Patterns of and Factors Associated with Postpartum Diabetes...
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i Patterns of and Factors Associated with Postpartum Diabetes Screening in Women Diagnosed with Gestational Diabetes Mellitus in Malappuram District Dr. Sakeena K Dissertation submitted in partial fulfillment of the Requirement for the award of Master of Public Health ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY, TRIVANDRUM Thiruvananthapuram, Kerala. India – 695011 OCTOBER 2016
Transcript of Patterns of and Factors Associated with Postpartum Diabetes...
i
Patterns of and Factors Associated with Postpartum Diabetes Screening
in Women Diagnosed with Gestational Diabetes Mellitus in
Malappuram District
Dr. Sakeena K
Dissertation submitted in partial fulfillment of the
Requirement for the award of
Master of Public Health
ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES
AND TECHNOLOGY, TRIVANDRUM
Thiruvananthapuram, Kerala. India – 695011
OCTOBER 2016
ii
Dedicated to my family members and to all those who have
supported me in the completion of the study.
iii
ACKNOWLEDGEMENTS
First and foremost I would like to thank my guide Dr. T. K. Sundari Ravindran for being
such a constant source of inspiration and directing me in the right path from the inception
of the idea regarding my topic to the completion of my dissertation. I would not have
been able to attain any concrete results without her incredible guidance and support
throughout the process.
I would like to thank my teachers Dr. P S Sankara Sarma for helping me in the sampling
process and methodology; Dr. V Raman Kutty, Dr. Manju Nair, Dr. Mala Ramanathan,
and Dr. Ravi Prasad Varma for guiding me whenever I had any doubts regarding my
thesis or otherwise. I would also like to thank Dr. K R Thankappan, Dr. Biju Soman, Dr.
Kannan Srinivasan and Ms. Jissa V T for teaching me the various areas of public health. I
express my heartfelt gratitude to my seniors Uma Santhosh, Dr. Malu Mohan, Dr. GK
Mini, Dr.Neethu Suresh for always lending a hand and helping me through my
presentations and thesis work.
I would like to acknowledge the love and support given by my family, especially my
husband Dr. Jafar M Backer over the years. This journey would not have been easy had
they not stood by me always. Lastly, I would like to thank all my batch mates for a
successful completion of these two years.
The study was funded by a research grant of Health Systems Research India Initiative
Trust (HSRII). I would like to express my sincere gratitude towards Mr.Ranjith R Menon
and Mr.Arun B Nair of HSRII Trust for their support.
With regards,
Dr. Sakeena K
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DECLARATION
I hereby declare that this dissertation titled ―Patterns of and Factors Associated with
Postpartum Diabetes Screening in Women Diagnosed with Gestational Diabetes Mellitus
in Malappuram District‖ is the bonafide record of my original research. It has not been
submitted to any other university or institution for the award of any degree or diploma.
Information derived from the published or unpublished work of others has been duly
acknowledged in the text.
Dr. Sakeena K
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum
Thiruvananthapuram, Kerala. India - 695011
October, 2016
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CERTIFICATE
Certified that the dissertation titled ―Patterns of and Factors Associated with Postpartum
Diabetes Screening in Women Diagnosed with Gestational Diabetes Mellitus in
Malappuram District‖ is a record of the research work undertaken by Dr. Sakeena K, in
partial fulfillment of the requirements for the award of the degree of ―Masters of Public
Health‖ under my guidance and supervision.
Guide:
Dr. TK Sundari Ravindran
Professor
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology,
TrivandrumThiruvananthapuram, Kerala. India - 695011
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Table of contents
Chapters Topic Page no.
List of tables and figures
Glossary of abbreviations
Abstract
Sections Sub sections Topic Page No
1 Chapter1- Introduction and review of literature 1
1 Background 1
1.1 Gestational Diabetes Mellitus (GDM) 1
1.2 Diagnostic Criteria 2
1.2.1 During pregnancy 2
1.2.1 During the postpartum period 3
1.3 Management of GDM 4
2 Prevalence of GDM 4
2.1 Prevalence in different parts of the world 4
2.2 Prevalence in India 6
3 Risk Factors 7
3.1 India 10
4 Prognosis 12
4.1 Poor pregnancy outcome and morbidities 12
4.2 Risk of developing Type2 Diabetes
mellitus(T2DM) in future
14
5 Universal postpartum screening of
women with GDM in pregnancy
15
5.1 Screening rates 15
5.2 Reasons for low postpartum screening rates
among women diagnosed with GDM
17
6 Rationale for the Study
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2 Chapter 2-Methodology 22
2.1 Objectives of the study 22
2.2 Study type/design 22
2.3 Study setting 22
2.4 Study population 23
2.5 Sample size estimation 23
2.6 Sample selection procedures 24
2.7 Inclusion Criteria- for GDM affected
women
26
2.8 Exclusion Criteria -for GDM affected
women
26
2.9 Inclusion Criteria –For the providers 26
2.10 Operational definitions 26
2.11 Data collection techniques 27
2.12 Analysis 28
2.13 Data storage 28
2.14 Ethical considerations 28
2.15 Dissemination of results 29
3 Chapter 3-Results and Explanations 30
Section1 30
3.1 Characteristics of the respondents 30
3.1.1 Socio-demographic characteristics of the
respondents
30
3.2 Reproductive profile of women affected
with GDM
32
3.3 Diagnostic profile of the respondents 34
3.4 Postpartum screening of the respondents 35
3.5 Morbidity profile of GDM affected women
with in their most recent pregnancy and
43
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delivery
3.6 Child characteristics 45
3.7 Morbidity profile among newborn babies 47
Section II
3.8 Timely postpartum screening and
associated factors
47
3.9 Results of age adjusted multiple logistic
regression of factors associated with timely
postpartum screening (≥6weeks)
51
Section III 53
Doctors’ perspectives on management and
postpartum screening and advice
53
3.10 Management of GDM during pregnancy 54
3.11 Management of GDM during labour 55
3.12 Postpartum advice and management 56
3.13 Postpartum screening 57
3.14 Perceived barriers to women using
postpartum screening
57
3.15 Recommendations and suggestions to
improve the rate of timely postpartum
screening
58
Chapter 4-Discussion and conclusions
59
4.1 Patterns of postpartum screening for diabetes 60
4.2 Factors associated with timely postpartum
screening for diabetes of women with GDM
62
4.3 Barriers to postpartum diabetes screening and
adequate post-screening follow-up
65
4.3.1 Barriers as reported by the women 65
4.3.2 Barriers related to doctors and the health system 66
4.4 Postpartum diabetes screening of GDM 67
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pregnancies-a case of repeated missed
opportunities to prevent T2DM
4.5 Strength and Limitations of the study 67
4.6 Conclusions and recommendations 67
References
Annexures
Annexure I Interview schedule for the survey (English)
Annexure II Interview schedule for the survey (Malayalam)
Annexure III Research information sheet (English)
Annexure IV Research information sheet (Malayalam)
Annexure V Informed consent form GDM affected women (English)
Annexure VI Informed consent form GDM affected women (Malayalam)
Annexure VII Research information sheet provider (English)
Annexure VIII Informed consent form provider (English)
Annexure IX In-depth interview guide provider
Annexure X Permission letter from District Medical Officer Malappuram
Annexure XI Permission letter from Almas hospital
Annexure XII Permission letter from MKHO hospital
Annexure XIII Permission letter from Laila‘s hospital
Annexure XIV Institute Ethics Committee clearance certificate
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List of tables and figures
Table
no:
Title Page
number
1.1 Risk factors of gestational diabetes mellitus 8
1.2 Maternal and fetal morbidity associated with gestational diabetes
mellitus
13
2.1 Details of deliveries of the four selected hospitals for the year 2015 23
3.1 Socio-demographic profile of the respondents in the study sample 31
3.2 Reproductive profile of women affected with GDM in the study
sample
32
3.3 Diagnostic profile of the respondents in the study sample 34
3.4 Postpartum diabetes screening profile of the respondents in the study
sample.
36
3.5 Reasons for not undergoing blood sugar examination after delivery. 37
3.6 Status of consultation after testing their blood in the postpartum
period.
38
3.7 Reasons for not consulting a doctor. 39
3.8 Instructions to respondents who consulted a doctor after testing their
blood sugar.
40
3.9 Status of adherence to doctors‘ instructions by the respondents. 41
3.10 Reasons for non-adherence for the respondents 43
3.11 Patterns of morbidity of women affected with GDM in their most
recent pregnancy, delivery and postpartum period
43
3.12 Child characteristics in the most recent delivery 46
3.13 Patterns of morbidity among new born babies of women affected
with GDM.
47
3.14 Timely postpartum screening and associated factors 48
3.15 Results of age adjusted multiple logistic regression of factors
associated with timely postpartum screening (≥6weeks)
52
3.16 Profile of the doctors included in the in-depth interviews 53
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Figure
no:
Title Page
number
1 Missed windows of opportunity to prevent or delay progression
from GDM to T2DM
69
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Glossary of abbreviations
WHO World Health Organization
DIP Diabetes In Pregnancy
GDM Gestational Diabetes Mellitus
ADA American Diabetes Association
IADPSG International Association of Diabetes and Pregnancy Study Groups
OGTT Oral Glucose Tolerance Test
DIPSI Diabetes in Pregnancy Study Group India
FPG Fasting Plasma Glucose
PPPG Post Prandial Plasma Glucose
HAPO Hyperglycemia and Adverse Pregnancy Outcome
T2DM Type 2 Diabetes Mellitus
IDF International Diabetes Federation
ASHA Accredited Social Health Activist
AWW Anganwadi worker
NICU Newborn Intensive Care Unit
Ob/Gyn Obstetrician/ Gynaecologist
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ABSTRACT
Background: The aim of this study is to examine rate and patterns of postpartum
diabetes screening for gestational diabetes mellitus (GDM) patients and factors associated
with the same. Other objectives are to document postpartum morbidity and provider
perspectives on appropriate postpartum follow up of this group.
Methodology: A cross sectional study was done among 200 women with GDM, who had
delivered in selected hospitals in Malappuram district between 9weeks and 6 months prior
to the survey using interviewer administered interview schedule in Malayalam. In depth
interviews were done of doctors who had managed the maximum number of GDM cases
from each of the four selected hospitals.
Results: Prevalence of timely postpartum diabetes screening among the respondents is
29%. Doctors‘ advice significantly influenced uptake of timely postpartum screening.
Only about 6% of the women with a GDM pregnancy received appropriate and adequate
postpartum follow-up. About a fifth of the respondents had a health problem during
pregnancy or in the postpartum period. A tenth of the infants experienced neonatal
morbidity. Doctors varied in the level of accurate knowledge and had diverse approaches
not consistent with standard guidelines in managing GDM cases postpartum. All doctors
reported difficulty in getting patients to come for screening beyond one month
postpartum.
Conclusion: There is urgent need to enforce adherence to national guidelines for
postpartum GDM screening. Increasing provider knowledge regarding high future risk of
Type 2 DM following a GDM pregnancy even among women who have normal blood
sugar levels postpartum is of utmost importance. Appropriate postpartum management of
GDM patients can be an important contribution to diabetes prevention and control in
Kerala.
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Chapter 1
Introduction and review of literature
1.1 Background
1.1.1. Gestational Diabetes Mellitus
Hyperglycemia (an excess of glucose in the blood stream) in pregnancy is one of the most
common medical conditions associated with pregnancy. Depending on the level of
hyperglycemia and the time of detection, WHO has classified hyperglycemia in
pregnancy as either diabetes mellitus in pregnancy (DIP) or as gestational diabetes
mellitus (GDM) (World Health Organisation, 2013).
Diabetes mellitus is defined as a condition where a person‘s blood glucose level is
increased, either due to the lack of production of enough insulin, or because the body
does not respond properly to it. Diabetes mellitus in pregnancy (DIP) is defined as
pregnancy in previously known diabetes or hyperglycemia diagnosed for the first time
during pregnancy that meets WHO criterion for diabetes mellitus in the non- pregnant
state. DIP may occur at any time during pregnancy including in the first trimester.
On the other hand, gestational diabetes mellitus (GDM) is defined as hyperglycemia
diagnosed for the first time in pregnancy that is not diabetes. This may occur at any time
during pregnancy but is most likely after 24 weeks. So hyperglycemia detected during
routine investigations in pregnancy which does not meet the criteria of diabetes mellitus
in pregnancy (DIP) is called gestational diabetes mellitus (GDM). This is a new and
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improved definition. Previously GDM was defined as ―any degree of glucose intolerance
with onset or first recognition during pregnancy‖ (Association, 2013).
1.2. Diagnostic Criteria
1.2.1 During pregnancy
The diagnostic criteria of GDM vary from country to country. As per the
recommendations of International Association of Diabetes and Pregnancy Study Groups
(IADPSG) (2010) and WHO (2013), the diagnosis of GDM is made using a single step
75-g oral glucose tolerance test (OGTT) when one of the following test results are
recorded during routine testing specifically between 24 and 28 weeks of pregnancy or at
any other time during the course of pregnancy:
(1) Fasting plasma glucose 5.1−6.9 m mol/L (92−125 mg/dl),
(2) 1-hour post 75-g oral glucose load ≥10 m mol/L (180 mg/dl),
(3) 2-hour post 75-g oral glucose load 8.5–11.0 m mol/L (153−199 mg/dl).
