A Golden Thread approach to transforming Maternal and Child Health in Singapore

Abstract

Maternal and child health (MCH) in Singapore is entering a new phase, with challenges different to those faced 50 years ago. The advancement of medical technologies and access to MCH resources have led to a dramatic fall in maternal and infant mortality rates. However, there has been a steep rise in the rates of obesity and related metabolic diseases. Alongside this is an emerging mental wellness challenge, with one in ten women experience depression across pre-, during and post-pregnancy. Maternal obesity and mental disorders before and during pregnancy not only increase a woman's risk of pregnancy complications, but also result in increased risks in the offspring of childhood obesity, behavioral disorders and later life metabolic disease, catalyzing vicious cycles of disease. Thus, there is a pressing need to transform the current MCH system to address a burgeoning metabolic and mental health challenge for Singapore. Initiating interventions during preconception and continuing into the postpartum has the potential to confer long-term maternal-child benefits, promoting virtuous cycles of health. However, the current MCH system emphasizes antenatal care and lacks focus on the equally, if not more important, preconception, postpartum and inter-pregnancy stages. We describe a new model-of-care framework that integrates a life-course approach to health across preconception, pregnancy and postpartum phases, with the social-ecological model comprising individual, interpersonal, institutional, community and policy as the major targets for health promotion interventions. This "golden thread" approach is being established at the Singapore KK Women's and Children's Hospital (KKH), to address both metabolic and mental health challenges to achieve the goal of a thriving, healthy nation. This new model-of-care is set up in KKH as a pilot program known as Healthy Early Life Moments in Singapore (HELMS). HELMS will reach out to women planning to conceive through coordinated interventions across preconception, pregnancy and postpartum periods. A mobile health platform is being developed to facilitate interventions and engage participants in the program through a digital, personalized and interactive approach. This new model-of-care is designed to secure a population with healthy life cycles, by influencing each life-course, early-in-life, to provide the best start for generations to come.

Keywords: Healthcare framework, Life-course, Maternal and child Health, Mental health, Metabolic disease, Non-communicable disease, Singapore, Transformation.

Fig. 1

Evolution of the maternal and child health system in Singapore. The development of the MCH system in Singapore between 1907 and 1957, 1958–1984 and 1985–2020. MCH, maternal and child health

Fig. 2

Maternal obesity and its complications across different life stages. Findings from the S-PRESTO and GUSTO studies. At preconception, women who were overweight or obese were at-risk of hyperglycemia and reduced fecundability. When entering pregnancy, these women were more likely to experience excessive gestational weight gain and develop gestational diabetes, which were associated with adverse delivery and birth outcomes. Children born to obese mothers were susceptible to low breastfeeding exposure, early weaning and accelerated weight gain, placing them at risk of early childhood obesity and metabolic disorders. Meanwhile, women themselves had increased risks of substantial postpartum weight retention and type 2 diabetes development. S-PRESTO; Singapore PREconception Study of long-Term maternal and child Outcomes; GUSTO, Growing Up in Singapore Towards healthy Outcomes

Fig. 3

Vicious and virtuous cycles of health. Vicious (in red) and virtuous forces (in green) of obesity and non-communicable diseases development. GDM, gestational diabetes mellitus; GWG, gestational weight gain; PCOS, polycystic ovarian syndrome; T1, first trimester; T2, second trimester; T3, third trimester

Fig. 4

Optimizing potential through a continuum of care model. Continuum of care acting upstream from preconception, through pregnancy until postpartum period involving mother-child dyad pair

Fig. 5

Interaction between environment and behavior. This model illustrates the design of interventions at multiple levels (social and physical environment) that can influence women’s behaviors and practices, and thus health (biological environment) across preconception, pregnancy and postnatal phases. Modified from Glass et al. [46]

Fig. 6

Healthy Early Life Moments in Singapore model-of-care. A new model-of-care framework for Reproductive, Maternal, Newborn and Child Health based on a life-course approach and delivered on a mobile health platform. BMI, body mass index; GWG, gestational weight gain; PPWR, postpartum weight retention. Boxes in green represent the existing care model; boxes in other colors represent the enhanced care model

Fig. 7

Mobile health messages. Samples of mobile health messages that serve as nudges which are phase-specific (A) and diet-specific (B)