location or socioeconomic status.