Why Diabetes in UP’s Poor Pregnant Women is Going Undetected
In UP, diabetes in poor pregnant women is going undetected as the purchase contract for glucose pouches is held up.
Two years ago, in August 2017, about 60 children died in Gorakhpur’s BRD Medical College hospital because oxygen was not available. Dr Kafeel Khan, a paediatrician, was made the fall guy and put behind bars for a few months.
But another silent tragedy is unfolding in Uttar Pradesh, because the state has not been able to finalise the tender for 75-gram glucose pouches that are used to detect diabetes in pregnancy, a person intimately associated with the programme said.
It is not known whether the failure to award the contract is due to the bickering over the price, or other considerations. Earlier, the person who wished not be named, said the pouches were procured from a private company for Rs 9.90 each. Email queries sent to Usha Gangwar, General Manager (Maternal Health), National Health Mission, UP, on 17 September — at her request — failed to elicit a response, despite reminders by email and text messages.
Pregnant Women to be Screened for GDM
UP is one of the few states that has taken a lead in screening women for gestational diabetes mellitus (GDM), which is a component of the National Health Mission (NHM). In 2014, national technical and operational guidelines for GDM detection and control were published.
They required pregnant women to be screened for GDM at their very first visit to the ante-natal clinic of a public healthcare facility.
Fasting was not required. The women were to be given 75 grams of glucose, dissolved in 300 ml of water. Two hours later their blood samples were to be drawn.
If the blood glucose level was at or above 140 mg/dl, GDM was to be diagnosed. If not, another test was to be conducted between the 24th and 28th weeks of pregnancy. Those testing positive were to be put on medical nutrition therapy (MNT) for two weeks, according to the guidelines. This is a diet that ensures enough energy for the mother and the baby, and adequate weight gain for the mother (300-400 grams per week and up to 10-12 kg during pregnancy), while keeping her post-meal blood sugar level normal at 110-120 mg/dl.
The guidelines also advised physical exercise. If the blood sugar levels did not reduce to normal, the expectant mother was to be put on metformin or insulin.
Risk of Indian Women Developing Glucose Intolerance During Pregnancy
GDM poses a higher risk of babies dying in the womb in the 28th week of pregnancy or after (stillbirth). It aggravates the chances of a new born dying within 28 days or birth (neo-natal death). A two-year study published in 2018 showed that UP’s pregnant women with GDM had double the risk of stillbirths. Of 12,784 pregnancies followed up, 406 (3.17 percent) resulted in stillbirths. In 191 or 1.49 percent of the pregnancies, the babies died within 28 days of birth.
For comparison, another group of 7,287 pregnant women who did not have GDM were observed.
They had a much lower incidence of stillbirths and neonatal deaths: 92 and 47 respectively. In all, 515,532 pregnant women were screened between October 2016 and November 2017. The women followed up were a sub-set of those detected with GDM.
Indian women have a 11-fold increased risk of developing glucose intolerance (pre-diabetes) during pregnancy, as compared to Caucasian women, says SV Madhu of the University College of Medical Sciences and GTB Hospital, Delhi, in an article published in an Indian diabetes journal.
Diabetes in pregnancy has serious consequences for the mother as well as the baby, she says. Apart from stillbirth, the complications for the mother include a greater need for C-section. It can cause large babies and congenital malformations in them (as also low birth weight babies – less than 2.5 kg, who are also prone to lifestyle diseases).
Risk of Diabetes for Women With GDM
Women with GDM have a seven-fold higher risk of developing Type-2 diabetes. This risk increases steeply five years after delivery. They also have a higher prevalence of metabolic syndrome and increased risk of cardiovascular diseases. Children of GDM mothers have a higher risk of obesity and diabetes. About one-third of children born of diabetic pregnancies develop glucose intolerance before the age of 17.
Nationally, the GDM prevalence rate is estimated to be 10-14 percent, according to the health ministry.
In Uttar Pradesh, a large study of more than 58,000 pregnant women, by Rajesh Jain and his team in Kanpur Nagar district, put the prevalence rate at 13.4 percent. Jain is associated with the programme for control of diabetes in UP. Another study conducted in 2016 at Queen Mary Hospital of King George’s Medical University in Lucknow, by four of its gynaecology professors, placed the prevalence rate at 13.9 percent.
UP has rolled out the GDM screening programme in 36 of 75 districts.
In another 14 districts, healthcare professionals – doctors, nurses and auxiliary nurse midwives – are being trained.
How many other states screen pregnant women for GDM? Dinesh Baswal, Deputy Commissioner (Maternal Health) in the health ministry names Bihar, Madhya Pradesh, Odisha and Tamil Nadu as the states that have sought funding for training of their healthcare professionals. He was unable to state whether they have GDM screening programmes, and if so, in how many districts.
“You are What Your Mother Ate”
Madhya Pradesh took a decision in 2018 to screen pregnant women in all 51 districts for GDM within three years, says an advisor with JHPIEGO, an NGO, which was formerly known as John Hopkins Programme of International Education in Gynaecology and Obstetrics. It has been doing a pilot in Hoshangabad district since 2016 to know the challenges of implementing the GDM guidelines at the field level. Its study of 21, 358 pregnant women (84 percent of those who showed up at the district’s ante-natal OPDs) in 2016-17 put the GDM prevalence rate at 9 percent (11 percent in urban areas and 8 percent in rural).
“You are what your mother ate,” says V. Seshiah, a former professor at Madras Medical College, where, his bio-data says, he set up the country’s first department of diabetes.
Seshiah was a member of the expert group that wrote the GDM guidelines for NHM. “It is nearly impossible to do anything about diseases that have a foetal origin,” Seshiah asserts. He says it is wise to spend Rs 20 on the test to detect GDM than for the mother and the child to spend tens of thousands of rupees on treating complications that may arise later in life.
A sense of urgency seems to be lacking in the government both nationally and at the state-level. UP which has high maternal and infant mortality rates, some of which can be ascribed to GDM, needs to be extra active. The bickering over the glucose pouch tender betrays a poor sense of responsibility.
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