A LIFE-COURSE APPROACH TO WOMEN’S HEALTH: IMPLICATIONS FOR HEALTH CARE AND IMPLEMENTATION IN THE UNITED KINGDOM (UK)

his article provides an overview Figure 1. Population view of women’s healthcare across the life-course (5). of a life-course approach to Twomen’s health, with some specific examples of implementation in the UK. The Royal College of Obste- tricians and Gynaecologists (RCOG) recently adopted the life-course model as the cornerstone of their twin reports on the future of women’s health care and specialist training (1, 2), prompting an enthusiastic assessment of a life-course approach more widely across Europe (3). First, what does a life-course ap- proach mean? The research that under- pins a life-course approach investigates the long-term effects of biological, behavioural and psychosocial exposures during gestation, childhood, adoles- cence and young adulthood on health

and chronic disease in later life and In the mid-1960s, National Health Ser- those that do more good than harm and across generations (4). In simpler, more vice (NHS) clinics were offering women at reasonable cost. More recently, the UK practical terms, a life-course approach regular cervical smear tests, but since the and most other European countries have focuses on the potential for early inter- approach was opportunistic, women at implemented HPV vaccination pro- vention to reduce disease risk or severity greatest risk of cervical cancer were not grammes for adolescent girls before they in later life. At the most general level, being screened and follow-up procedures become sexually active; if successfully therefore, it includes stopping smok- for women who screened positive were implemented, these programmes should ing to reduce the risk of cardiovascular inadequate. It was only after introduc- reduce cervical cancer rates by around disease and cancer. In this sense, much tion of a centrally-managed call-recall 70%. of health promotion exemplifies the system in 1998 that screening coverage The examples above of protecting life-course approach. However, the life- increased to around 80% and cancer sexual health across the life-course to course approach outlined here goes be- rates began to fall. Over the last 20 years, prevent cancer, ectopic pregnancy and yond general health promotion to those screening in England has reduced the in- infertility are relevant to all sexually ac- aspects of sexual and reproductive health cidence of cervical cancer by a third and tive women regardless of whether or not (SRH) that have particular implications deaths by more than a half (6). they go through pregnancy. ‘Life-course for women’s future health and, through A national chlamydia screening interventions’ in maternal healthcare can pregnancy, the health of the next genera- programme (NCSP) in England was target the future health of the mother, or tion (see Figure 1) (5). launched in 2003 to offer opportunistic the child, or both. Some such interven- 26 Screening and immunization are clas- screening to sexually active women and tions derive from the stressor effect of sic examples of public health interven- men under 25 years of age. However, due pregnancy on maternal metabolic or car- tions that fit the life-course model. to many factors, evidence that screen- diovascular function providing an ‘early More specifically, screening for cervical ing has directly reduced the prevalence warning’ of health problems in later life dysplasia and genital chlamydia infec- of chlamydia or the incidence of clinical (see Figure 2) (8). For example, women tion both illustrate a life-course approach complications (pelvic inflammatory who develop diabetes in pregnancy (ges- to women’s health aimed at preventing disease, ectopic pregnancy or infertility) tational diabetes) have a much higher risk cervical cancer and pelvic inflammatory is lacking. Consequently key questions of developing type 2 diabetes in the years disease (leading to ectopic pregnancy and about the programme’s effectiveness following their pregnancy even if their infertility) respectively. But experience remain unanswered and its value for blood sugar returns to normal just after in the UK of implementing these two money unknown (7). These contrasting delivery; two out of every five women screening programmes and the evidence examples illustrate the huge challenge with gestational diabetes will have type for their impact on women’s health are and high stakes involved in establishing 2 diabetes within 5 years. Furthermore, very different. successful screening programmes i.e. babies born to mothers with gestational

354727_Entre_Nous_82_v5.indd 26 14/10/15 12.11 Judith Stephenson

diabetes have significantly higher birth tive review of women with diabetes or shown that a mother’s diet before concep- weight, which is associated with increased high blood pressure in pregnancy, includ- tion can permanently affect how her risk of childhood obesity and diabetes. ing annual risk assessment and healthy child’s genes function (14). In this study, While the precise contribution of genes lifestyle counseling, should become more researchers took advantage of a ‘natural versus environment to this increased feasible as electronic systems for linking experiment’ in the Gambia where people’s risk is unclear, gestational diabetes has health care records improve. normal diet differs markedly between been called a disease of two generations. Interventions around the time of rainy and dry seasons. By measuring Fortunately, it is clear that maternal conception that target the baby’s health blood levels of nutrients in pregnant screening and treatment of gestational have long been recommended, with folic women who conceived in rainy versus dry diabetes leads to better pregnancy and acid supplementation to prevent neural seasons and later analyzing blood samples birth outcomes. Because of the high risk tube defects being one of the best known from their infants, researchers found that of developing type 2 diabetes in the years examples; the evidence from randomized a mother’s diet before conception led to following pregnancy, evidence based trials that folic acid reduces neural tube significant changes (epigenetic modifica- guidance in the UK recommends annual defects by around 70% is clear cut (11). tions) to her child’s DNA. Although the review of all women with gestational Although there is substantial obser- health significance of the DNA changes diabetes (9). However, since the transfer vational data linking pre-conception is not yet clear, this study is an important of information from maternity care to exposures (e.g. smoking and alcohol) to step towards defining an optimal diet for primary care is highly inconsistent in the birth outcomes (e.g. low birthweight and mothers-to-be, ultimately with known UK, general practitioners (family doctors) congenital defects) evidence for the effec- health benefits for their children. are often unaware that their patients have tiveness of preconception interventions In conclusion, these few examples been diagnosed with gestational diabetes: in reducing adverse outcomes is relatively illustrate the impact, both potential and a recent study in England showed that sparse (12). achieved, of interventions designed to less than 20% of women were followed Implementing interventions before improve women’s health across the life- up within 6 months of delivery and less conception may be limited by the extent course. Interventions may differ accord- than 1% were followed up annually for 5 of pregnancy planning and awareness of ing to the target population including, for years (10). preconception health issues, but robust example, all girls aged 11-12 years (for A similar situation pertains for women evidence shows that over two thirds of HPV vaccination), all women prepar- found to have raised blood pressure in pregnancies leading to childbirth are ing for pregnancy (for folic acid sup- pregnancy or pre-eclampsia: these women planned to some extent and a recent ob- plementation) or high risk subgroups are at much higher risk of hypertension servational study found that women who of pregnant women (for screening and and heart disease in later life, but annual reported advice from health profession- management of gestational diabetes). review, as recommended by the National als before pregnancy were significantly Such interventions may be intended Institute for Health and Care Excellence more likely to adopt healthier behaviours to benefit women’s future health, their (NICE), is seldom delivered in practice. before pregnancy, including taking folic child’s, or both. Action for successful Implementing a life-course approach to acid and eating a healthier diet (13). This implementation may be required primar- reducing cardiovascular disease by effec- is encouraging because new research has ily at individual level (such as stopping