To standardize the diagnosis of GDM, the World Health Organization (WHO)
recommends using a 75 g oral glucose load which can be given in either a non-fasting or
fasting state or one blood sample to be drawn 2 hours after the glucose load. The
diagnostic cut-off point for GDM is with140 mg/dL, irrespective of whether the GTT is
done in the fasting or no fasting state(Mohan et al., 2015,Alberti and Zimmet, 1998). The
Diabetes in Pregnancy Study Group of India (DIPSI) guidelines also recommends the
same diagnostic criteria.
The usual recommendations are for screening pregnant women for GDM between 24 and
28 weeks of gestation, but there is a possibility of missing the chance for detection of
unrecognized type2 DM (pre-GDM) (Ben-Haroush et al., 2004,Bartha et al., 2000).
Universal screening of all pregnant women is recommended to identify mothers at high
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risk of GDM and follow them up appropriately. Life style modification and/or
pharmacological intervention with high risk women can delay or prevent progression to
type 2 DM of women diagnosed with GDM during pregnancy (Tandon et al, 2015,Ratner
et al, 2008). Regular postpartum screening of all women diagnosed with GDM is also
recommended (Buchanan and Page, 2011).
1.2.2 During the postpartum period
The 75-g oral glucose tolerance test (OGTT) is considered as the most sensitive test
for postpartum screening of GDM. It helps in detecting maximum number of cases of pre
diabetes /diabetes as compared to fasting plasma glucose (FPG) and glycated hemoglobin
(HbA1c) (ADA, 2014). FPG alone may miss 30–40% of cases of type 2 diabetes and will
not detect isolated impaired glucose tolerance (Tandon et al., 2015).
The National Diabetes Education Program and the American College of Obstetricians and
Gynecologists (the College) jointly recommend postpartum screening of women with a
history of GDM at 6-12 weeks postpartum. If the test is normal, retest every 3 years and
at the first prenatal visit in subsequent pregnancy is recommended. If pre-diabetes is
diagnosed, then annual testing must be done. The role of family support in healthy diet
and development of physical activity behavior is crucial, because of increased risk of
children of GDM mothers to obesity and T2DM (Gabbe et al., 2012) .
As per National Guidelines for Diagnosis and Management of Gestational Diabetes
Mellitus for India, a FPG and a 2hr postprandial plasma glucose(PPPG) is performed on
the third day of delivery at the place of delivery and hence GDM cases are discharged
only after 48 hours following delivery. Subsequently there are instructions to the
Auxiliary Nurse Midwife (ANM) who is the front-line health worker, to perform 75 g
OGTT at 6 weeks postpartum to evaluate glycemic status of women. Cut off values for
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normal blood glucose values are fasting plasma ≥ 126 mg/dl, 75g OGTT 2 hr plasma
glucose normal value <140mg/dl, impaired glucose tolerance 140-199mg/dl and
diabetes ≥ 200 mg/dl. The guidelines are silent on further screening of women detected to
be normal during postpartum screening.
1.3. Management of GDM
A comprehensive approach to managing GDM and preventing GDM from progressing to
type 2 diabetes includes life style interventions, breast feeding support, appropriate
pharmacological treatment, and continuous follow-up for the mother and child for their
future health (Ratner., 2007).
According to the ―The International Federation of Gynaecology and Obstetrics (FIGO)
Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management,
and care-2015‖, GDM should be managed as per the available infrastructure and
resources available in a specific setting. The management primarily starts from the
empowerment of women to choose the right quantity and quality of food and level of
physical activity, and nutritional counseling and physical activity should be the primary
tool. Repeated advice and reinforcement is needed. When the lifestyle modification alone
fails to achieve blood sugar control, metformin, glyburide, or insulin should be
considered as safe and effective treatment options for GDM (Hod, Kapur, et al., 2015)
2. Prevalence of GDM
2.1. Prevalence in different parts of the world
According to the 2015 estimates of the International Diabetic Federation (IDF), globally
16.2 % of women with live births had some form of hyperglycemia in pregnancy. Out of
this, GDM accounted for 85.1 %, other types of diabetes first detected in pregnancy was
5
7.4% and diabetes detected prior to pregnancy was 7.5%. This shows the alarming nature
of the situation which needs urgent global action (IDF.,2015).
A survey on prevalence and country practices administered to diabetologists, obstetricians
and others working on gestational diabetes mellitus in 173 countries reported that there
was a variation in GDM prevalence, ranging from <1% to 28% ,which included data
derived from single or multisite studies, national data, and /or estimates from expert
assessments (Jiwani et al., 2012).
The prevalence of GDM in Europe is 6-10% of pregnancies (Buckley et al., 2012). In the
United States of America, the figures were 4.6 % as per birth certificate and 9.2% as per
both birth certificate and Pregnancy Risk Assessment Monitoring Questionnaire
(PRAMS) using 2007-2010 data from PRAMS (De Sisto et al., 2014) and in Africa the
prevalence was 3.2% (2.1%-6.7%) as per International Diabetic Federation diabetic atlas
of 2015.
This variability may be due to ethnicity and ethnic heterogeneity among different
populations, as well as differences in screening and diagnostic criteria used (Hod et al.,
2015). Variations in prevalence of GDM by ethnicity is also reported by a comparison
study in Melbourne in Australia among 1928 GDM diagnosed parturient women out of
35,253 (5.5%) pregnant women, during 1979 to 1988. There were more severe grades of
GDM in women born in the Indian subcontinent , Mediterranean region, Asia, Egypt and
Arab countries, and the incidence of GDM was rising in all racial groups from 3.3%
during 1979-1983 to 7.5% during 1984-1988 (Beischer et al., 1991) .
Women entering pregnancy are at an increased risk of hyperglycemia due to a decline in
the age at onset of diabetes and pre-diabetes, and the increase in some countries in the age
at child bearing. This along with the rise in prevalence of overweight and obesity
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globally are deemed to contribute to an increase in GDM in many parts of the globe
(Mendez et al., 2005).
2.2. Prevalence in India
Compared to other populations of Southeast Asia, the prevalence of GDM is high in the
Indian population (Seshiah et al., 2004). Women of Asian origin and especially ethnic
Indians are at a higher risk of developing GDM and subsequent type 2 diabetes. It is
possible that undiagnosed GDM in the past has resulted in the high prevalence of type 2
diabetes (T2DM) in India (Seshiah, Balaji et al., 2008).
The prevalence of GDM in India varies in different parts of the country, depending upon
the geographical locations and diagnostic methods used. A study by Rajesh Rajput and
others in 2011, estimated a prevalence of 7.1% in Haryana (Rajput et al., 2013). Studies
from southern states done in recent years have reported a much higher prevalence of
GDM. For example the prevalence in a prospective observational study in a tertiary care
hospital in north Kerala in 2014 was 15.9% (Mohan and Chandrakumar, 2015). A study
on prevalence and risk factors associated with gestational diabetes in a medical college in
south India during December 2013 to January 2014 found that the prevalence was 17%
(Sreekanthan et al., 2014). A high prevalence of 27% was reported by a study in
Pondicherry during August 2011 to June 2012 using the International Association of
Diabetes and Pregnancy Study Group‘s (IADPSG) diagnostic criteria (Nayak et al.,
2013). Another multi-centric study observed that the highest prevalence of GDM was in
southern region (Ernakulum, Kerala) and lowest prevalence in North Eastern region
(Manipur) (Baruah et al., 2014).
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GDM has been found to be more prevalent in urban areas than in rural areas (Zargar et
al., 2004, Seshiah et al., 2009, Seshiah et al., 2008 , Nayak et al., 2013) . In Tamil Nadu,
urban (Chennai), semi-urban (Saidapet), and rural (Thiruvallur) area prevalence were
17.8%, 13.8% and 9.9%, respectively in 2009 (Seshiah et al., 2009) .
The variations in the prevalence of GDM in India in different geographical locations may
be ascribed to variations in caste, religion, socioeconomic status, life style and food habits
and access to health care services (Baruah et al., 2014).
There are indications of a dramatic increase in the prevalence of GDM in India. A 2004
study in Kashmiri women reported GDM prevalence to be 3.8% but in 2014 (Zargar et
al., 2004), a study to determine the prevalence of GDM in urban block of Kashmir valley
found that the prevalence was 7.8% (Raja et al., 2014). In a multi centric study among
3674 pregnant women from different parts of India in 2004 the prevalence of GDM was
16.6%, with an increase in prevalence from 1% in 1998 to 16.6 % in 2004 in the country
(Seshiah et al., 2004). The increasing prevalence of GDM in general is attributed to the
urbanization and the epidemic of obesity and physical inactivity.
3. Risk factors
Knowledge regarding the nature and type of risk factors plays a significant role in
planning and implementing prevention strategies to control the epidemic of gestational
diabetes mellitus (GDM). Evidence from the literature shows that risk factors are more or
less same at the global, national and local levels except in certain factors like the
geographical peculiarity, ethnicity, life style and food habits.
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Table.1.1 Risk Factors of Gestational Diabetes Mellitus
Maternal Factors Past Obstetric
History
Pregnancy Factors Family
History
Diabetes
Protec
tive
Factor
s
Ethnicity(women of
Asian Origin,
especially Indians)
Increased
age*(women who are
older than 25 have a
greater risk )
Parity
Pre-pregnancy weight
Weight gain during
pregnancy
BMI >27
Polycystic ovarian
syndrome
Low birth weight
Abortions,
Fetal loss
Past history of GDM
Previous abnormal
GTT
Hydramnios*
( a condition with
excess amniotic
fluid accumulation
in pregnancy)
Bleeding*
Large weight
babies(macrosomia)
*
Previous fetal
malformations
Pregnancy induced
hypertension
Degree of hyperglycemiain
pregnancy and immediate
postpartum period1
Multiple pregnancy
Sex of the fetus (4% more
relative risk for male than
female)
Prematurity2
Polyhydramnios2(Excess of
amniotic fluid in the
amniotic sac)
Macrosomia2
Preterm labor2
GDM in
women‘s
mother*
Young
age
Physic
al
activity
1
Health
y diet2
Breast
feeding
3
9
Maternal Factors Past Obstetric
History
Pregnancy Factors Family
History
Diabetes
Protec
tive
Factor
s
Educational level*
Socioeconomic
status*
Acanthosis nigricans*
Lack of exercise and
diet control
Dietary fat
Smoking
Certain drugs
(influence insulin
resistance)
Urban habitat*
low adult height*
Premature rupture of
membranes*2
Hyperbilirubinemia*
*Indian studies; 1, 2, 3- potentially prevent progression to type 2 diabetes
1-risk factor for subsequent pregnancies, 2-complications during previous pregnancy is a
major risk factor (Sreekanthan et al., 2014)
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Other than the above factors, ethnicity (women of Asian origin, especially ethnic Indians)
and maternal factors such as polycystic ovarian syndrome (PCOS), a past history of poor
pregnancy outcome (abortion, foetal loss) are also contributing to Gestational diabetes
mellitus incidence(Cheung et al., 2001).
Factors such as persistent obesity, weight gain in future and subsequent pregnancies can
be modified (modifiable risk factors), but factors like ethnicity, pre pregnancy weight,
age, parity, family history of diabetes, and degree of hyperglycemiain pregnancy and
immediate postpartum period unmodifiable risk factors. Another unmodifiable risk factor
is sex of the baby. In a systematic review and meta-analysis by Jaskolka D et al 2015,
pregnant women carrying a boy had a 4% higher relative risk of GDM than those
carrying a girl, thus the fetus had an unsuspected effect on the glucose metabolism of the
mother in pregnancy (Jaskolka et al., 2015).
Physical activity, dietary fat, and avoidance of certain life style factors that adversely
influence insulin resistance, such as smoking and certain drugs are additional modifiable
risk factors, and diabetic prevention strategies should address the potentially modifiable
risk factors using the unmodifiable risk factors to identify women at risk (Dornhorst and
Rossi., 1998).
3.1 India
In a case control study in a tertiary care hospital in south India carried out during August
2007 to June 2008, the results showed association of several modifiable and unmodifiable
risk factors to GDM. Those based on personal and family history were body mass index
(BMI), those who had treatment for infertility, family history of diabetes among first
degree relatives especially in the mother. Related to the past history were history of
previous pregnancy losses, past GDM, prematurity , pre eclampsia , urinary tract
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infections, moniliasis (yeast or fungal infection of vulva and vagina), polyhydramnios
(excess of amniotic fluid in the amniotic sac), macrosomia (a new born who‘s
significantly larger than average) and pre-term labor (Bhat et al., 2010).
In a study carried out during June 2009 to January 2011 in an antenatal care clinic at a
tertiary care hospital in Haryana, the risk factors identified were age, educational level,
socioeconomic status, pre - pregnancy weight and BMI, weight gain, acanthosisnigricans
(a brown to black, poorly defined, velvety hyper-pigmentation of the skin, usually found
in body folds), family history of diabetes or hypertension and past history of GDM. But
on multivariate analysis, only upper middle class and presence of acanthosisnigricans
were found to be significantly associated with GDM (Rajput et al., 2013).
