Strategies To Reduce Maternal Mortality And Morbidity In Rural India

Dilip Kumar Dutta

INTRODUCTION:

India is the second most populous country of the world and has fast changing socio-political-demographic patterns that have been drawing global attention in recent years. Worldwide an estimated five lakh woman die as a result of pregnancy each year.  Approximately one quarter of all pregnancy and delivery related maternal deaths worldwide occur in India. This tragic picture has only gradually become clearer largely as a result of a growing number of good community surveys conducted since the mid 1970’s which drew attention to the uunexpectedly  high rates of maternal mortality and serious morbidity.

WHY INDIA DRAWING WORLD ATTENTION?
India is drawing world attention, not only because of its population explosion but also for emerging health profile and profound political, economic and social transformations. Since independence during last  sixty four  years, a number of urban and growth-oriented developmental programmes have been implemented, nearly 716 million rural people (72% of the total population) half of which are below poverty line (BPL) continue to fight a hopeless and constantly losing battle for survival and health. The policies implemented so far, which concentrate only on growth of economy not on equity and equality, have widened gap between Urban & Rural and haves and have-nots. Nearly 70% of all deaths and 92% of deaths from communicable diseases, occur among the poorest 20% of the population..

THE GLOBAL PICTURE

Today’s status of maternal mortality and health issue shows a far greater disparity between  developed and developing countries. As per 1993 statistics maternal mentality in devolved country is 30% per 100000 live births as compered  to 450/100000 live births in developing countries. South Eastern Asia is 420/1 Lakh as compared to Southern Asia (650/1 Lakh). Maternal mortality in India is not a chance event. It has its origins in many interwined factors, starting with the social status , position of women, greatly effected by the economic resource and infrastructure of the country, and immediately dependent on accessibility and availability of skills, materials and facilities for family planning and maternity care.

CURRENT HEALTH SCENARIO IN RURAL INDIA

The health status of Indians, is still a cause of grave concern, specially that of the rural population. This is reflected in the life expectancy (63 years), infant mortality rate (80/1000 live birth) and maternal mortality rate (438/100000live birth). Reasons why woman die in pregnancy and child birth have many layers. Beside-direct, indirect,  and co-incidental causes, there are also logistic causes that is failure in the health care system, lack of transport, lack of manpower and apathy towards patient care. And behind this are all the social  cultural and political factors which together determine the status of woman, their health, fertility and health seeking behavior. To improve this scenario, the problem of the rural health is to be addressed both at the district, regional (micro) state and national (macro) level.

STEPS  TO REDUCE HEALTH ISSUES IN RURAL WOMEN

Working for last couple of years at grass root level at rural area, following steps have been formulated by  the author for prevention of maternal mortality and morbidity rate at rural area..  Woman health issue  was divided into three ‘C’(Dutta’C)i.e. crisis, care and cure.

OBJECTIVE

IN STEP – I CRISIS
Every woman should  know about the  crisis (Problem) that may come to her life from pre-reproductive period to post reproductive period.

IN STEP – II CARE

Having knowledge about the crisis - care (Prevention) should be instituted (a) to protect against child hood and adolescent health issue (b) To prevent complications of pregnancy through early detection and treatment . (c) To provide clean and safe delivery (d) To promote the implementation of family planning programme (e) Predicting the early diagnosis of post reproductive disease. (f) centpercent encouragement fo Institutional delivery

IN STEP – III CURE
Cure (immediate action) is  to be immediately implemented (a) To promote action and management of puberty and adolescent problem  if any.(b) early diagnosis of complications of pregnancy and prompt management (c) To ensure clean and safe vaginal delivery (d) To ensure immediate step to prevent third stage complications.

 ACTION PLAN
To ensure success-The following important steps are to be formulated.

