Prevention and control of non-communicable diseases in antenatal, intrapartum, and postnatal care: a systematic scoping review of clinical practice guidelines since 2011

We adopted the Institute of Medicine’s definition for defining clinical practice guidelines (see above). WHO’s definition of a health intervention was used: “an act performed for, with or on behalf of a person or population whose purpose is to assess, improve, maintain, promote or modify health, functioning or health conditions” [10]. We used a broad definition for NCD categories identified from Global Health Estimates [11], including cardiovascular diseases, neoplasms, digestive diseases, respiratory diseases, diabetes mellitus, genitourinary diseases, neurological conditions, mental and substance use disorders, endocrine/blood/immune disorders, musculoskeletal diseases, congenital anomalies, skin diseases, and oral conditions. The list of NCD categories and their conditions are specified in the Additional file 2: Table 1. Additionally, to define antenatal, intrapartum, and postnatal care, the WHO definitions for stages of care [12] were used.

With support from an information specialist, a search strategy was developed using medical subject headings and keywords to identify guidelines related to specified NCDs (Additional file 3: Tables 1-3. The search terms for guidelines were derived from a search filter developed by the Canadian Agency for Drugs and Technologies in Health [13]. We searched PubMed, Global Index Medicus, TRIP database, and Guideline International Network on 31 May 2021. In addition, we searched the websites of 137 specialist societies of obstetrics and gynecology (if available), 28 medical associations, and WHO (Additional file 4: Table 1).

Guidelines meeting the following criteria were included: (1) meets the definition of clinical practice guidelines by the Institute of Medicine (i.e., informed by a systematic review of evidence); (2) developed by a nationally recognized committee or a medical society for national, regional, or international use; (3) published between 1 January 2011 and 31 May 2021, and accessible in the public domain; and (4) provides recommendations related to NCDs for interventions on detection/diagnosis, clinical treatment or care, or health system management. To focus on contemporary clinical practice and minimize inclusion of outdated or superseded guidelines, we limited inclusion to guidelines published within the last 10 years. If multiple versions of the same guideline were identified, only the most recent version was included. Guidelines were excluded if the recommendations were provided for non-chronic conditions caused or aggravated by pregnancy. Guidelines that were developed for subnational, hospital, or local use were not eligible.

Screening was conducted using Covidence [14]. Two authors independently screened title and abstracts of records identified from the search using the aforementioned eligibility criteria. We retrieved the full texts for potentially eligible guidelines, which were also assessed in duplicate by two review authors against the same criteria. For guidelines published in a language other than English, Google Translate was used to assess eligibility. If researchers found Google Translate was insufficient to translate the guideline, they had an option to receive assistance from a translator or a public health researcher who was native in the language requiring translation. At all stages of screening, disagreements were resolved by discussion or through involvement of a third reviewer. For studies that could not be retrieved, a librarian was contacted to request a copy.

Two authors independently extracted data using a standardized form which was pilot tested on a sample of 20 eligible guidelines and refined. At the guideline level, extracted data included title, authors/organization, publication year, country/region of publication, type of guideline (general or pregnancy-specific), number of pages, NCD category, and condition. We tagged guidelines as corresponding to an NCD condition if they had at least one recommendation for that condition. Included guidelines were classified into two broad areas—“pregnancy-specific” guidelines (i.e., the scope of the guideline pertained only to the management of pregnant, intrapartum, or postnatal women) or “general” guidelines (i.e., guidelines where the scope related to management of NCD conditions in adults or across multiple population groups, and which included specific sections on NCD-related antenatal, intrapartum, or postnatal care).

Preliminary review findings were presented at the WHO technical consultation, which informed the selection of high-priority conditions for guideline development (see Additional file 2: Table 1). We then identified the subset of guidelines that included recommendations pertaining to one or more of the high-priority conditions, and extracted all relevant recommendations. While obesity was identified as a high-priority condition during the technical consultation, it was not included in the original review protocol as it was considered to be a risk factor. For the other high-priority conditions, we extracted recommendations and classified them by stage of care (antenatal, intrapartum, or postnatal) and intervention type (screening/diagnosis, clinical, or health system). Any disagreements were resolved by discussion or with the involvement of a third reviewer.