A medical college- based study in Kollam district of Kerala during December 2013 to
January 2014 found that the risk factors were higher age of pregnant women, over weight
and obesity, GDM in first degree relatives, previous abnormal GTT, lack of exercise and
diet control. The study also identified that women with previous large weight babies
(macrosomia), previous loss of pregnancy, GDM in previous pregnancy, complications in
previous pregnancy like hydramnios, bleeding etc. had increased chances of getting GDM
(Sreekanthan et al., 2014).
A mixed methodology study in Kerala (2013) identified many environmental and
personal factors leading to unhealthy life styles along with inadequate accessibility and
availability of health care services, cultural bias, norms, other misconceptions to risks and
low expectations on life style modification and risk reduction. The prevalence of risk
factors were found to be very high and increasing in Kerala (Daivadanam et al., 2013).
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4. Prognosis
GDM is associated with poor pregnancy outcome and a range of maternal and neonatal
morbidities, and women with GDM are also at high risk of developing Type 2 Diabetes
Mellitus.
4.1. Poor pregnancy outcomes and morbidities
GDM affects both mother and offspring adversely. A study in Kerala in 2014, showed
that 80% of abortions had a history of previous GDM in pregnancy (Sreekanthan et al.,
2014, Metzger, 2007). According to the Hyperglycemia and Adverse Pregnancy Outcome
Study (HAPO study) which enrolled between July 2000 and April 2006 more than 25,000
non-diabetic pregnant women from 15 field centers located in 9 different countries, there
was a positive association of maternal blood glucose levels below those diagnostic of
diabetes with adverse perinatal outcomes (Coustan et al., 2010, The HAPO Study
Cooperative Research Group, 2008).
A retrospective study with a cohort of 180 from a rural area of Thiruvananthapuram
district, Kerala, taken from the database of INDADE (Indo Danish Collaboration on
Diabetes Epidemiology) from 2007 to2011 (the report is based on 2010 analysis)
observed that the major neonatal outcomes were increased birth weight and increased
IBN(in-born nursery ) admissions (Sreelakshmi et al., 2015). The risk for development of
obesity and abnormal glucose metabolism during child hood, adolescence, and adulthood
were more in offspring of mothers with GDM(Metzger., 2007). The perinatal and
neonatal morbidities include macrosomia, shoulder dystocia and other birth injuries,
respiratory distress, hypoglycemia (low blood glucose level), polycythaemia (abnormally
increased concentration of haemoglobin in the blood), and hyperbilirubinemia (elevated
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level of bilirubin in the blood). The long term sequelae of uterine exposure to maternal
hyperglycemia include higher risks of obesity, impaired glucose metabolism, and diabetes
later in life (Hod et al., 2015).
Common maternal outcomes in women with GDM were: delivering the child through
surgical intervention, progression to type 2 diabetes mellitus, and higher incidence of
maternal morbidity including birth trauma, hypertensive disorders of pregnancy
(including preeclampsia), and subsequent development of T2DM (Sreelakshmi et al.,
2015).
In a prospective cohort study in Pondicherry during August 2011 to July 2012, there was
significant association of family history and low gestational age with more antenatal
complications in GDM mothers, when compared to non GDM group (25% vs 12%)
(Maiti et al., 2012,Sreelakshmi et al., 2015). Table 2 below summarizes the major
maternal, neonatal, and infant and child morbidities associated with GDM.
Table 1.2: Maternal and fetal morbidity associated with gestational diabetes
mellitus.
Maternal morbidity Foetal/neonatal/child morbidity
Early pregnancy
Spontaneous abortions Neonatal death
Pregnancy Non-chromosomal congenital
malformations
Pre eclampsia Shoulder dystocia
Gestational hypertension Respiratory distress syndrome
Excessive foetal growth
(macrosomia, large for gestational age)
Cardiomyopathy
Urinary tract infections Neonatal polycythaemia
Delivery Neonatal hyperbilirubinemia
14
Maternal morbidity Foetal/neonatal/child morbidity
Pre-term labour Neonatal hypocalcaemia
Traumatic labour NICU admissions*
Instrumental delivery
(as a consequence birth injury
Erb‘s palsy
Caesarian delivery Programming and imprinting:-
Foetal origins of disease: diabetes Obesity, hypertension, metabolic syndrome
Postoperative/postpartum infections
Postoperative/postpartum haemorrhage
Thromboembolism
Maternal morbidity and mortality
Haemorrhage
Pueparium
Failure to initiate and/or maintaining
breastfeeding
Infections
Long-term postpartum
Weight retention
GDM in subsequent pregnancies
Future overt diabetes
Future cardiovascular disease
Adapted from the International Journal of Gynaecology &obstetrics,volume 131,
supplement3(2015), *added from Sreelakshmi et al.
4.2. Risk of developing Type 2 Diabetes mellitus (T2DM) in future
Women with a history of GDM are more prone to develop type 2 diabetes mellitus in
future (Metzger., 2007,Bellamy et al., 2009a, Jiwani et al., 2012).
In a systematic review of 28 epidemiological studies published between January 1961
and August 2001, with follow up times ranging from 6 weeks to 28 years, the cumulative
incidence of diabetes ranged from 2.6% to 70% after the index pregnancy, and maximum
was in the first five years after delivery and appeared to plateau after 10 years (Kim et
15
al., 2002). In a four year follow up study in 2000 in Hungary of previous GDM women
who received their care during pregnancy between 1996 and 1998 the prevalence of
diabetes was 21% (Madarász et al., 2009).
South Asians are found to have high rates of development of diabetes after GDM, and
they develop the condition earlier than people of other ethnicities (Girgis et al., 2012). A
five year follow up study during 1997-1998 in Mysore, India found the conversion rate to
T2DM to be 34% in 35 GDM women as compared to 2% among controls (Krishnaveni et
al., 2007).
The most important predictor of the development of type 2 diabetes following a GDM
pregnancy was found to be an elevated blood glucose value at GDM diagnosis or at an
early postpartum examination. In a study conducted in 1999-2002 among Danish women,
the incidence of diabetes with previous diet –treated GDM was very high and they had an
elevated blood sugar value in the postpartum period (Lauenborg et al., 2004).
Hence to modify natural history and reduce risk of future diabetes, uniform postpartum
screening of women with GDM is necessary (Tandon et al., 2015).
5. Universal postpartum screening of women with GDM in pregnancy
5.1. Screening rates
Across the world without any difference between advanced economic and low and middle
income countries the screening rates for postpartum diabetes are very low. Globally, the
postpartum screening rates are reported to be 50% or lower (Keely, 2012).
In a cross sectional study of women aged 18-44 years who gave birth at one medical
centre at Boston, USA between 2003 and 2009, only 23.4% of GDM affected women had
any kind of glucose test by 6 months postpartum. Half of them completed screening by
10 weeks and out of this only 29% had undergone the recommended oral glucose
16
tolerance test (OGTT). This emphasizes the need for awareness among providers, family
as well as the need for system support to the women because unlike other diseases, here
the system as well as the provider misses the opportunity of providing primary care
(McCloskey et al., 2014).
Even though the testing rates have increased over fourteen years in a population based
cohort study in Ontario, Canada among women who had delivered between 1994 and
2008, the number of women who received the recommended oral glucose tolerance test
(OGTT) was low, showing lack of standard protocol and awareness among the concerned
health care providers (Shah et al., 2011).
Participation in follow up screening was low in North Denmark region, in a study among
2171 women who were selected from Danish National Registers covering the years 1994-
2011. Women with high income had comparatively low testing status than women in the
low income group, in a Danish national based registry (2014) (Olesen et al., 2014).
The International Diabetes Federation (IDF) is an umbrella organization of over 230
national diabetes associations over 173 countries and territories and functioning with its
mission, to promote diabetes care, prevention and a cure worldwide. The Abstract of IDF
World Diabetes Congress, 2013 indicates that Indian women with GDM should have
frequent post-partum screening if we aim to modify natural history and reduce the risk of
diabetes (IDF, 2015).
A longitudinal study in Delhi (2015) on the prevalence of glucose intolerance at 6 weeks
postpartum, according to American Diabetes Association (ADA) Criteria reported that
17.3 % did not return for the follow up screening. Out of those who were tested , 33%
had an abnormal oral glucose tolerance with 6.4 % of women having overt type 2
17
diabetes, while 19.3% had borderline risk and 8% were at high risk of conversion to
T2DM (Jindal et al., 2015).
5.2 Reasons for low postpartum screening rates among women diagnosed with GDM
Low risk perception
Women with GDM may not believe that they are at risk of diabetes (Jones et al., 2009) .
In a cross sectional study among 217 women with a history of gestational diabetes within
the past 5 years, in US, 90% of women recognized a risk of future diabetes but only 16%
had a high perceived risk of future diabetes. The perceived risk increased to 39% when
they were asked to estimate their risk if they followed the same lifestyles (Kim et al.,
2002).
Low motivation for screening in the postpartum period
In a qualitative study using semi-structured interviews in 2013 in the UK, even though
women were aware of their future risk of diabetes, they did not follow the instructions
.While they were pregnant, the pregnancy itself motivated the behavioral change but after
delivery, the behavioral changes were not maintained. Further, factors like tiredness,
childcare demands, and maternal attachments were the prominent barriers in the early
postpartum period and after that work, family and child development become the barriers
(Lie et al., 2013). Personal factors such as low educational level, socio-economic status
and high parity, and the requirement for fasting before testing also contributed to
difficulties in getting screened (Yarrington, Zera, et al.,2015).
Provider and health-system factors
A number of studies point to provider factors such as lack of awareness and failure to
give proactive advice, as well as large health system factors such as poor access and
18
availability and low level of coordination as contributing to low uptake of postpartum
screening for blood sugar levels in women experiencing GDM during pregnancy.
Lack of access to care (prenatal, postnatal) or barriers such as the unsuitable timing of
testing services, lack of availability of insulin for treatment during pregnancy were all
identified by studies as important factors (Coustan et al., 2010, Kwong et al., 2009). In a
Danish study, those who tested their blood from a biochemical unit rather than consulting
a health care provider, were at a high risk of treatment non-initiation (Olesen et al., 2014).
Hence access to providers is an important factor.
In a survey among health care professionals in September 2014, in East London and West
Midlands in England, it was found that 81% of midwives and 52% of obstetricians
underestimated or were unsure of future risk of diabetes in women experiencing GDM.
There was a lack of consensus among them regarding the responsibility for screening in
the immediate postpartum period (Rayanagoudar et al., 2015) .
A mixed method study in the greater Boston area during December 2011 and May 2012,
which recruited subjects with a history of GDM in their most recent completed pregnancy
6 months to 4 years before enrollment, examined reasons given by women who did not
present themselves for postpartum screening. Untested women stated their reason for not
testing as the providers‘ reassurance that diabetes would resolve after delivery. They
believed that the providers did not send reminders to reschedule missed appointments to
complete testing because the providers did not perceive the women‘s risks to be serious
(Paez et al., 2014) .
A qualitative study in North Denmark (2015) to understand the influence of women‘s
experiences with treatment and care during pregnancy on participation in follow-up
screening, found that there was lack of continuity in care between hospital departments
19
and health sector, lack of coordination, ineffective communication and lack of
coordination of responsibility regarding follow-up screening among health care providers
and lack of focus on their individual needs and preferences (lack of patient-centeredness)
(Nielsen et al., 2015).
According to a cross-sectional study in Ohio in 2010 to identify factors associated with
high rates of postpartum screening by a randomly sampled licensed obstetricians and
gynaecologists, those who were frequent screeners followed a clinical protocol for
postpartum testing (67.2% vs 26.7%),an electronic reminder system for providers(10.8%
vs 2.2%) and sent reminders to patients (16.4% v/s 4.4%) (Ko et al., 2013).
Reminders on postpartum screening, written materials on GDM and use of standard
checklist showed an increase in screening rate ( Yarrington, Zera, et al., 2015, Nielsen et
al., 2015).
To address the increasing prevalence, the National Diabetes Education Program (USA)
brings to the notice of providers to take action to improve postpartum screening in order
to identify high- risk groups, provide early treatment and prevention, counsel the mother
to test for diabetes prior to subsequent pregnancy and also counsel regarding the risk of
offspring to future diabetes and their prevention strategies. The Program also alerts
obstetrician-gynaecologists and other primary care providers to keep a system in place to
test glucose intolerance as recommended, support breastfeeding, refer to a registered
dietitian or community program for weight management, consider pharmacological
agents for pre-diabetes, treatment of existing hypertension and counselling regarding
regular testing, contraceptive options to ensure planned pregnancy, healthy food, regular
physical activity, quit smoking and inform their treating pediatrician regarding the history
of GDM status of mother.
20
6. Rationale for the Study
A large proportion of women with GDM in India progress to Type-2 diabetes mellitus
(T2DM). There is an urgent need to develop standardized protocols for GDM care in
India that can improve the maternal and fetal outcomes and help prevent future diabetes
in women with GDM (Metzger, 2007).