1. To involve Neonatologist, Paedetrician and Physician-To ensure that childs  family  must have knowledge about  their Blood Group,Rh Factor and girl should have atleast >14gms  Haemoglobin and devoid of Malnutrition, UTI and RTI  etc.
2. To involve Gynaecologist-To prevent and treat PCOS, Endometrosis and infection of Adolescent Girl. Before marriage.
3. To inform Head of Family-Marriage of girl should be > 20 years of age.
4. To involve head of the family and Husband-Before Pregnancy  wife should have  atleast above 14gms of haemoglobin, No abortion without proper knowledge of Blood Group and RH Factor ect.
5.  To involve  Obstetrician , midwife and paramedical staff-- to find out any complications of pregnancy and prompt treatment.
6. To Involve GOVT, NGO (FOGSI), IMA- for Awareness Programme at School/ College/ Media/ Religious Places/ Marriage/ Functions-Regarding Reproductive Health Care/Sex education/Bad Effects of Drugs/ Smoking/ Alcohol etc.
7. To Involve Health Care Staff- to perform Community studies, Household Survey, Sisterhood and other measures and reproductive age mortality surveys.
8.  To Involve Office Staff-To maintain hospital data, data from other sources and other health records.
9. To involve DM,SDO,BDO AND PANCHAYAT SABADIPATI – Io initiate action plan and generate economic resources ect for implementation of this programme.

SELF INVESTIGATED RESULT

Maternal Mortality at Tertiary Level Hospital
J. N. M. Hospital, Kalyani, Nadia, W.B.

CAUSE  OF DEATH

Since 2007 ,involvement of obstetricians from  KALYANI OBSTETRIC AND GYNAECOLOGICAL SOCIETY,IMA,NGO and stepwise implementation-à to improve access to adolescent health problem(ANEMIA,INFECTION), pregnancy related health  services and timely interventions during intra and postpartum care, 50% to75% maternal  death and morbidity has been prevented at tertiary level hospital (JNM HOSPITAL) KALYANI ,NADIA,WB(8 TO 10 THOUSANDS DELLIVERY  PER YEAR). Observation showed that maternal mortility 738/1000000 live births during 2006 was  found to be drastically reduce to 389(2007),280(2008), 211(2009) and 302 (2010)  after implementing   stepwise measures and plan of action .  However  our aim is to reduce maternal mortality  below  150 per one lakh during 2011.

Conclusion :

Strategies to improve coverage of effective interventions during pre-reproductive  period by involving  doctor and govt and others manpower could reduce the incidence of health related complications or mortality and morbidity at rural India.

Early intensive efforts to improve family planning ,to control of fertility choices,  to provide safe abortion and integrated maternal health services  - were the most important interventions to reduce pregnancy related mortality i.e. 150,000 maternal deaths-could be prevented in next 5 years.

References:-

• Sue J. Goldie, Steve sweet etal, Alternative strategies to reduce maternal mortality in India: A cost effectiveness Analysis-PLOSMEDICINE,APRIL 2010/Vol-7/Issue-4.
• Ashok Vikhe Patil etal: “Current Health Scenario in Rural India”, Am J. Rural Health (2002), 11,129-135.
• CARLA ABOUZAHR AND ERICA ROYSTON-Maternal Mortality-An India Factbook, WHO, Cover,1991.
• Dr. D. K. Dutta, Reproduction & Child health Care, FOGSI Publication,2008.

About Author

Dr Dilip Kumar Dutta  is an  ex. Teacher, Good  Academician,   Excellent clinician and dedicated  his service to rural women academic qualification

M.D. Ph.D., M.A.M.S., F.I.C.O.G., F.I.M.C.H., M.A.A.G.L., M.A.F.S. DIPLOMA HIGH RISK PREGNANCY (USA) DIPLOMA PELVISCOPIC SURGERY

