UP lets down pregnant women, fails to supply 75-gram Glucose Pouches to test for diabetes

For a state known for medical tragedies and poor health indicators, Uttar Pradesh commendably had taken the lead in screening pregnant women for diabetes. A pilot programme was launched in Kanpur Nagar district between October 2012 and September 2014.

Based on that experience, universal screening was extended to 36 of the state’s 75 districts in two instalments. In another 14 districts training of public healthcare professionals – doctors, nurses and auxiliary nurse midwives – is about to be rolled out.

But the programme has lost momentum because pouches of 75-gram glucose powder required for the blood test have not been available for the past few months, confirms a doctor intimately associated with the programme. The state’s medical supplies corporation has been unable to finalise the tender, the doctor who didn’t wish to be named, said.

Emailed questions 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.

Earlier, a private company used to supply the pouches for Rs. 9.90 each, the doctor said. Whatever the reason for the delay in placing the order and arranging supplies, diabetes in thousands of pregnant women may be going undetected.

For want of a nail, as the ditty goes, the state seems to be losing a battle.

The lesson from Gorakhpur has clearly not been learnt. In 2017, more than 60 children admitted to BRD Medical College Hospital in Gorakhpur lost their lives because oxygen was not available. A doctor was made the fall guy and spent a long time behind bars, though an inquiry exonerated him of negligence.

“You are what your mother ate,” says Professor Seshiah from Madras Medical College. He 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,” he asserts. 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,” he adds.

Seshiah thinks that the government is not “beating the drumbeat (sic)” of GDM loud enough. He says screening for GDM should be like the pulse polio campaign.

DIABETES & PREGNANCY

Diabetes is a lifestyle disease caused, among other factors, by obesity and lack of physical exercise. A population-based study of 14 states and one union territory (Chandigarh) published in 2017, said the prevalence of diabetes was 7.3 percent. The prevalence rate in the general population varied from 4.3 percent in Bihar to 10 percent in Punjab.

People in urban areas were more at risk than those in rural areas. The results of the survey in UP, Delhi, Madhya Pradesh and a few other states will be published next year. It is being conducted by the Indian Council of Medical Research and the INdia DIABetes study group.

During pregnancy insulin resistance is brought on by placental hormones. A year-long study in 2016 conducted at Queen Mary Hospital in Lucknow by the professors of the department of gynaecology and obstetrics at King George’s Medical University, (to which the hospital is attached) revealed a GDM prevalence rate of 13.9 percent. (The prevalence of Gestational Glucose Intolerance ─GGI or pre-diabetes─- was higher at 19.8 percent).

The Kanpur Nagar pilot programme revealed a similar GDM rate – 13.4 percent. Rajesh Jain of Kanpur who trains healthcare professionals in association with the World Diabetes Foundation, Denmark, had screened 57,000 pregnant women over two years. Jain is the president of the implementation committee of the Diabetes in Pregnancy Study Group India (DIPSI) which prescribed the oral glucose tolerance test (OGTT) for GDM screening.

In 2014, technical and operational guidelines for screening of pregnant women for diabetes were made part of the National Health Mission (NHM). They require pregnant women to be tested for GDM when they first contact a public healthcare facility, whether it is a sub-centre or a district hospital.

They are required to be given 75 grams of glucose powder dissolved in 300 ml of water. The blood test is to be performed exactly after two hours. If the OGTT is negative the test is to be repeated between the 24th and 28th week of pregnancy.

Indian women have an 11-fold increased risk of developing glucose intolerance (pre-diabetes) during pregnancy compared to Caucasian women, says S. V. 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).

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.

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 by Rajesh Jain and his team of doctors showed that UP’s pregnant women with GDM had double the risk of stillbirths.

Since the foetus’s renal glucose threshold levels is 110 milligrams per decilitre of blood (mg/dl), the mother’s blood sugar level should be in the 110-120 mg/dl range, says Prof Seshiah.

Normally a person is said to be diabetic if their blood sugar level is above 199 mg/dl. If it is between 140 mg/dl and 199 mg/dl, they are considered to be pre-diabetic. In pregnancy, a diagnosis of diabetes is made at a lower level: 139 mg/dl and above. If it is in the range of 119-139 mg/dl, GGI is inferred.

According to the NHM guidelines those with GDM have to be put on a diet that will ensure adequate weight gain (10-12 kg during pregnancy), while keeping blood sugar levels normal. They are also required to exercise. (Those who are obese will be required to shed weight). If diet and exercise are not effective, the pregnant women are to be put on metformin or insulin.

SCREENING IN OTHER STATES

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.

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).

Uttar Pradesh has high maternal and infant mortality rates. Its MMR was 201 per one lakh live births in 2014-16. In 2004-6 it was more than double at 440. UP’s IMR was 43 per one thousand live births in 2016 and 72 in 2004. It has made good progress, but its performance is below the national average. India’s MMR is 130 and IMR is 34. The state should be striving to do better, not lagging.