Kerala represents 1.8% of the total land area of India and 3.4% of the total Indian
population. During the past two decades, there is a significant improvement in the
economic status of the state, especially from income generated by family members
working abroad. This has resulted in improvement in living standards with subsequent
changes in diet and lifestyle of the population. These changes have resulted in a marked
increase in the prevalence of non-communicable diseases (lifestyle-related) especially
diabetes, hypertension and coronary artery disease among the population similar to the
demographic features of the western population.
From the evidence of prevalence studies conducted in India ,Kerala has the maximum
diabetes burden in India(Mohan et al., 2012, Reddy et al., 2006). Amrita Diabetes and
Endocrine Population Survey (2002-2005),a study from central Kerala, reported a T2DM
prevalence of 20% and a pre-diabetes prevalence of 11% (Menon et al., 2006) .
A study from southern Kerala (2000) shows wide variations in age-standardized
prevalence (30-64) of diabetes among urban, rural, midland and coastal regions
emphasizing the role of lifestyle factors. The prevalence was 16.9% in the urban, 10.1%
in the midland, 6.8% in the highland and 3.6% in the coastal area, respectively. Women
showed a higher prevalence in the highland and coastal area and men in the urban and
midland area. There were 23.5% undetected cases in the community (Kutty et al., 2000) .
A study by Thankappan et al (2010) on a total of 7449 individuals (51% women) reported
21
a high burden of non-communicable disease risk factors in the community in Kerala,
which was comparable to that in the United States (Thankappan et al., 2010).
In a medical college based study in Kollam during December 2013 to January 2014
among pregnant women, there was a significant association of GDM with obesity and
older age. Due to lack of physical activity and diet control, obesity is becoming an
epidemic in Kerala.
A significant proportion of women in Kerala in the reproductive age group are
overweight and obese (NFHS 3). A proven risk factor in developing GDM is high BMI
(WHO 2015,WHO, 2010, Matyka, 2008). The current huge burden of diabetes in the
state of Kerala will increase with the increasing prevalence of GDM. The high prevalence
of type 2 diabetes in the state increases the probability that a woman has a family history
of T2DM or GDM, which also adds to the risk of gestational diabetes mellitus. In this
situation, preventing or delaying the development of type 2 diabetes is crucial. But no
standard GDM management is being followed in Kerala at the present time. Regular
postpartum screening of all GDM affected women will help to prevent progression to
T2DM.
In Kerala, the rate of postpartum screening is very low. According to gynaecologists in
Kerala compulsory postpartum screening is not a routine practice, and even if
postpartum screening is carried out, the standard test, viz., OGTT is followed very rarely.
Further, there are no published studies on postpartum screening rates and barriers to it in
the Kerala context. This study aims to bridge this gap in evidence.
22
Chapter 2
Methodology
2.1 Objectives of the Study
I. Primary objectives of the Study
1. To assess the timely postpartum diabetes screening rate of GDM affected women
who had delivered at selected hospitals in Malappuram district.
2. To examine the patterns of and factors associated with postpartum diabetes
screening by women who had GDM during their most recent pregnancy.
II. Secondary Objective
1. To document postpartum morbidity patterns among women with GDM and morbidity
among their infants.
2. To understand provider perspectives on appropriate postpartum follow up of GDM
patients.
2.2 Study type/design
This is a mixed methodology study. In-depth interviews were carried out with doctors
and a cross sectional study was done with interviews of recently delivered women
diagnosed with GDM, using a structured interview schedule administered by the principal
investigator (PI). The study period was two months starting from July 2016-August 2016.
2.3 Study setting
23
One public and three private hospitals were selected from Malappuram district. As per
data collected from government birth registries, the proportion of public hospital
deliveries is only 11 % of total deliveries in the district (HMIS 105-16 –public hospital
deliveries 19.6%& HMIS 2016 April –September 11.8%)
2.4 Study Population
Women residents of Malappuram district who experienced GDM during their most recent
pregnancy and had delivered in the selected hospitals in Malappuram district no less than
9 weeks and no more than 6 months before the survey.
2.5 Sample size estimation
a) In-depth interviews: A total of eight doctors were interviewed till saturation was
reached.
b) Cross-sectional study: For the four hospitals (one public and three private hospitals)
in the sample, the total number of deliveries for the year 2015 was collected from
government birth registration centers.
Table 2.1 Details of deliveries of the four selected hospitals for the year 2015.
Name of Hospital Total deliveries in 2015 Deliveries in 6 months
Private Hospital A 3820 1910
Private Hospital B 3044 1522
Private Hospital C 3600 1800
Public hospital D 999 500
Total study population 11,463 5732
The sample frame had a population of 5732women delivered with six months before the
study. Sample size was calculated based on the prevalence of GDM during pregnancy
(15.9 percent) reported from an earlier study in the same district in 2014 (Mohan and
Chandrakumar, 2015). The sample size was calculated with 95% confidence interval and
24
1% precision using Open Epi version 3.03. This gives a sample size of 154. Adding 25%
to adjust for non-response, we arrived at a total of 193, which was rounded off to a total
sample size of 200.
Since the American Diabetes Association‘s (ADA) recommended time period for
postpartum screening is 6-12 weeks of delivery (National guidelines for diagnosis and
management of GDM recommends postpartum screening at 6weeks), and allowing
enough time for the women to undergo the test, we have selected a period of between 9
weeks and 6 months because in that period it would be possible to get an adequate sample
and recall bias can be minimized. We approached the respondent after getting consent for
the interview over telephone.
2.6: Sample selection procedures
Four hospitals (one public and three private) were selected purposively as they were
managing and keeping records of gestational diabetes mellitus (GDM) patients and were
willing to cooperate with the study. Anticipating complications to both mother and child,
the delivery of a woman diagnosed with GDM is always conducted in a facility where at
least physician, pediatrician and anesthesiologist are available along with facilities for
managing new born babies who need special care.
In our pilot study we came to notice that many hospitals including both public and
private, were not recording and documenting gestational diabetes mellitus unlike
pregnancy induced hypertension (PIH).Hence we could not select hospitals randomly.
Those who kept some records and were willing to participate in the study, and had a
sufficient number of deliveries were selected, because there were a few hospitals with
good records but where due number of deliveries per month were very few.
25
A list of study subjects who fulfilled the inclusion criteria was prepared from the hospital
registers. A total of 200 respondents were randomly selected from the four hospitals. The
number of respondents selected from each hospital was proportionate to the total number
of deliveries in each hospital. The randomly selected study subjects were interviewed at
their houses using interviewer administered interview-schedule in local language. The
interview schedule had nine sections. First section was designed to capture socio-
demographic details of the respondents, second section for past history (excluding the
most recent pregnancy), third section had questions regarding most recent pregnancy and
delivery. The fourth section had details of child characteristics while the fifth had
questions on management of GDM in most recent pregnancy. This had two parts,
management during pregnancy and after delivery. The sixth section asked about personal
barriers for postpartum screening and seventh section regarding spacing/family planning
.The eighth and ninth sections were about risk perceptions and postpartum health
respectively.
The principal investigator alone did the data collection at their homes after getting prior
consent through their providers. Among the selected study subjects three were not able to
participate as one went abroad, one shifted to Tamil Nadu to her husband‘s residence
three days prior to my visit as she had to prepone her shifting, and the third had to move
to her parents‘ house at neighborhood district as her father had some illness. They were
replaced by subjects from the corresponding hospital registers randomly.
For the in-depth interviews, doctors who managed the highest numbers of GDM patients
were identified from the out-patient departments of the hospitals in which they worked.
26
2.7 Inclusion Criteria- for GDM affected women
Women who had delivered in the selected health facilities within a period of not less than 9
weeks and not more than 6 months from the date of survey and were residing continuously in
the district for the past 6 months.
2.8 Exclusion Criteria -for GDM affected women
1. Not residing in the district at the time of interview. They delivered in the selected
hospital, but belonged to the neighboring districts.
2. Those who were seriously ill at the time of interview.
2.9 Inclusion Criteria –For the providers
Physicians specifically involved in the management of GDM-affected-women practicing
in the selected facilities in Malappuram district (Specialized in Obstetrics and
Gynecology or General Medicine) and managing the maximum number of GDM patients
in the selected facilities.
2.10 Operational definitions
Gestational diabetes mellitus (GDM): is defined as hyperglycemia diagnosed for the first
time in pregnancy that does not meet the criteria of diabetes mellitus in pregnancy (DIP).
This may occur at any time during pregnancy but is most likely after 24 weeks
Test for postpartum screening as per guidelines: 2 hr 75 –g oral glucose tolerance test
(OGTT) either in the fasting or non-fasting state.
Timely postpartum screening: Screening at ≥6 weeks postpartum and < 6 months using
any test for blood glucose level.
27
2.11Data collection techniques
Two techniques are used for data collection.
a) Interview schedule
b) In-depth interview of the provider using in-depth interview guidelines
From those who were selected randomly, their consent to participate in the study was
obtained by the health providers known to the women. Once they agree to participate, the
principal investigator (PI) fixed a day and time suitable to the respondent and visited them
in their homes and conducted the interview using the interview schedule.
Data of GDM affected women was done using interview schedule in local language
(Malayalam). The interview schedule and consent forms were translated to local language
and back translated to English to maintain consistency.
Height in kilogram and weight in meters, of the respondents were measured using
standardized calibrated equipment along with the interviews to calculate the body mass
index (BMI).
For the in-depth interview: Doctors who were managing the largest numbers of GDM
cases were identified from the outpatient department register and interviews were
conducted till saturation was reached (n=8). In-depth interview guide in English was used
for conducting the in-depth interviews, which were done at their hospitals as all of them
suggested their hospitals as a convenient place for the interview. The interviews were
conducted by the Principal Investigator, and audio recording of the interviews was done
after getting the consent of the doctors. Each interview lasted for about 20-25 minutes.
The busy schedule of the doctors was one of the main challenges. All of them had a heavy
work load and had to manage both inpatients in labor room and outpatients (OPD) at the
28
same time. I think that only because I was working as a senior government officer and
had worked in the field of public health, they cooperated for the interview.
2.12 Analysis
Data analysis was done using SPSS version 21(IBM). Data were first analyzed
descriptively which gave various patterns of postpartum screening. The factors associated
were explored using bivariate and multivariate analysis. The testimonies in the in-depth
interview were transcribed, read and re-read to identify codes. The identified codes were
collapsed into broader themes and linkages between the codes were identified and finally
the conceptual frame work was identified.
2.13 Data storage
The data collected are kept safely with the Principal Investigator, who is responsible for
safe keeping of data and respect of confidentiality. The data collected will be stored in the
computer with password encryption of the file. The hard copy of the filled interview
schedule, questionnaire and consent forms will be strictly confined to personal locker of
the principal investigator in sealed covers and will not be shared under any circumstances.
After one year, the entire hard copies will be destroyed. Only the final report will be
shared with the concerned persons, authorities, scientific or governmental bodies.
2.14 Ethical considerations
Confidentiality: Utmost priority was given to protect the privacy of the participant and
confidentiality of the participant‘s personal information by giving a unique identification
number. Any information given by the respondent was not disclosed to anyone.
Consent: Written informed consent was obtained from the participants before
administering the interview schedule and from the doctors before starting the in-depth
interview. Participants were free to refuse at the outset or during any stage even after they
had consented if they felt uncomfortable at any point. The data collected will be used for
29
research purpose only. A clearance was obtained from the Institutional Ethics Committee
of SCTIMST before the commencement of the study (Reference number:
SCT/IEC/913/May 2016)
2.15 Dissemination of results
The final thesis report will be submitted to the Institute for evaluation. The conclusions
emerging from the study will be presented to experts in the field for comments and to
initiate further research. The findings will be shared with health department for
implementing new actions and policy changes and will be presented in scientific
conferences. Attempts will be made to publish the results in appropriate scientific
journals.
30
Chapter 3
Results and Explanations
Section I
The findings of the study are presented in this chapter in three sections. In the first
section, the socio-demographic characteristics of the respondents, details of their past
obstetric history, details of recent pregnancy including postpartum screening, barriers to
screening, adherence to follow-up and morbidities during pregnancy and after delivery
are discussed. It also includes a brief description of the infants of the respondents
regarding their weight, general health status, postpartum care, immunization and
morbidities. The second section of the chapter describes the various factors associated
with timely postpartum diabetes screening in their most recent pregnancy. The third
section describes the providers‘ perceptions.
3.1 Characteristics of the respondents
3.1.1 Socio-demographic characteristics of the respondents
Table.3.1 shows the socio- demographic profile of the respondents. Out of 200
respondents, 68 were of age group 25-30years (34%) and the majority belonged to the age
group of 25-35years (65%).
More than half of the women had completed schooling between VIII and X standard
(59%) and the majority of the respondents (97%) were home makers. The remaining six
women, who were employed previously, left the jobs temporarily to take care of their
infants.