 AUTHOR  PREVIOUS PUBLICATIONS

• Safe Motherhood at rural India – How we can improve it (1999).
• Unsafe Abortion – global Emergency (1999).
• Early Pregnancy Hemorrhage (2000).
• Ante Partum Hemorrhage (2001)
• Post Partum Hemorrhage (2002)
• Caesarean Delivery (2003)
• Update in Contraception (2004)
• Polyestic Ovary (2004)
• RCH (2005)
• Manual of Births Defect & Conginatal Abnormality (2006)
• Obstetrics Haemorrhage Made Easy (2007)
• Laparoscopy Made Easy (2007)
• Hysterectomy Made Easy (2007)
• Gynae Urology Made (2007)
• Drugs in Pregnancy – How Safe (2008)
• Anaemia : How Safe are Indian Women – An Epidemiological Stud (2008)
• Manual of FOETAL Medicine (2009)
• Genital and Breast Cancer : How safe are Indian Women – an Epidemiological Study (2009).
• High Risk Pregnancy (2010)

Uploaded in January 2011

Screening For Gestational Diabetes

Dr Sujata Misra MD FICOG

Pregnancy induces progressive changes in maternal carbohydrate metabolism. As pregnancy advances insulin resistance and diabetogenic stress due to placental hormones necessitate compensatory increase in insulin secretion. When this compensation is inadequate gestational diabetes develops. ‘Gestational Diabetes Mellitus’ [GDM] is defined as carbohydrate intolerance with onset or recognition during pregnancy. Women diagnosed to have GDM are at increased risk of future diabetes predominantly type 2 DM as are their children  . Thus GDM offers an important opportunity for the development, testing and implementation of clinical strategies for diabetes prevention [ . Timely action taken now in screening all pregnant women for glucose intolerance, achieving euglycemia in them and ensuring adequate nutrition may prevent in all probability, the vicious cycle of transmitting glucose intolerance from one generation to another.

Screening & Diagnosis

A number of screening procedures and diagnostic criteria (ADA, WHO, CDA, NDDG and Australasian criteria) are being followed in the same as well as in different countries. American Diabetes Association (ADA) recommends screening for selective (high risk) population. But compared to selective screening, universal screening for GDM detects more cases and improves maternal and neonatal prognosis [4,5]. Hence universal screening for GDM is essential, as it is generally accepted that women of Asian origin and especially ethnic Indians, are at a higher risk of developing GDM and subsequent type 2 diabetes.

ADA procedure

ADA recommends two step procedures. Step 1: A 50 g glucose challenge test (GCT) is used for screening without regard to the time of last meal or time of the day. Step 2: If 1 hour GCT value is more than 140 mg/dl, 100g Oral Glucose Tolerance Test (OGTT) is recommended and plasma glucose is estimated at 0, 1, 2 and 3 hours. Gestational Diabetes Mellitus is diagnosed (Carpenter and Coustan criteria) if any 2 values meet or exceed FPG > 95 mg/dl, 1 hr PG > 180 mg/dl, 2 hr PG > 155 mg/dl and 3 hr PG > 140 mg/dl. The drawback of this criteria is that, the glycemic cut off was originally validated against the future risk of these women developing diabetes and not on the fetal outcome . Further, in the community health centers, pregnant women are reluctant to undergo ADA procedures for two reasons

1. The number of blood samples drawn are many (a) for screening and (b) for subsequent 3- hour OGTT to confirm the diagnosis (4 blood samples).
2. They have to visit the ante-natal clinic on two occasions – (a) for screening and (b) again for diagnostic procedure.

WHO Procedure

When a glucose tolerance test is administered to a non-pregnant individual, it is standard to use the 75-g, 2-hour OGTT. Using a different glucose challenge in pregnant versus non-pregnant persons leads to confusion in the laboratory and may result in errors in applying the proper diagnostic criteria . To standardize the diagnosis of GDM, the World Health Organization (WHO) recommends using a 2 hour 75 gm OGTT with a threshold plasma glucose concentration of greater than 140 mg/dl at 2 hours, similar to that of IGT ( > 140 & < 199 mg/dl), outside pregnancy . WHO procedure also has a shortcoming in that, the criteria suggested for diagnosis of GDM was also not based on the maternal and fetal outcome but probably the criteria was recommended for its easy adaptability in clinical practice.