Figure 2. Potential for life-course interventions in pregnancy to improve long term health. Adapted from Sattar N and Greer IA (8). 27

FigureFigure 2.2. PotentialPotential forfor lifelife coursecourse interventionsinterventions inin pregnancypregnancy toto improveimprove longlong termterm health.health. Adapted Adapted fromfrom SattarSattar NN andand GreerGreer IAIA (8).(8). No.73No.82 - 20112015

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A LIFE-COURSE APPROACH TO WOMEN’S HEALTH: IMPLICATIONS FOR HEALTH CARE AND IMPLEMENTATION IN THE UNITED KINGDOM (UK) (CONTINUED)

smoking before becoming pregnant), at 3. Bitzer J and Horne AW. A new aged 10. McGovern A, Butler L, Jones S et al. health service level (for example annual has come: the redefinition of women’s Diabetes screening after gestational follow-up of women with gestational health care. J Fam Plann Reprod diabetes in England. Br J Gen Prac diabetes in primary care) or at the level Health Care 2012; 38: 68–69. 2014; doi:10.3399/bjgp4X6776410. of public health policy for implementa- 4. Kuh DL, Ben-Shlomo Y. A Life-course 11. De-Regil LM, Fernández-Gaxiola AC, tion of national screening or vaccination Approach to Chronic Disease Epidemi- Dowswell T et al. Effects and safety of programmes. ology; Tracing the Origins of Ill-health periconceptional folate supplemen- from Early to Adult Life. Oxford: tation for preventing birth defects. Judith Stephenson, BA, MBBS, Oxford University Press, 1997. Cochrane Database Syst Rev 2010; 10: Margaret Pyke Professor of Sexual 5. Stephenson J, Kuh D, Shawe J et al. CD007950. and Reproductive Health, Why should we consider a life-course 12. Temel S, van Voorst SF, Denktas S et Programme Director for approach to women’s health care? al. Evidence-based preconceptional Maternal Health, Scientific Impact Paper No. 27. RCOG lifestyle interventions. Epidemiol Rev Institute for Women’s Health, University College London, 2011. 2014; 36(1): 19-30. [email protected] 6. Profile of cervical cancer in England. 13. Stephenson J, Patel D, Barrett G et al. Incidence Mortality and Survival. How Do Women Prepare for Preg- Trent Cancer Registry 2012. nancy? Preconception Experiences of 7. National Audit Office Department of Women Attending Antenatal Services Health - Young people’s sexual health: and Views of Health Professionals. References the National Chlamydia Screening PLoS One 2014; 9 (7), doi: 10.1371/ 1. Royal College of Obstetricians and Programme. http://www.nao.org.uk/ journal.pone.0103085. Gynaecologists. High Quality Women’s wpcontent/uploads/2009/11/ 14. Dominguez-Salas P, Moore SE, Baker Health Care: A proposal for change. 0809963.pdf MS et al. Maternal nutrition at con- RCOG Working Party report. Lon- 8. Sattar N and Greer IA. Pregnancy ception modulates DNA methylation don: RCOG, 2011. [http://www.rcog. complications and maternal cardio- of human metastable epialleles. Nat org.uk/high-quality-womens-health- vascular risk: opportunities for in- Commun 2014; 5:3746. doi: 10.1038/ care]. tervention and screening? BMJ 2002; ncomms4746. ISSN. 2. Royal College of Obstetricians and 325: 157-60. Gynaecologists. Tomorrow’s Specialist. 9. Diabetes in pregnancy: management RCOG Working Party report. Lon- of diabetes and its complications from don: RCOG, 2011. [https://www.rcog. preconception to the postnatal period. org.uk/en/guidelines-research-servic- NICE guideline. 2015. http://www. es/guidelines/tomorrows-specialist]. nice.org.uk/guidance/ng3

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This excellent impact paper nicely outlines the rationale for a life-course approach to women’s health care, including the implications for health service delivery. Available in English at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/sip27/

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