31
Table 3.1 Socio-demographic profile of the respondents in the study
Variables Response N=200(100%)
Age group
<20 5(2.5)
20-25 28(14)
25-30 68(34)
30-35 62(31)
35-40 35(17.5)
>40 2(1)
Educational Status
1-7th std 23(11.5)
8-10th std 118(59)
Higher secondary 36(18)
Post higher secondary 8(4)
Graduate and above 14(7)
Others1
1(0.5)
Occupational status
Home maker 194(97)
Salaried employment 1(0.5)
Self-employment 1(0.5)
Other2 4(2)
Gravidity
One 33(16.5)
Two 38(19)
Three 49(24.5)
Four 47(23.5)
Five 19(9.5)
Six 11(5.5)
Seven 2(1)
Eight 1(0.5)
Parity One child 34(17)
Two children 52(26)
Three children 53(26.5)
Four children 49(24.5)
Five children 8(4)
Six children 3(1.5)
32
Variables Response N=200(100%)
Eight children 1(0.5)
Caesarian section 66(33)
BMI
Underweight (<18.5) 5(2.5)
Normal weight (18.5-24.9) 79(39.5)
Overweight (24.91-30) 80(40)
Obese (>30) 36(18)
1- Others include ‗B tech‘ (n=1), 2- Others (specify) include ‗dental surgeon‘ (n=1),
engineer (n=1), tailor (n=1) and ‗teacher on leave‘ (n=1) to look after the baby.
The parity ranged from primipara (17%) to grand multipara (2%) and 57% had three or
more children. It appeared that those who had more than four children had experienced
child losses or only female children. About 40% of the women were overweight and 18%
were obese.
3.2Reproductive profile of women diagnosed with GDM
Table 3.2 Reproductive profile of women affected with GDM in the study sample 2016
Variables Response N=200(%)
History of most recent pregnancy
Pregnancy term completion Preterm(less than 37 weeks) 11(5.5)
Term (37-41 weeks) 189(94.5)
Type of delivery Normal 134(67)
C-section 66(33)
Pregnancy outcomes Still births 5(2.5)
Live births 195(97.5)
Previous pregnancy history (Total past pregnancies=611)
Pregnancy wastage Miscarriage 67(10.96)
Still births 17(2.78)
Neonatal death 4(0.65)
Infant deaths 2(0.32)
33
Variables Response N=200(%)
Delivery complications including Caesarian sections in the past pregnancies (Total
past pregnancies=611)
Type of complications
Preterm delivery 6(0.98)
Retained placenta 2(0.32)
Hand prolapse 2(0.32)
Premature rupture of
membranes(PROM )and
cord prolapse
5(0.81)
Postpartum
Haemorrhage(PPH)
1(0.16)
Antepartum
haemorrhage(APH)
2(0.32)
High blood pressure 19(3.10)
Foetal distress 5(0.81)
C-section 17(2.78)
Past treatment advice for women diagnosed GDM before this pregnancy
GDM in past pregnancies in the study
sample
38(19)
Advice received for further follow up 4(10.81)
Those able to follow the advice 2(50)
In their most recent pregnancy, majority of the respondents had term deliveries (94.5%)
while 5.5% had preterm deliveries. One third of the respondents underwent C-sections
and 97.5% had live births. Of the 611 past pregnancies among the 200 respondents, 11%
had ended in miscarriages, about 3% were stillbirths and about 1% had ended in neonatal
or infant deaths.
Delivery complications in past pregnancies included preterm delivery in about 1%,
retained placenta (0.32%), hand prolapsed (0.32%), premature rupture of
membranes(PROM) and cord prolapsed(0.81%), high blood pressure(3.1%%), ante-
34
partum(0.32%) and postpartum hemorrhage(0.16%), fetal distress(0.81%%) and C-
section in about 3%.
3.3 Diagnostic profile of the respondents:
Table 3.3 shows the diagnostic profile of the respondents.
Table 3.3 Diagnostic profile of the respondents in the study sample.
Variables
Response N=200(100%)
GDM diagnosed in previous
pregnancies
Yes 38 (19)
No 162 (81)
GDM diagnosed in all
pregnancies
Yes 7(18.42)
No 31(81.58)
Advice received for further
follow-up
Yes 4 (10.8)
No 34 (89.2)
Advice adhered to Yes 2(50)
No 2 (50)
GDM diagnosed in most
recent pregnancy
First trimester 59(29.5)
Second trimester 73(36.5)
Third trimester 68(34)
Reason for diagnosis
As part of routine investigations 169(84.5)
Family history of diabetes mellitus 1 (0.5)
Symptoms of diabetes mellitus* 20 (10)
Previous GDM 4 (2)
Big baby 2 (1)
Hypertension 3 (1.5)
Previous still births 1 (0.5)
*severe fatigue, thirst, non-healing ulcers, tiredness, giddiness, dryness of mouth etc
35
Among the study respondents, 19% (n=38) had gestational diabetes (GDM) in their past
pregnancies. Among them, seven had GDM in all the previous pregnancies. However,
only 10.8% had received a medical advice for further follow up and screening and only
half of those who received advice were able to adhere.
Of those who were diagnosed with GDM during the most recent pregnancy, about 30%
were diagnosed in the first trimester and roughly equal proportions (36.5% and 34%)
were diagnosed in their second and third trimesters, respectively. Routine blood
examinations during antenatal visits were the most common mode of diagnosis (84.5%)
of the condition, while, symptoms of hyperglycemia led to diagnosis among 10% of the
respondents. Previous history of GDM was found to be the cause of diagnosis among 2%
of the women, although more than 18% had past histories of GDM.
3.4 Postpartum screening of the respondents
According to the existing guidelines, the blood sugar should be tested at six weeks or later
postpartum; based on the level of blood sugar further blood investigations are decided.
For the purpose of this study, those who had tested before 6 weeks or not tested were
taken as ―not tested‖ and those who had tested at or more than 6 weeks period were taken
as ―timely tested‖. Timely postpartum screening rate was found to be very low. Only
29% of respondents reported having undergone testing at or after six weeks postpartum
(Table 3.4).
36
Table 3.4 Postpartum diabetes screening profile of the respondents in the study
sample
Variables Response N=200(100%)
Blood test after delivery Yes 115(57.5)
No 85(42.5)
Timing of blood test
Not tested& tested less than 6
weeks
142(71)
≥ 6 weeks after delivery 58(29)
Place where blood test was
conducted N=115(100%)
Public hospital 13(11.30)
Private hospital 58(50.43)
Laboratory (self-referred) 39(33.91)
Self (at home) 5(4.34)
Status of blood sugar level Hyperglycaemia Normal Total N=115(100%)
Tested from public hospital 0 13 13 (100)
Tested from private hospital 7(12.06) 51(85.93) 58 (100)
Self - tested at home 4(80) 1 (20) 5(100)
Tested at laboratory 15(38.46) 24 (61.54) 39(100)
Among the respondents who had tested their blood (57.5%), 11.3% had utilized public
hospitals, 50.4% had utilized private hospitals and 33.9 % had made use of laboratory for
testing. In addition to this 4.3% of respondents had self-tested at home using diagnostic
kits bought in pharmacies. Out of this, all respondents who had tested from public
hospitals, 85.9% of respondents who tested from private hospitals, 61.5% of respondents
tested from laboratory and 20% of those who had self –tested at home were
normoglycemics. Majority of those who had tested self at home (80%) had
hyperglycaemia. It may be noted that those who self-initiated the test were highly likely
to be hyperglycemic.
37
Table 3.5 Reasons for not undergoing blood sugar examination after delivery.
Variable Responses N=85(100)
Reasons for not testing
blood after delivery
Doctor‘s reassurance that ―nothing
to worry, it will subside after
delivery‖
6(7.1)
Low blood sugar level before
delivery
4(4.7)
Difficulty in going out with a small
baby
10(11.8)
Nobody informed me 50(58.8)
Fear to know that I am diabetic 4(4.7)
I have no symptoms 5(5.8)
It will subside after delivery 6(7.1)
Total Not undergone blood testing after
delivery
85
When the reasons for not testing blood after delivery were explored (Table 3.5), 58.8% of
respondents stated that they were not aware of postpartum follow up and they complained
that nobody informed them about blood testing after delivery. Difficulty in going out with
a small baby was the reason cited by 11.8% of respondents. The other reasons reported by
women were doctor‘s reassurance of ‗nothing to worry, it will subside after delivery‘
(7.1%), general belief in society that GDM will subside after delivery (7.1) ,absence of
symptoms (5.9%), fear to know the diabetic status (4.7%) and a normal blood sugar result
before delivery (4.7) .
All the respondents who had undergone postpartum screening tests from either private or
public hospitals consulted their doctors after testing their blood glucose level. However,
38
60% of those who tested at home and 38.5 % of respondents who tested at a laboratory on
their own initiative did not consult a doctor after obtaining their test results (Table 3.6).
Table 3.6 Status of consultation after testing their blood in the postpartum period by
glycemic status
Consulted a doctor after testing blood sugar
Categories Yes N (%) No N (%) Total N (%)
Tested from public hospital 13(100) 0 13 (100)
Tested from private hospital 58(100) 0 58(100)
Self at home 2 (40) 3 (60) 5(100)
Laboratory 24 (61.54) 15(38.46) 39(100)
Total 97(84.35) 18(15.65) 115(100)
Status of consultation among hyperglycemics
Tested from
Hyperglycemic
N (%)
Consulted a
doctor N (%)
Not consulted
N (%)
Public hospital 0 n. a n. a
Private hospital 7(100) 7(100) 0
Self -tested at home 4(100) 2(50) 2(50)
Laboratory 15(100) 9(60) 6(40)
Total 26(100) 18(69.23) 8(30.76)
Status of consultation among normoglycemics
Tested from
Normal blood sugar
N (%)
Consulted a
doctor N (%)
Not consulted
N (%)
Public hospitals 13(100) 13(100) 0
Private hospitals 51(100) 51(100) 0
Self at home 1(100) 0 1(100)
Laboratory 24(100) 15(62.5) 9(37.5)
Total 89(100) 79 (88.76) 10 (11.23)
Among those with hyperglycemia, 8(30.76%) had not consulted a doctor after getting the
blood examination results. Of these, two (25%) had self -tested at home and six (75 %)
39
had tested from a laboratory through self-referral. Among those who were
normoglycemic, ten women (11.23 %) had not consulted a doctor, among whom one (10
%) had self-tested at home and 9(90 %) had tested from laboratory.
Table.3.7 Reasons for not consulting a doctor after obtaining test results
Reasons for not consulting a doctor after
obtaining test results
Response
N=18(100%)
Result was normal 10(55.6)
Doctor‘s reassurance 2 (11.1))
Fear to know the status 1 (5.5)
Waiting for symptoms 1 (5.5)
Difficult to go out with a small baby 3(16.8)
Self-medication 1 (5.5)
All normoglycemic women said that they did not consult a doctor after obtaining test
results because the results were normal. Reassurance from providers that GDM will
subside after delivery played a major role in not seeking consultation. Among the eight
women who had tested positive, difficulty in going out with the infant (3 women),
doctors‘ reassurance that ―everything will become normal after delivery (2 women) were
most frequently stated as reasons. Absence of symptoms, fear to know the diabetic status
and self-treatment (1 woman each) were the other reasons cited for not consulting a
doctor.
Of those who consulted a doctor following postpartum screening, many were not given
specific instructions to repeat the tests at regular intervals and especially in the first
antenatal visit of the next pregnancy. For example, among the 79 normoglycemic
respondents who consulted a doctor, the majority (78.48%) were reassured that there was
―nothing to worry‖ and were not given any instructions. Seventeen normoglycemic
40
respondents (21.51%) were given some instructions along with ―Nothing to worry‖ on
consulting a doctor. One subject (1.26) reported that she was not given any instruction or
reassurance (Table 3.8).
Table 3.8 Instructions to respondents who consulted a doctor after testing their
blood sugar.
Management of normoglycemics
respondents
N (%)
Nothing to worry 62(78.48)
Nothing to worry, but control diet 5(6.32)
Nothing to worry, but test blood glucose
occasionally
7(8.8)
It will subside after delivery 3(3.79)
Test after six months, if the values are normal
do not report back
1(1.26)
No instructions 1 (1.26)
Total 79(100)
Management of hyperglycemic respondents*N
To start medicine 13
Diet control 3
To start medicine &diet control 3
To test blood occasionally 1
Continue injection insulin 2
Diet control &exercise 1
Psychiatry consultation for mood disorder 1
Total 24
*Same person may get more than one advice
Among the respondents who were hyperglycemic, 13 were advised to start medication
and 3 were advised a combination of both medication and diet control and an equal
proportion was advised diet control alone. Two were advised to continue insulin. One was
41
advised diet control and exercise and another one who had mood disorder was advised
psychiatric consultation.
Table 3.9 shows the status of adherence among the respondents to various instructions. A
total of 17(21.51%) normoglycemic respondents and 18 hyperglycemic respondents who
consulted a doctor after blood test were given instructions of some kind. Only nineteen of
the thirty five respondents who were given instructions adhered to the instructions. Some
respondents have received more than one instruction. Both drug adherence (61.53%) and
injection insulin (100%) were found to be better than following diet control (37.5%) and
testing blood occasionally (25%). A combination of diet control and exercise and also
medicine and diet control were the major areas of non- adherence.
Table.3.9 Status of adherence to doctors’ instructions by the respondents.