Reconciliation factors between ADA and WHO

GDM based on two hour 75gm OGTT defined by either WHO or ADA Criteria predicts adverse pregnancy outcome . There was no significant difference between prevalence of GDM using Carpenter & Coustan (ADA) and WHO criteria . WHO criteria of two hour PG ≥ 140mg/dl identifying a large number of cases may have a greater potential for prevention of diabetes. The glycemic criteria for diagnosis of different categories of glucose intolerance by 75 g, 2 hr OGTT is listed in table 1.

Table 1.
Glycemic Criteria for Diagnosis of different categories of glucose intolerance by
75 g, 2 hr OGTT

*Glycemic cut-off for the diagnosis of IGT outside pregnancy is the same for the diagnosis of GDM during pregnancy.

Significance of cut-point of 2 hr plasma glucose level of 140 mg/dl

Increasing maternal carbohydrate intolerance in pregnant women is associated with a graded increase in the adverse maternal and fetal outcome . The primary outcomes of both birth weight and Serum C peptide level > 90th percentile occurs at the cut point of 2 hr PG > 140 mg/dl . In yet another follow-up study of  children born to mothers who had third trimester plasma glucose, 120-139 mg/dl, the cumulative risk of type 2 diabetes was 19% at age 24 years and this risk increased to 30% with respect to those women who had 2 h plasma glucose 140 -199 mg/dl. Thus both short–term and long-term morbidity in the offspring occurs at the inflective cut-point of maternal 2 hr plasma glucose > 140 mg/dl and as such, this level assumes clinical significance. A pregnant woman, whose 2 hour plasma glucose is 120-139 mg/dl, needs follow-up.

A single test procedure to diagnose gestational diabetes mellitus in the community

Seldom, a pregnant woman visiting the ante-natal clinic for the first time comes in the fasting state. If she is asked to come on another day in the fasting state she may not return . Hence it is important to have a test that detects the glucose intolerance without the woman necessarily undergoing a test in the fasting state and it is preferable to perform the diagnostic test at the first visit itself.

In the antenatal clinic, a pregnant woman after undergoing preliminary clinical examination, has to be given a 75g oral glucose load*, without regard to the time of the last meal.  A venous blood sample is collected at 2 hours for estimating plasma glucose by the GOD-POD method. GDM is diagnosed if 2 hr plasma glucose is ≥ 140 mg/dl.

* If 75g glucose packet is not available, remove 5 level teaspoons (not heaped) of glucose from a 100 g packet which is freely available. In hospitals where glucose is supplied in bulk, a cup or container of 75 g may be used.

Performing this test procedure in the non-fasting state is rational, as glucose concentrations are affected little by the time since the last meal in a normal glucose tolerant woman, whereas it will, in a woman with gestational diabetes. After a meal, a normal glucose tolerant woman would be able to maintain euglycemia despite glucose challenge due to brisk and adequate insulin response, whereas, a woman with GDM who has impaired insulin secretion, her glycemic level increases with a meal and with glucose challenge, the glycemic excursion exaggerates further. Therefore, this procedure assumes clinical relevance as WHO criteria based on glucose concentration 2 h after 75 g glucose load was able to correctly identify subjects with GDM . Yet another reason for recommending the single step procedure is that, the specificity of ADA screening with 50 gm 1-hr GCT without regard to time of the last meal  is low . Hence, instead of performing screening test using 50 gm-1 hr test and then 100 gm OGTT, this single step procedure serves both as screening and diagnostic test for GDM, is simple, economical and feasible.

ADVANTAGES

• The pregnant women need not be fasting .
• Causes least disturbance in a pregnant woman’s routine activities.
• Serves as both screening and diagnostic procedure.

