Scaling up screening, diagnosis, and treatment of gestationaldiabetes mellitus in Karnataka: Policy Brief

Gestational Diabetes Mellitus: Public health concern

The prevalence rates of Diabetes in India have been a matter of concern for the state and hasled to the establishment of a number of committees, guidelines, and programme to address the issue. The Indian Council of Medical Research–India Diabetes (ICMR–INDIAB) conducted a populationbased cross-sectional study which shows that the prevalence is higher in urban areas (11.2%) than in rural areas (5.2%).¹ With an estimate of 77 million patients diagnosed with Type 2 Diabetes mellitus, International Diabetes Federation (IDF) estimates that the number can go up to 101 million by 2030.² Diabetic complications include diabetic retinopathy, diabetic nephropathy, peripheral vascular diseases, cardiovascular and cerebrovascular diseases. It not only adversely affects the human capital of a country by significantly impacting its efficiency and productivity, but also adds to the economic burden of ensuring adequate public health of the country.³

Along with the evident increase in the number of patients diagnosed with diabetes, there are also an increased number of women diagnosed with Gestational Diabetes (GDM) during their pregnancy period in India. Prevalence of GDM varies from region to region, ranging between 0% to 42% in India, the wide range could be attributed to the different tests, cut offs, timing of tests and the demography of the region.^4,5 The nine months of pregnancy is accompanied by numerous hormonal changes including elevation of blood glucose levels and misbalanced cellular functions. These changes render glucose tolerance in the women as abnormal, making her more susceptible to GDM.

Risk Factors of GDM

From adverse outcomes ranging from abnormalities in the child post birth, to even death of the infant and added risk for both mother and child to be diagnosed with Type 2 diabetes later in life are only some of the consequences of not being treated adequately, once diagnosed. Other maternal complications of GDM are preeclampsia, polyhydramnios, elevated rates of operative delivery and preterm labour.⁶ The major morbidities associated with infants of diabetic mothers include respiratory distress, macrosomia, shoulder dystocia, polycythaemia, hypoglycaemia, hypocalcaemia and congenital malformations.⁷ There are various risk factors attached to the lifestyle of the women causing impaired glucose intolerance such as age, ethnic backgrounds, Polycystic Ovarian Disorder and obesity.^8,9 There is a high risk of South Asian and Indian women to be diagnosed with GDM.¹⁰ Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study was one of the first researches to confirm the association between obesity and adverse maternal outcomes.¹¹ Maternal antecedents of adiposity and studying the transgenerational role of hyperglycaemia and insulin (MAASTHI): a cohort study in public hospitals of Bengaluru¹², has demonstrated the link GDM and obesity in infants.¹³

Strategies of Screening

There is no universal criteria identified by the state or the administrations of public hospitals for screening and diagnostic processes which include cut off points for the glucose levels, methods of screening which severely impacts the results of interventions and management of GDM cases. There are guidelines and criteria given by Ministry of Health and Family Welfare, World Health Organisation, Diabetes in Pregnancy Study Group in India(DIPSI), International Association of Diabetes and Pregnancy Study Group (IADPSG), American Diabetes Association(ADA) and National Institute for Health and Care Excellence, UK(NICE) guidelines. Physicians and gynaecologists recommend different diagnostic criteria resulting in different cut off periods and the precise period of diagnosis is not known to majority of them. As mentioned above, there is a high prevalence of diabetes in India and to avoid adverse maternal outcomes, we need to ensure that the women are screened at the time of registration and family history is taken into account while testing the women.The Government of India GDM guidelines recommends using Glucose Challenge Test (GCT) for GDM screening, irrespective of the fasting state. Single-step 75-gram oral glucose test aids in GDM diagnosis when the blood sugar level of ≥140 mg/dl.¹⁴

Strategies of Management

Once diagnosed, the next stage requires management of patients to ensure that the adverse outcomes associated with GDM can be minimised. This stage includes referring mothers to the dieticians for Medical-Nutritional Therapy(MNT) with dietary plans keeping in mind their routine food habits and religious practises, if any. The women are also suggested some exercises to manage their weight and blood sugar levels. The follow up part of management, post identification of GDM patients becomes an issue for most rural women and women from poor socio-economic backgrounds, as even if the tests are free, travelling takes up a lot of their time and energy. The follow up is important to understand the effects of the MNT suggested. If dietary modifications are unable to have the desired effect, Medical therapy with oral hypoglycaemic drugs, is suggested along with insulin in case that is required. If they are on insulin treatment they have to get tested every 3 days until the dosage is fixed.

Follow up is important for both mother and neonate, to check if the mother is diabetic postdelivery. The motivation for follow up is present amongst the women during their pregnancy and the support of the family and community plays a huge role in it but once they have delivered the child, the motivation severely falls down. One of the reasons found through primary research was that women with low motivation had to take care of themselves without the motivation of someone being directly affected by it. The other reasons were that even after undergoing all the tests suggested by the doctor, they were unaware of the reasons behind undergoing diagnosis for GDM or the risk factors associated with it and the consequences.

Qualitative research methods were used to develop the recommendations. We conducted in-depth interviews with 3 dieticians, 5 pregnant women, 4 gynecologists and 1 medical officer.