Responses Normoglycemics who
had received advice for
life style changes or
future screening (N=17)
Hyperglycemics
N=18
Total
Advised
N(%)
Adhered to
advice
Advised Adhered
to
advice
Advise
d
Adhered to
advice
Diet control 5(6.32) 1(20) 3(16.66) 2 8 3(37.5%)
Test blood
occasionally
7(8.86) 1(14.28) 1 (5.55) 1 8 2(25%)
It will subside after
delivery
3(3.79) Not
applicable
3 No
instruction
s
Test after
6months,if normal
no need to come
1(1.26) NA** 1
42
Responses Normoglycemics who
had received advice for
life style changes or
future screening (N=17)
Hyperglycemics
N=18
Total
Advised
N(%)
Adhered to
advice
Advised Adhered
to
advice
Advise
d
Adhered to
advice
No advice 1(1.26)
To start medicine 13(72.22) 8 13 8(61.53%)
To start medicine
&diet control
3(16.66) 0 3 0
Continue
injection Insulin
2 2 2 2(100)
Diet control
&exercise
1 0 1 0
Psychiatry
consultation for
mood disorder
1 1 1 1
Able to follow all
instructions
3 3
Total 17(21.51) 2 24* 17 40 19(47.5%)
*Total won‘t add up because same person may get more than one advice, ** the survey period
was within 6 months of delivery.
While exploring the reasons for non-adherence (Table 3.10), apprehension regarding
reduced quantity of breast milk caused 22.7 % of respondents to avoid diet control.
Difficulty in going out with the infant (13.6 %) especially when the husbands were out of
station were the other commonly reported reasons for non -adherence by the respondents.
About 22.7 % of respondents cited childcare demands as their reason for non-adherence
and an equal proportion expressed ignorance about the importance of adherence, and they
had not taken seriously. Household work was cited as the reason for non-adherence by
43
13.6% of respondents. About 7.7 % reported that they did not receive any information
from any source to maintain a strict follow up.
Table. 3.10 Reasons for non-adherence for the respondents
Reasons for non-adherence N=22(%) Responses
Child care demands 5(22.7)
Diet restriction reduces breast milk 5(22.7)
Household work 3(13.6)
Difficult to go out with small baby 3(13.6)
No instructions from anywhere 1(7.7)
Not taken it seriously 5(22.7)
Total 22(100)*
*Included no instruction also
3.5 Morbidity profile of GDM affected women in their most recent pregnancy and
after delivery
Table 3.11 Patterns of morbidity of women affected with GDM in their most recent
pregnancy, delivery and postpartum period.
Variables Response N (%)
Health problems during
pregnancy (N=200)
Yes 97(48.5)
No 103(51.5)
Nature of Morbidities(N=97)
Symptoms of
hyperglycaemia
57(28.5)
Genitourinary infections1 7(3.5)
High Blood Pressure 19(9.5)
Ante-partum hemorrhage 8(4)
Gastrointestinal discomfort 4(2)
Mood disorder 1(0.5)
Hydramnios 1(0.5)
Delivery Yes 25 (12.5)
44
complications(N=200) No 175(87.5)
Details of delivery
complication
Hypertension 6(3)
Foetal distress 4(2)
Postpartum haemorrhage 7(3.5)
Cord prolapse 1(0.5)
PROM2 6(3)
Retained placenta 1(0.5)
Total 25(12.5)
Details of complications after
delivery
Fatigue 8(4)
Stress due to low milk
secretion
1(0.5)
Delayed wound healing 2(1)
Recurrent UTI 1(0.5)
Recurrent vulvovaginal
candidiasis
3(1.5)
Peripheral neuritis 3(1.5)
Low back ache myalgia 8(4)
Others3 6(3)
Total 32(16)
Genitourinary infections include vulvo-vaginal candidiasis, urinary tract infections, low
back ache, 2- PROM is premature rupture of membrane,
3- Others include umbilical
hernia (1), skin diseases(1), abdominal discomforts(3), treatment for mood disorder (1)
and knee joint pain(1)
Out of the 200 respondents, 97 (48.5%) had health problems during pregnancy, of them,
majority being symptoms of hyperglycemia (28.5%) and high blood pressure (9.5%).
Antepartum bleeding requiring bed rest was seen in eight (4%) respondents.
Complications during delivery were found in 12.5% of women. Among this 3% were
hypertensive, 2% had foetal distress, 3.5%% had postpartum haemorrhage, 3% had
45
premature rupture of membranes (PROM) and 0.5% had retained placenta and an equal
proportion had cord prolapse.
After delivery, 4% of respondents reported fatigue and another 4% reported low back
ache and myalgia. The other common conditions seen were vulvo-vaginal candidiasis
(1.5%) and symptoms of peripheral neuritis (1.5%).Delayed wound healing and recurrent
urinary tract infections were the other health problems. The rest was shared by umbilical
hernia (0.5%), skin disease (0.5%), abdominal discomforts (1.5%), treatment for mood
disorder (0.5%) and knee joint pain (0.5%).
3.6 Child Characteristics
Among the outcomes of most recent pregnancy, 2.5% was stillbirth and all others live
births, 2.5% of the babies were overweight and 11.5% were low birth weighted babies.
The proportion of female babies was 52% and 72% had initiated breastfeeding within half
an hour of delivery.
Maternal causes for delay in initiating breastfeeding were inadequate breast milk (4.10%)
and retracted nipple (1.02%). Low birth weight (1.02%), convulsions (1.02%), foetal
distress (2.05%) and baby kept in ICU (2.56%) were the infant-related reasons for delay
in initiating breast feeding. Routine blood examination (newborn screening) after delivery
was carried out in 69% of newborns. Among the infants, 37.5% had jaundice within one
week of delivery. The rate of ICU admission was 37%. Twelve percent of the babies were
unimmunized for age at the time of the survey.
46
Table 3.12 Child characteristics in the most recent delivery
Variables Response N (%)
Birth weight
Low birth weight
23(11.5)
Normal weight 172(86)
Over weight
5(2.5)
Sex of the child
Male 96(48)
Female 104(52)
Breast feeding initiated Less than one hour 144(72)
Less than 24 hours 34(17)
More than 24 hours 15(7.5)
Others* 7(3.5)
Difficulty in initiating breast
feeding
Baby kept in ICU 7(2.56)
Inadequate breast milk 8((4.10)
Low birth weight (unable to
suck)
2(1)
Retracted nipple 2(1)
Convulsions 2(1)
Foetal distress 4(2.05)
Status of blood examination
after delivery
Yes 138(69)
No 21(10.5)
Don‘t know 36(18)
Still birth 5(2.5)
Unimmunized for age 24(12)
Jaundice within one week of
birth
75(37.5)
ICU admissions 74(37)
*5 still births,2 low birth weight babies kept in ICU for more than 3days ,<2.5kg-
underweight, 2.5-4kg-normal weight and >4kg-overweight .
47
3.7 Morbidity profile among newborn babies
Table 3.13 Patterns of morbidity among new born babies of women affected with
GDM.
Variables Response N=200(100)
Health problems Recurrent respiratory
infections
8(4.10)
Hypoglycemia 3(1.53)
Convulsions 2(1.02)
Low birth weight 2(1.02)
Recurrent ADD 1(0.5)
Jaundice 1(0.5)1
Others* 3(1.53)
Jaundice within one week of
birth
75(38.5)
Still births 5(2.5)
Total live births 195(97.5)
Total infants who had
health problems
95(48.71)
*others include dermatitis (1) chickenpox (1) &delayed milestones (1) 1-jaundice after
one week.
Despite the protection offered by maternal antibodies (as the infants were aged six
months or less) 48.7 % of infants had health problems. Seventy five (38.5%) of the
newborn babies in the most recent delivery had jaundice within one week of delivery.
Excluding morbidity due to jaundice, which can be physiological, the proportion of
infants with morbidity was 10.26%. Other major problems included recurrent respiratory
infections (4.1%), hypoglycemia (1.5%) and convulsions (1%). Low birth weight was
seen in another 1 % of newborns.
Section II
3.8 Timely postpartum screening and associated factors
In this section we explore factors associated with the odds of postpartum screening (Table
3.14).Out of 200 respondents, 57.5% tested their blood after delivery for diabetes
screening. There was a statistically significant association between timely postpartum
48
testing and age with high odds of timely screening. It was maximum in the age group 31-
35.
Proportion of women with timely screening was highest among graduates followed by
women with eight to ten years of education. The association between education and
timely screening was not statistically significant.
Parity had an association with timely postpartum screening (39.30%) and was highest in
respondents having four children or more. The association is significant at 10% level.
Past history of GDM had an association with timely postpartum screening and is
statistically significant.
Table 3.14 Timely postpartum screening and associated factors
Respondent
characteristics
Postpartum Screening Status P value
Response Not tested (not
tested+tested
>6weeks) N (%)
Timely
screening (≥6
weeks) N (%)
Total
N (%)
Age group 15-20 5(100.00) 0 5(100) 0.032
21-25 24(85.70) 4(14.30) 28(100)
26-30 51(75.00) 17(25.00) 68(100)
31-35 36(58.10) 26(41.90) 62(100)
36-42 26(70.30) 11(29.70) 37(100)
Total 142(71.00) 58(29.00) 200(100)
Education 1-7th standard 18(78.30) 5 ( 21.7) 23(100) 0.452
8-10th
standard
81(68.60) 37(31.40) 118(100)
Higher
secondary and
post higher
secondary
34 (77.30) 10 (22.70) 44(100)
49
Respondent
characteristics
Postpartum Screening Status P value
Response Not tested (not
tested+tested
>6weeks) N (%)
Timely
screening (≥6
weeks) N (%)
Total
N (%)
Graduate and
above
9(60.00) 6 (40.00) 15(100)
Total 142 (71.00) 58 (29.00) 200(100)
Parity one to two
children
64(74.40) 22(25.60) 86(100) 0.095
Three children 41(77.40) 12(22.60) 53(100)
Four children
and above
37(60.70) 24(39.30) 61(100)
Total 142(71.00) 58(29.00) 200(100) .018
Past history of
GDM
Yes 21(55.30) 17(44.70) 38(100)
No 121(74.70) 41(25.30) 162(100)
Total 142(71.00) 58(29.00) 200(100)
Health
problems
during
pregnancy
Yes 65 (67.00) 32(33.00) 97(100) .228
No 77(74.80) 26(25.20) 103(100)
Total 142(71.00) 58(29) 200(100)
Blood glucose
testing
necessary after
delivery(Awar
eness)
Yes 77(60.20) 51(39.80) 128(100) <.0001
No 65(90.30) 7(9.70) 72(100)
Total 142(71.00) 58(29.00) 200(100)
Doctor‘s
advice
Doctor 29(47.50) 32(52.50) 61(100) .003
Others 51(72.90) 19(27.10) 70(100)
Total 80(61.10) 51(38.90) 131(100)
Higher chance
of getting
diabetes
mellitus(Risk
Yes 26(55.30) 21(44.70) 47(100) .010
No 116(75.80) 37(24.20) 153(100)
Total 142(71) 58(2) 200(100)
50
Respondent
characteristics
Postpartum Screening Status P value
Response Not tested (not
tested+tested
>6weeks) N (%)
Timely
screening (≥6
weeks) N (%)
Total
N (%)
perception)
Feeling
―down‖
Yes 17(47.20) 19(52.80) 36(100) 0.001
No 125(76.20) 39(23.80) 164(100)
Total 142(71.00) 58(29.0) 200(100)
Ever had a
feeling of little
interest
Yes 16(45.70%) 19( 54.30% 35(100%
)
<.0001
No 126(76.40% 39(23.60%) 165(100
%)
Total 142(71.00%) 58(29.00%) 200(100)
About 33% of respondents who had health problems during pregnancy had undergone
timely postpartum screening but it is not statistically significant.
There was no significant association between health problems during pregnancy and
timely screening. However, women who had moods of feeling down‖ (52.8%) or felt
―little interest‖ in anything (54.30%) in their postpartum period were significantly more
likely to undergo timely postpartum screening.
The proportions undergoing timely screening were significantly higher among women
who were aware about the need for such screening, and among women who perceived
that they were at risk of developing diabetes in future. We examined whether family
history of diabetes was associated with risk perception and found no statistically
significant association. Neither was there a significant association between awareness and
risk perception (tables not included).
51
The likelihood of timely screening was significantly higher among women who had been
directly advised by doctors to go for postpartum screening, as compared to those who had
received advice from others such as health workers, ASHA/AWW, media, community or
those who made self -decision.
There was significant association between psychological wellbeing and timely screening.
The proportion of respondents who were doing timely screening were 52.8% (―feeling
down‖) and 54.3% (those who were feeling little interest) and the association was highly
significant at the 1% level.
3.9 Results of age adjusted multiple logistic regression of factors associated with
timely postpartum screening (≥6weeks)
Independent variables having significance in the bivariate analysis and variables which
we had reason to believe to influence postpartum screening were selected as independent
variables for the multiple logistic regression analysis with timely postpartum screening as
dependent variable. We found that those who were advised by a doctor had a three times
higher chance of timely postpartum screening compared to those who had been advised
by other health workers or others.