Clarity in Labeling the Different Magnitude of Abnormal Glucose Intolerance in Pregnancy

Increasing maternal carbohydrate intolerance in pregnant women without GDM is associated with a graded increase in adverse maternal and fetal outcomes  implying that the fetal morbidity starts at a lower maternal glycemic level (<140 mg/dl).  The occurrence of macrosomia was continuum as the 2 h plasma glucose increased from 120 mg/dl . Yet another study on long-term follow-up documented that, the cumulative risk of type 2 diabetes at 24 years in the offspring born to mothers who had third trimester plasma glucose, 120-139 mg/dl was 19% . In the same study, the cumulative risk was found to be 30% in offspring born to women who had 2 h plasma glucose > 140 mg/dl. Hence it may be prudent to label 2 hr plasma glucose value > 140 mg/dl as GDM and a 2 hr plasma glucose value ≥ 120 and ≤ 139 mg/dl as ‘Gestational Glucose Intolerance’ (GGI). The term IGT is used outside pregnancy and as such should not be used to denote any abnormal value during pregnancy. The nomenclature and glycemic levels suggested in table 2 are easy to remember.

Table 2:
With 75 gm OGTT (WHO criteria)

Gestational Weeks at Which Screening is Recommended

Insulin is detectable in the fetal pancreas as early as 9 weeks after conception.  An increase in pancreatic beta cell mass and insulin secretion in the fetus occurs by the 16th week of gestation, in response to maternal hyperglycemia. The priming of the fetal beta cells may account for the persistence of fetal hyperinsulinemia throughout pregnancy and the risk of accelerated fetal growth. This necessitates performing the test procedures to diagnose GDM in the first trimester itself.  

By following the usual recommendation for screening between 24 and 28 weeks of gestation, the chance of detecting unrecognized type 2 diabetes before pregnancy (pre- GDM) is likely to be missed  .  If the 2 – h PG is > 200 mg/dl in the early weeks of pregnancy, she may be a pre-GDM and A1c of > 6 is confirmatory  {Normal A1c levels during pregnancy is 5.3 - 6}. A pregnant woman found to have normal glucose tolerance [NGT], in the first trimester, should be tested for GDM again around 24th – 28th week and finally around 32nd – 34th week.

Women with a history of GDM as well as offspring exposed to maternal diabetes in utero should be a major area of focus for preventive medicine . Preventive measures against Type 2 DM should start during intrauterine period and continue throughout life from early childhood [8]. In conclusion, a short term intensive care gives a long term pay off in the primary prevention of obesity, IGT and diabetes in the offspring, as preventive medicine starts before birth. The maternal health and fetal outcome depends upon the care by the committed team of diabetologists, obstetricians and neonatologists.

FURTHUR READING

1. Dornhorst A, Rossi M. Risk and Prevention of Type 2 Diabetes in women with Gestational Diabetes. Diabetes Care 1998 Aug; 21(suppl 2): B43-9.
2. Thomas A Buchanan, Anny Xiang, Siri L Kjos, Richard Watanabe. “What is gestational diabetes?” Diabetes Care  2007 July; 30 (2): S105-111
3. Seshiah V, Balaji V, Madhuri S Balaji. Scope for Prevention of Diabetes – Focus Intrauterine milieu Interieur. JAPI 2008 Feb; 56: 109-113. 
4. Cosson E. Screening and insulin sensitivity in gestational diabetes. Abstract volume of the 40th Annual Meeting of the EASD, September 2004: A 350.
5. Griffin ME, Coffey M, Johnson H, Scanlon P, Foley M, Stronge J et al. Universal vs risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome. Diabet Med 2000 Jan; 17(1): 26 – 32.
6. Dornhorst A, Paterson CM, Nicholls JS, Wadsworth J, Chiu DC, Elkeles RS et al. High prevalence of GDM in women from ethnic minority groups. Diabet Med.  1992 Nov; 9 (9): 820-5.
7. Beischer NA, Oats JN, Henry OA, Sheedy MT, Walstab JE. Incidence and severity of gestational diabetes mellitus according to country of birth in women living in Australia. Diabetes 1991 Dec; 40 Suppl 2: 35-8.
8. Tuomilehto J. A paradigm shift is needed in the primary prevention of type 2 diabetes. In: Manfred Ganz, editor. Prevention of type 2 diabetes. England: John Willey & Sons Ltd; 2005. p. 153 – 165.

Uploaded in January 2011