Descriptive analysis was used to summarize identified guidelines by NCD category and condition, stage of care (antenatal, intrapartum, postnatal), and intervention type. For each high-priority condition, we prepared narrative summaries and overview tables which mapped the scope of all identified recommendations, and how many guidelines covered each intervention. We did not conduct critical appraisal of the evidence supporting the interventions recommended in identified guidelines, as this was not within the scope of the review.

Patients and public were not directly involved in this review; we used publicly available data for the analysis.

A summary of the characteristics of included guidelines is provided in Table 1, and a further detailed table of characteristics is provided in Additional file 5: Table 1. Of the 405 guidelines, 132 were pregnancy-specific and 273 were general type guidelines. In total, 246 (61%) guidelines were published between 2016 and 2021, and the highest number of guidelines published in 1 year was in 2019 (n=53) (Fig. 2). The countries with highest number of guidelines issued were United States of America (USA) (n=88), United Kingdom (UK) (n=47), Canada (n=29), Australia (n=22), and Italy (n=11). The majority of guidelines were from high-income countries (HICs, n=285), while the remaining 39 guidelines were from middle-income countries (MICs), most commonly Brazil (n=9), China (n=6), Malaysia (n=6), and Thailand (n=3). Other middle-income countries were Georgia, India, South Africa, Argentina, Colombia, Costa Rica, Iran, Kenya, and Romania. There were no guidelines identified from low-income countries. Guidelines were published by a wide range of organizations, including medical specialty societies and organizations from USA (n=67), Europe (n=52), and the UK National Institute for Health and Care Excellence (NICE) (n=11).

The number and distribution of guidelines by disease category and condition are described for pregnancy-specific and general guidelines (Figs. 3 and 4 respectively). In pregnancy-specific guidelines, the most common conditions for which recommendations were provided were GDM, other circulatory diseases, disorders of the thyroid gland, hypertensive disorders of pregnancy, general cardiovascular diseases, and depressive disorders. For general guidelines, common conditions were other circulatory diseases, cervical cancer, disorders of the thyroid gland, inflammatory bowel disease, and migraine/headache. Among the 39 guidelines published from MICs, 13 were pregnancy-specific, and guidelines commonly provided recommendations for cardiovascular diseases [15‐20], GDM [21‐25], rheumatoid arthritis [26], and multiple sclerosis [21].

A total of 47 guidelines were identified which related to the high-priority NCD conditions identified by the WHO expert group. From these, we extracted 1834 individual recommendations.

We found that across 405 identified guidelines, recommendations provided were largely focused on a small number NCD conditions with higher prevalence in pregnant women such as GDM and mental health disorders. Other clinically important conditions were found to have limited or no guidelines, demonstrated by our guideline mapping of which less than one-third of all guidelines accounted for nine of 14 NCD categories (neurological conditions, digestive diseases, genitourinary disease, congenital anomalies, musculoskeletal disease, respiratory diseases, skin diseases, oral conditions, and sense organ diseases). This distribution might reflect stronger international collaborative efforts to address higher-profile conditions which were specified in the United Nation’s Sustainable Development Goals such as cancers, cardiovascular diseases, chronic respiratory diseases, and pre-existing diabetes mellitus [73]. Such international goals shape allocation of resources, but may mean that other, less prevalent, conditions are overlooked. There is a need to ensure that up-to-date guidelines are available to promote evidence-based care for all NCD conditions, regardless of prevalence. To our knowledge, this is the first scoping review of published guidelines for a comprehensive range of NCDs in the maternity care context. Findings of this study has proved critical for WHO in planning their future guideline development activities for high-priority conditions (diabetes, chronic hypertension, respiratory conditions, hemoglobinopathies and sickle cell disease, and mental and substance use disorders).

Only one guideline, published by NICE [51], addressed a range of different NCD conditions as the main topic. All other guidelines focused on a single disease or condition, highlighting the current “vertical” approach to NCDs in pregnant or postpartum women. However, this approach is not well-suited to address the issue of multi-morbidity affecting pregnant women, where a more integrated, holistic approach to clinical care is required. Many NCD conditions co-occur due to shared risk factors. Additionally, having one NCD condition can predispose women to develop another condition. Evidence from the UK found that more than 40% of pregnant women had multi-morbidities and 70% of women with multi-morbidities had a mental health condition [74]. These complex relationships between NCDs and the lack of integrated NCD guidelines identified highlight the need to transition away from the “single disease” approach in current guidelines, towards a more woman-centered approach which facilitates the integration of a range of NCD care recommendations with maternity service provision.