52
Table 3.15 Results of multiple logistic regression analysis of factors associated with
timely postpartum screening (≥6weeks)
*Others includes health worker, ASHA (Accredited social health
activist)/AWW(Anganwadi worker), media, community & self -decision, OR: Odds
Ratio, CI: confidence interval. The independent variables are past history of GDM,
advised by whom, risk perception, feeling down and age group
Respondent's
characteristics
N (%) Unadjusted
O.R(95% C.I)
Adjusted
O.R(95% C.I)
P value
Past history
of GDM
Yes
No
17(44.7)
41(25.3)
2.38(1.15-
0.96)
1.74(0.67-
4.53)
0.285
Reference
Advise by Doctor
Others*
32(52.5)
19(27.1)
2.96 (1.43-
6.13)
3.2(1.4-6.9)
0.004
Reference
Risk
perception
Yes
No
21(44.7)
2.53(1.27-
5.01)
1.81(0.78-4.2)
0.161
Reference
Feeling
down
Yes
No
19(52.8)
39(23.8)
3.58(1.69-
7.55)
2.17(0.87-
5.36)
0.081
Reference
Age group 35-42
26-35
≤25
37(18.5) 1.17(0.53-
2.59)
2.06(0.47-
8.99)
0.135
130(65) 0.33(0.09-
1.15)
2.59(0.74-
9.09)
0.338
33(16.5) Reference
53
Section III
Doctors’ Perspectives on Management and Postpartum Screening and Advice
This section describes the perspectives of doctors who regularly manage a large number
of GDM patients in the four sample health facilities regarding postpartum screening and
management of GDM patients. We also gathered information about how they managed
GDM during pregnancy and delivery.
There were eight participants from the four selected hospitals and their selection criterion
was based on their GDM case load.
Table.3.16 Profile of the doctors included in the in-depth interviews
Characteristics of the Respondents
Serial
number
Sex Age Qualifications Years of
Experience
Studied
at
Medical
college
Working in
Public/private
sector
1 50 Male MBBS,MD
General
Medicine
22 Public Private sector
2 46 Female MBBS,DGO 19 Public Public sector
3 47 Female MBBS,MS
OBG &
Gynaecology
9 Public Private sector
4 44 Male MBBS,MD
O&G
10 Private Private sector
5 37 Female MBBS,MD
O&G
10 Public Public sector
6 39 Female MBBS,DGO 14 Public Public sector
7 41 Female MBBS,DGO 8 Private Private sector
8 35 Female MBBS,DGO 6 Private Private sector
54
3.10 Management of GDM during pregnancy
All doctors reported seeing GDM patients very often. The perceived frequency of seeing
GDM patients ranged from about 25% to as high as four in a week or even one or two per
day. Advice and management varied widely and often was not as per the national
guidelines. Each doctor had his or her own protocol to manage GDM patients. For
example, while all of them reported giving routine advice on strict diet control, only one
had emphasized the importance of exercise and used medical nutrition therapy (MNT) for
management. As per the National Guidelines for Diagnosis and Management of
Gestational Diabetes Mellitus India, the principle behind MNT is healthy eating during
pregnancy. For this individualized nutritional assessment is done. It is a carbohydrate
controlled balanced diet which promotes optimal nutrition for maternal and gestational
weight gain along with maintenance and achievement of normoglycemia.1
Initiation of treatment also varied from referring to a physician, to a stepwise
management of GDM. Three of the providers had started with diet control and waited for
two weeks to control the blood sugar value. If the blood sugar value was not controlled by
diet alone, Metformin was prescribed along with diet control. After this step, if the sugar
value was still not controlled, insulin would be started. One of the provider started the
GDM patient on insulin if there was a family history of T2DM. The remaining four
providers were managing according to whether the patient was on diet control, metformin
or insulin (For patients on diet control and metformin, they were not much strict about
1 This assessment includes defining the Body Mass Index (BMI) or percentage of
desirable pre-pregnancy body weight and optimal pattern of weight gain during
pregnancy. The energy requirement is calculated using the formula
Energy requirement (K.cal/d) = BMR ×PAL
*BMR= Basal metabolic rate
*PAL= Physical activity level
55
instructions). Except one, all the providers said they advised about frequent antenatal
visits of once in two weeks. One provider advised two-weekly antenatal visits only for
GDM patients with uncontrolled sugar values.
Almost all doctors reported to not have discussed with the women concerned about the
implications of GDM on health, pregnancy, fetal complication or on the outcome of
pregnancy. Four of the providers said that for women whose blood sugar levels were very
high in the very beginning, they would discuss the risk of congenital anomalies. Only one
respondent said that she discussed with her patients about their future risk for progression
to T2DM soon after GDM diagnosis. Future risk was often communicated very gently:
―in some patients there is a chance of continuation of this condition in future and hence
proper glycemic control is necessary‖.
3.11 Management during Labour:
Routine admission of GDM patients two weeks prior to the expected date of delivery
(EDD) seemed to be a routine practice for some (four of eight doctors), while others
decided on this on a case-by-case basis. All of them believed that management of GDM
patients during labour called for team work with a team having physician, paediatrician,
obstetrician; and facility to resuscitate the baby, Newborn Intensive Care Unit (NICU)
and facility to perform emergency cesarean sections and blood transfusion were very
important to have.
Only some (four of the eight) doctors reported withdrawing insulin prior to delivery as the
women are highly prone to hypoglycemia, which is recommended practice. Other
practices reported included using insulin along with a 5% dextrose drip, and skipping one
dose of insulin prior to delivery and giving one or two doses of insulin after delivery, and
testing blood glucose after 6 hours to decide further treatment. All of them reported that
56
cesarean sections are not routinely performed on women with GDM, and that the usual
indications for cesarean sections applied also to GDM patients.
Two of the doctors reported hourly blood sugar level monitoring after delivery, while two
others said they monitored blood sugar every two hours. The fifth doctor was monitoring
4th
hourly blood sugar value, while one monitored the blood glucose level six hours
following delivery after giving immediate postpartum insulin doses. Referring patients
having uncontrolled DM to physicians was also mentioned by some doctors.
3.12 Postpartum advice and management
As with advice and management during pregnancy and labour, advice and management in
the postpartum period also varied even within this small group of doctors. Four of the
eight doctors reported advising diet control after delivery with one of them instructing
avoidance of primary sugars too. Advice regarding regular exercise postpartum (two of
eight) and frequent breastfeeding to prevent hypoglycemia (three of eight) was far less
common. None of them routinely prescribed drugs for glycemic control in the postpartum
period, and prescription of insulin or oral drugs depended on the status of hyperglycemia
of the patient. All except one said that they advised GDM patients at the time of
discharge after delivery on the use of contraceptive methods. The only doctor who did not
do so said, ―even if we say something about it, they will nod their head and go, the body
language itself will be self-explanatory that they are not going to use this”. According to
the doctors, Cu T is the best postpartum contraceptive method for women with GDM in a
previous pregnancy, if their blood sugar values were normal. Otherwise to prevent
infections, they would advise them to control blood sugar before inserting CuT. One
doctor felt that the advice regarding family planning can be given to the woman herself
57
and not to her family members. From his experience, most husbands were working
abroad and mothers in law would not usually consider contraception to be important.
3.13 Postpartum screening: All doctors reported very low level of postpartum screening
ranging from 2% to 25%. While some (four of eight) doctors were advising postpartum
screening at or after 6 weeks routinely, they also reported that none of the women
returned for any reason after one month postpartum. Two of them were advising to test
blood at 10th
day and then on 15th
or 20th
days and then after one month. One doctor
referred all postpartum cases to a physician, but she was not sure if the patients were
following the physician‘s advice. One doctor was not concerned about this issue as
according to the doctor none of the patients obeyed their instructions. All reported good
follow up initially, that is within four weeks of delivery and after four weeks, losing
patients to follow-up. Some (three of eight) reported that they counseled both the patient
and the bystander at the time of diagnosis that ―it is a temporary condition and will
subside after delivery”.
3.14 Perceived barriers to women using postpartum screening
There was a perception among a couple of doctors that women did not take the problem
of hyperglycemia seriously and hence ignored the advice of doctors for postpartum
screening. One of the doctors summarized their patients‘ attitude as follows: ―We are too
young to control diet and sugar. It will come (sugar) after getting old. Why do we waste
our good time under stress thinking about all these things?‖ The difficulty in going out
with a small baby and the absence of a screening facility in the nearby locality were cited
by others as potential barriers. Another doctor expressed his view in terms of
prioritization as most of the mothers had a lot of family responsibility as their husbands
were working abroad.
58
3.15 Recommendations and suggestions to improve the rate of timely postpartum
screening All providers suggested a reminder system to improve postpartum screening
status. Majority (seven) suggested a message as well as reminder call from hospital.
However some doctors were unsure about the authenticity of the phone number given at
the time of admission as the phone number given was usually of a relative accompanying
the patient at the time of hospitalization. One suggested giving a booklet/pamphlet or
some information to the patient at the time of discharge by the doctor and then a phone
call from hospital at the time of screening.
Health system initiatives to improve postpartum screening status were suggested by
almost all the doctors. These included:
Registering and documenting GDM cases at the health sub centre level and
keeping line list of cases in the PHCs
Counseling, advice and follow up of women with GDM both during pregnancy
and postpartum, including arrangement of facilities to screen them at local level
Seeking the help of ASHA to track defaulters and bring them for screening.
Mass IEC or community training programs to increase personal and public
awareness about GDM and its appropriate management to prevent or delay
progression to T2DM.
59
Chapter 4
Discussion and conclusions
The prevalence of risk factors of diabetes are relatively high in Kerala as compared to
other states (Mohan et al., 2012, Reddy et al., 2006). Also, the prevalence of T2DM is
20% in Kerala (Baruah et al 2014). Women of reproductive age in Kerala have a higher
than average prevalence of obesity and a relatively high probability of a family history of
T2DM, which increases their risk of developing gestational diabetes mellitus (GDM).
Although the present study did not aim to assess the prevalence of GDM, the doctors who
were interviewed in-depth as part of this study reported seeing GDM patients were seen
very often in their practice, and perceived that GDM prevalence had increased in recent
times.
Previous GDM is associated with a significant life-time risk of T2DM (Kim et al., 2002).
The blood glucose level comes to normal in most of the women after delivery in GDM.
But they have up to seven times more chance of getting type 2 DM in future (Bellamy et
al., 2009b). According to a retrospective cohort study conducted in rural Kerala, the study
participants were followed up for a period of four years (Sreelakshmi et al 2015),
progression to T2DM was 10%. Life style modification and pharmacological intervention
can delay or prevent progression to T2DM in women with a history of GDM (Ratner et
al., 2008). For this, postpartum follow-up and timely and appropriate screening are of
utmost importance. Postpartum diabetes screening and appropriate follow-up have a
major role in reduction or delaying progression to T2DM in mothers and in reducing
future risk of obesity and diabetes in future among infants.
60
4.1. Patterns of postpartum screening for diabetes
The aim of the present study was to assess the rate of ―timely‖ postpartum diabetes
screening in women affected with GDM in their most recent pregnancy and examining
the various patterns of and factors associated with the same. About 58% of the women in
our study had undergone postpartum screening at some time before 6 months following
delivery. These figures are lower than that reported by a recent longitudinal study in 2015
in Delhi, according to which more than 80% of the women diagnosed with GDM had
returned for follow-up screening at 6 weeks postpartum or later (Jindal et al., 2015).
However, low rates of postpartum screening for diabetes in women with GDM in the
immediately preceding pregnancy are reported from many sites across the globe including
in high income countries, usually below 50% (Blatt et al., 2011, Keely 2012, Clark, Keely
et al ., 2012).
The timing of postpartum diabetes screening of GDM mothers appears to be important,
and most of the available guidelines recommend screening after at least 6 weeks
postpartum. For example, the American Diabetes Association (ADA) recommends
screening between 6-12 weeks postpartum, the National Institute for Health and Care
Excellence (NICE), UK guidelines mention 6-13 weeks postpartum, while India‘s
National guidelines for Diagnosis and Management of Gestational Diabetes Mellitus
recommends screening at or after 6weeks postpartum.
In the present study we have defined ―timely testing‖ as diabetes testing in GDM mothers
done at or after 6 weeks but before 6 months postpartum. The rate of timely postpartum
diabetes screening in our study is 29%, while an equal proportion (28.5%) have tested
their blood after delivery but before 6 weeks. The rates of timely screening obtained in
our study are lower than that in a retrospective study carried out in USA between 7 weeks
61
and 6 months among GDM affected women, in which 46% were tested during the 6-12
weeks postpartum and 12.3% during 12 weeks to 6 months (Lawrence et al., 2010).
Screening immediately after delivery may underestimate the proportion with
hyperglycemia especially if the patient was under drugs for glycaemic control during
pregnancy. A study comparing results from postpartum diabetes testing between 24-72
hours following delivery with those obtained from the same cohort at 6 weeks or later
found that the early test underestimated the prevalence of diabetes (3.7% versus 8.5% )
and over-estimated the prevalence of pre-diabetes (32.9% versus 20.7%) (Nabuco et al.,
2016). Accurate diagnosis and appropriate management requires that all GDM mothers be
tested at or after 6 weeks postpartum. Those who tested before 6 weeks postpartum and
were told that their status was ―normal‖ could well be cases of T2DM within the next few
weeks.