Policy Recommendations

1. Developing consensus on the processes involved amongst the stakeholders through operational guidelines

There is no consensus on the guidelines or screening, diagnosis and management of GDM in Karnataka. The national level guidelines, “Diagnosis and Management of Gestational Diabetes Mellitus: Technical and Operational Guidelines” which was published in February of last year by Maternal Health Division, Ministry of Health and Family Welfare, GOI to universalize the guidelines, have not been uniformly implemented in public hospitals of Karnataka. Most of the medical officers and gynecologists are not aware of these guidelines and blamed the government for not making them aware about the new developments in the policy sphere. The state intervention is absolutely necessary in this respect, to develop mechanisms to identify models of developing operational guidelines for the state which have uniform monitoring and evaluation criteria so that follow up processes can become more impactful. Added to that, the universalization will also aid in identifying the patients in the first trimester itself to suggest appropriate changes in their dietary plans and glucose intake. State level guidelines will ensure that the methods used are cost-effective and have trained staff to conduct tests and manage the cases efficiently.

2. Awareness through multimedia along with community based scaling up

Generating awareness becomes a key factor when addressing public health concerns with such adverse impacts. Once diagnosed with GDM, it becomes absolutely necessary for the women to follow up with gynecologists and physicians on the nutrional requirements for the child and herself. Through primary research, it was found out that the women followed up on the prescriptions made by the doctor only till the delivery and stopped afterwards. The main reason for this was attributed to the lack of awareness about the risk factors causing GDM, the reasons for the tests conducted and the consequences. Educating pregnant women through multi-media modes of communications will enable women to understand the intricacies related to child birth and required precautions that are to be taken resulting in better pregnancy outcomes. Multi-media modes of communication can include short films that can be telecasted on the televisions in the waiting halls of OPD all over Karnataka, or pamphlets with information about GDM which the nurses or the doctors can hand over to the patients at the time of first registration. This will be instrumental in helping women understand the significance of regular checkups, follow up and will make sure that she relies on reliable sources of information and medical officers for her checkups. The information provided can also inform her about the nourishment requirements for her as well as the child and required amount of physical activity for her to indulge in self-management of lifestyle as well.

This will be able to develop mechanisms of interpersonal communication between gynecologists, nurses which is essential along with family support to ensure proper management of GDM cases. Once the woman becomes pregnant, it becomes absolutely necessary for her and her family to ensure that she is undergoing all the tests suggested by the doctor, taking the desired amount of nutrients, taking enough rest and is taking the medicines suggested. It becomes the responsibility of the pregnant mother, her family and the community to inculcate in her the need to take care of herself, not only for the baby but also to maintain her wellbeing. Through primary research, it was found out that the women who would come for regular follow up and tests, were accompanied by either their mothers or husbands to the hospitals. Even though the women are motivated for the follow ups for the well-being of the child, an external system of support was required for them to take care of themselves. Theawareness generated through multi-media modes will educate women about the adverse outcomes and with the help of Accredited Social Health Activist(ASHA) Workers at ANC level, medical officers, gynecologists, and nurses. It will ensure that the community, family and the mother herself take more cognizance of her well-being and health care.

3. Adding GDM to existing frameworks to ensure allocation of funds and resources

There has been no mention of GDM or Diabetes in the Karnataka Health Policy recommendations suggested by Karnataka Knowledge Commission in September 2017, and this has been also reflected in the funds allocated to the government hospitals for the same. Through primary research, it was noticed that most government hospitals do not have a dietician in the premises of the hospital to advise women on the Multi-nutrional therapy and the diet for it with adequate proteins and carbohydrates with fiber intake. The public hospitals face severe lack in the terms of logistical requirements including insulin and metformin.In case multi-nutrional therapy does not work for some patients, they are advised to take insulin injections. With the lifestyle choices of the population of Karnataka, constant availability of insulin and metformin has become a necessity. Added to this, adequate funds are also not allotted for screening procedures for the women. To address this issue, GDM should be added to the Essential Diagnostics List that was published last year which will ensure that women are screened and the capacity built for the list can be utilized in dealing with GDM. The Essential Medicines List contains insulin which is widely used for diabetic patients to maintain stability in their blood glucose level, making it easier to obtain at all levels of the health sector.

Tamil-Nadu state and Uttar Pradesh states in India launched a Universal GDM Program in 2007 and 2016 respectively.¹⁵ National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) was launched in 2010 to deal with the increasing burden of non-communicable diseases in India. Even while the programme sought to deal with non-communicable diseases in its entirety, with focus on diabetes, it did not deal with the screening and management of pregnant women diagnosed with GDM. Under this programme, there is a part of sanctioned fund for developing NCD clinics which can be utilized in treating GDM patients as well.  

Conclusion

Literature and research studies demonstrates the gap in screening, diagnosis and management of GDM patients which is also backed by statistical evidence stating prevalence of GDM in India. Current estimation states that about 5 million women are affected by GDM and effective operational guidelines are required to control the prevalence of the epidemic. There is an urgent need to fill the knowledge gaps by addressing the existing problems and inefficiencies of the public health system in delivering on its promises. Through primary and secondary research, probable solutions have been identified and potential policy gaps have been recommended in developing consensus on screening and management practises.