One of the major challenges for NCD management is ensuring delivery of effective care in limited-resource settings. An estimated 295,000 maternal deaths occur worldwide each year, 99% of which occur in low- and middle-income countries (LMICs), with 14.8% due to pre-existing medical conditions [75]. Most guidelines were published in HICs, with less than 10% of the guidelines found published in MICs and no guidelines identified in low-income countries. Notably, two countries (India and South Africa) had published a number of NCD-related guidelines for national use, and both have a considerable burden of NCD-related maternal morbidity and mortality [76, 77]. This finding highlights the need for guidelines tailored to limited-resource contexts, particularly those with a high burden of NCD-related morbidity and mortality. By strengthening NCD prevention and management, it will contribute as a critical component to reach SDG targets for reduction of both maternal mortality, and premature mortality due to NCDs [73]. The difference in guideline availability between HICs and LMICs is consistent with previous studies which compared NCD guidelines for non-pregnant adults [78‐81]. This could be partly explained by low prioritization of NCD-related activities in national health policies, or limited human and financial resources to support guideline development. Thus, efforts to develop and implement context-appropriate guidelines are urgently required to help improve NCD-related care in LMICs.

This mapping of over 1800 recommendations from 47 guidelines on high-priority conditions revealed that most recommendations pertained to antenatal interventions, such as early detection, screening tools, and pharmacological treatment for diseases and their complications. Our generated map of interventions was used to guide development of future WHO maternal health guidelines, as well as identified gaps in currently recommended practice. While the antenatal period is longer and presents more opportunities for clinical intervention, the intrapartum and postnatal periods remain important for provision of NCD care to reduce the risk of obstetric and perinatal complications [82]. Additionally, the postnatal period is a critical window for optimizing NCD prevention and management in long-term, as well as ensuring continuity into primary or specialist care [83]. Given the variation in quality and depth of recommendations, it was challenging to identify which group of interventions would be considered part of an essential “minimum package” for managing NCDs in pregnant and postpartum women. Future guideline development efforts could consider focusing on the most critical interventions for reducing NCD-related maternal morbidity and mortality, as well as interventions to reduce variation in quality of NCD-related care. Future analyses that compare recommended interventions from different countries might help explain national differences in coverage or quality in NCD-related maternity care, or NCD-related health outcomes.

While guidelines are important and useful tools, the translation of knowledge into improved health outcomes is largely dependent on guideline uptake. Limited implementation of guidelines in maternity care contexts are frequently reported in LMICs [84, 85], due to key barriers such as low awareness of the guideline and/or disease burden, physician disagreement or perceived lack of relevance, and inadequate training or infrastructure to promote intervention use [86]. Thus, in development of future NCD guidelines, policymakers should consider the contextual factors in low-resource settings which may affect the adoption and uptake of recommendations. This should be supplemented with ongoing research to explore barriers and facilitators of guideline implementation in antenatal, intrapartum, and postnatal care particularly in LMICs.

To assess as many guidelines as possible, we undertook a broad, comprehensive search in four databases and searched websites of over 160 national and international societies, colleges, and organizations. This study also focused on selected high-priority conditions informed by judgements of expert stakeholders participating in a WHO technical consultation. We also adhered to best-practice principles in conducting the searches, duplicate screening, and data extraction in this scoping review. However, we recognize that certain limitations exist. While we aimed to capture as many guidelines as possible, guidelines are not well-indexed in electronic databases, and it is possible some eligible guidelines may not have been identified. Other evidence-based products are used to support clinical decision-making but were not included in this review, such as hospital protocols, job aids or textbooks. As a scoping review, we did not undertake quality appraisal of individual guidelines, though to partially mitigate this the eligibility criteria specified including only those guidelines where recommendations were based on a systematic review of evidence. Detailed quality assessments of individual guidelines using validated tools such as AGREE II [87] could help distinguish higher-quality guidelines. We also acknowledge that most identified guidelines were from HICs, and it is not known whether these guidelines are applicable or appropriate for limited-resource settings. In addition, more detailed comparisons at the level of individual recommendations for the same condition would help identify where and why different guidelines disagree. Lastly, though this review was reasonably broad, an expanded focus to explore guidelines on pre-conception care (particularly regarding diet and nutrition) would provide value to ensuring continuity of care. Similarly, as obesity-related guidelines for maternity care settings were not included in this study, future exploration in this area is warranted.