Postpartum screening for diabetes done too early by GDM affected women may be a
consequence of inaccurate advice given by their obstetrician/gynecologists at the time of
discharge after delivery. In a study by Mahalakshmi et al among diabetologists /
endocrinologists and obstetrician/gynecologists in India, more than 40% of both sets of
specialists had advised postpartum screening within 6 weeks of delivery (Mahalakshmi et
al., 2016).
Not only the timing of postpartum screening but also the type of screening test used for
postpartum diabetes screening of GDM mothers is very important in obtaining an
accurate diagnosis. The most widely recommended test in many high income countries
and in India is 75-g -2h OGTT, because HbA1c would miss many women with lower
levels of hyperglycemia and would be sensitive only to women with the highest glucose
levels. However, in places where it is not feasible to administer 75g-OGTT, HbA1C test
would at least detect those in need of urgent attention (Kitzmiller et al., 2007) .
62
In our study we were not able to obtain accurate information on the type of screening test
performed. However, based on women‘s description of what was done when they
presented for screening, we deduce that practically none of the women had undergone the
recommended test. Thirty four percent of women who had undergone testing in our study
had self-referred themselves to a laboratory and 4% had carried out a test at home using a
kit. Both these groups of women did not undergo the appropriate test for diabetes
screening and those who were reported to be ―normal‖ from these tests could be at risk of
diabetes. Although facilities for OGTT were present in the public as well as private
hospitals where women tested, women did not report waiting for two hours to be tested
after a glucose load, which implies that some other test for diabetes was performed. From
the doctors interviewed in this study, we learnt that although they were aware of the
importance of the 75g-2hr- OGTT test postpartum, they did not insist on performing the
same for the women under their treatment, but used a suitable test convenient to the
women.
4.2. Factors associated with ‘timely’ postpartum screening for diabetes of women
with GDM
In the present study, doctors‘ advice on postpartum screening emerges as the single-most
significant factor associated with timely postpartum diabetes screening, both in the
bivariate and in the multivariate analysis. Age adjusted multiple logistic regression
analysis found that those who were advised by a doctor to undergo postpartum diabetes
screening had a three times higher chance of undergoing timely postpartum screening
compared to those who had been advised to do so by any other health care provider or lay
persons. While studies that have examined the role of physicians‘ advice on the rate of
postpartum screening are limited, a review of 58 studies from high, middle and low-
income countries (Nielesen et al., 2013) reported ―receiving postnatal information‖ as an
63
important predictor of postpartum screening following a GDM pregnancy. Another study
(Kim 2007) similarly reported that women who recalled receiving advice about
postpartum diabetes screening and receiving a laboratory slip were more likely to undergo
screening. Direct advice regarding postpartum screening in the form of written or two-
way communication by treating doctors was found in an Australian study to increase the
odds of postpartum diabetes screening (Morrison et al., 2009). Unlike our study, none of
these studies specify any differences in the odds of screening by type of health provider.
There is another reason for the lack of direct advice from the physician to the woman with
GDM, which evolved from our study. This was that the doctor conducting delivery often
considered revealing any information to the mother regarding her health status and future
risk of diabetes as a sensitive issue which may affect the mother adversely by increasing
her anxiety. This attitude prevented him/her from disclosing routine advice directly to the
women and he/she tended to provide information only to the bystanders, usually other
members of the family. But after discharge from hospital there is not much
communication between the bystander and the patient, and the information does not reach
the woman concerned.
Studies have found a number of patient characteristics to be associated with postpartum
screening. These include among others, age, parity, past history of GDM, awareness
regarding the importance of postpartum screening and risk perception. In our study, we
found that older women (31-35yrs) and women of parity 4 or higher were more likely to
have undergone timely postpartum screening. While Tovar et al., similarly reported older
age to be a predictor of postpartum screening, their study found nulliparity and not
multiparity to be a predictor (Tovar et al., 2011). In the Indian setting, as age increases the
parity also increases. The rise in timely screening status among women of relatively older
64
age and parity may be due to a greater autonomy enjoyed by them after many years of
marriage and several children.
We also found that a greater proportion of women with awareness on the importance of
postpartum diabetes screening had undergone timely screening. The association was
significant at the 5% level in the bivariate analysis alone. Based on an extensive review of
literature on postpartum diabetes screening after GDM, Case et al (2006) recommend that
improving awareness on timely postpartum screening, and mass IEC on future risk of
T2DM and scope for prevention of T2DM are possible areas of interventions (Case et al.,
2006). We need to concentrate not only on public awareness but also on training of health
workers and doctors regarding the implications of GDM and the importance of timely
screening (Mithal et al., 2015).
In our study, a higher proportion of those who had perceived risk of getting T2DM in
future had done timely screening as compared to others and the association was
statistically significant in the bivariate analysis. Other studies have also reported on the
role of risk perception, but its association with timely screening was not examined. For
example in a study to examine the risk perception (on progress to T2DM) in women with
a history of GDM, 90% believed that GDM was a risk factor for future diabetes in
general, but only 16% perceived that they specifically were at increased risk of getting
T2DM. Those who perceived moderate/high risk planned to modify their lifestyle
behaviors (Kim et al., 2007).
It may be of interest to note than in our study, timely screening was higher among those
who self-referred themselves to a laboratory or had undergone screening in a private
hospital (66.7% and 62.1% respectively), and three of five women who tested themselves
at home also had timely screening. Eighty percent of those who had tested their blood at
65
home and around 40% of those who self- tested at laboratory were hyperglycemic. Thus,
awareness of the need for postpartum screening and probably ‗risk perception‘ motivated
their self-referral for timely testing.
GDM is known to increase risk of postpartum blues and even postpartum depression
(Mom et al., 1998), and we found almost a third of the respondents (36%) in our study
reported feeling thus. GDM mothers who reported that they felt ‖little interest in
anything‖ and were ―feeling down‖ were significantly more likely to have timely
postpartum diabetes screening as compared to other GDM mothers (in the bivariate
analysis). We did not find any other study reporting such an association. One possible
explanation for the association is that their inability to perform routine day- to-day work
may have compelled them to test to find out whether this condition was due to diabetes.
4.3. Barriers to postpartum diabetes screening and adequate post-screening follow-
up
4.3.1 Barriers as reported by the women
One of the most common barriers to postpartum diabetes screening was lack of
information, cited by almost 60% of women in our study who did not undergo screening.
Other reasons included doctors‘ reassurance that the condition would resolve after
delivery (14%), difficulty in going out with a small baby (12%), being asymptomatic, and
fear of learning about the diagnosis. Among those who tested at any time postpartum
(n=115) about 16% did not consult a doctor after testing their blood. A normal blood
glucose result (55.6%), difficulty in going out with a small baby (16.8%) and doctor‘s
reassurance (11.1%) were the major reasons for not consulting a doctor.
In a qualitative study conducted by Bennet et al among women affected with GDM in a
high risk obstetric clinic, a number of themes emerged as barriers to postpartum follow-
66
up care including screening. These included recent delivery experiences and baby‘s health
issues; burden of child care, emotional stress, lack of time and feeling overwhelmed;
feeling healthy and not in need for care; fear of receiving bad news; and dissatisfaction
with the logistics of accessing care (Bennett et al., 2011) . Another qualitative study in the
US reported that the barriers cited by women were not finding time for testing amidst
demands of childcare and domestic chores, and interpreting physicians‘ reassurance of
resolution of GDM after delivery as indicating low importance for screening (Paez et al.,
2014).
4.3.2 Barriers related to doctors and the health system
According to doctors interviewed in this study, major barriers to postpartum screening
and follow-up included women‘s inability to find time to come for follow-up care
because of their workload; lack of decision-making power especially among younger
women and lack of appreciation of the importance of follow-up care by women‘s
bystanders, usually mothers-in-law.
Nielsen et al (2014) similarly report from their review of studies that barriers to
postpartum screening from the perspective of health care providers included loss of
patients to follow-up, patient‘s lack of information or lack of understanding of the need
for the test. Other barriers mentioned were the lack of uniform protocols for postpartum
screening and management.
From our in-depth interviews with doctors, our observation is that the National
Guidelines for Diagnosis and Management of Gestational Diabetes Mellitus, India were
not known to any of them. Each of them was following a different set of procedures for
diagnosing as well as management during pregnancy and postpartum. It may be that as
obstetricians / gynaecologists, they are mainly concerned about managing safely the
67
GDM patient‘s pregnancy and doing their best to ensure a positive pregnancy outcome.
The subsequent management of the postpartum woman is not usually their concern.
Many doctors told this researcher that gestational diabetes is relieved after delivery and
only overt diabetes will continue after delivery, and did not seem to appreciate the
elevated risk of progression to T2DM. We wonder if this belief is gradually disseminated
into the society through their advice to the patient and bystanders during pregnancy. This
could prevent the majority from undergoing postpartum blood glucose testing and from a
consultation following the test.
About 80% of women in this study who had a normal blood sugar level in postpartum
screening and consulted their doctors were advised that there was nothing to worry. No
one was advised to repeat the test periodically, or to report their GDM history at the time
of their antenatal registration in their next pregnancy. The American Diabetes Association
(ADA) recommends three-yearly repeat screening for women testing normal in
postpartum screening. For Indian women, Tandon et al (2015) recommend screening
after one year in women with normal blood glucose results and 3-6 months in women
with abnormal blood glucose results instead of three yearly intervals as per ADA criteria
(Tandon et al., 2015).
4.4 Postpartum diabetes screening of GDM pregnancies – a case of repeated missed
opportunities to prevent T2DM.
Postpartum screening rate of GDM is very low. GDM affected women are not followed-
up or managed appropriately and those presenting with GDM in first pregnancy end up
with overt diabetes in succeeding pregnancies or present as overt diabetes adding to the
existing pool of diabetes mellitus in the community. There is also a high risk of morbidity
for the mother and the infant, causing avoidable suffering on a large scale.
68
This study brings out the alarming failure of the health system to use the window of
opportunity provided during pregnancy and postpartum period in preventing mothers with
GDM from progressing to full-blown T2DM at an early age, and living for many years
with a progressively debilitating condition that can affect multiple organs and needs
continuous management with drugs for several decades. Figure 1 illustrates the tragedy of
how of 200 women who actually came to the health services and were managed well
during pregnancy and delivery, barely 6%, or 11 women received appropriate postpartum
advice and management that could help prevent future T2DM. The other 94% represent
missed opportunities that could be easily avoided through appropriate policies and
interventions.
4.5. Strengths and limitations of the study:
All the interviews were conducted by a single investigator who is a physician. The
respondents were interviewed in their residence, so detailed response could be captured.
Since the sample frame is taken from hospitals, it won‘t be a representative sample of the
population. Facilities were identified around 6 months prior to the study and hence, it
might have influenced the practices of providers and hence the postpartum screening rate
4.6. Conclusions and recommendations
Timely postpartum screening and follow up of women following a GDM pregnancy can
help significantly in preventing adverse health consequences to the mother and her baby.
While planning effective postpartum diabetes screening programs at the grass root level,
various barriers at the level of the client, the health care provider and the health system
have to be kept in consideration. Hence understanding of factors associated with timely
postpartum screening can help to plan proper interventions according to the local
scenario. The health system can play a central and key role in ensuring appropriate
69
management of GDM during pregnancy and postpartum and through the rest of the
woman‘s lives.
70
The following are some recommendations for the public health system in India and
Kerala:
Uniform protocol: A standard protocol for advice, management, and timelines of
screening and contraceptive advice has to be established for India, in order to improve the
maternal and foetal health and preventing future diabetes in women with GDM.
Uniform postpartum diabetes screening intervals for the country: Considering the
local factors like high risk of T2DM for Indian women, we have to carry out postpartum
diabetes screening suitable and appropriate for our settings. Postpartum screening at 6-12
weeks after delivery and subsequent screening after one year in women with normal
blood glucose results and 3-6 months in women with abnormal blood glucose results may
be adopted.
Special thrust on contraceptive advice: Hyperglycemia at the time of pregnancy will
affect the baby adversely. Hence advice on using of spacing methods of contraception,
and on the importance of control of blood sugar before the next pregnancy is a must.
Physician education: Training of all health care providers who are managing GDM
affected women on the uniform protocols and the importance of adhering strictly to these
is an urgent priority. Physicians‘ capacity needs to be strengthened in areas such as
counselling for postpartum healthy life style, including physical activity, behavioral
changes, nutrition, breastfeeding and weight loss.
Postpartum referral by the Ob/Gyn conducting delivery to a physician as routine
practice: To ensure uninterrupted support and management of all GDM affected mothers,
the treating obstertician/ gynaecologist should routinely refer them after delivery to a
physician, with a written request.
71
Reminder system: Advice regarding future management and follow up should be of
utmost priority at the time of discharge and institution-wise facilities for reminders on
timely postpartum screening must be established under the responsibility of the treating
physician.
Education of physicians of other systems of medicines: Physicians in other systems of
medicine should also be included in the training programme to percolate the message
across all potential health care providers.
Enhancing patient and public awareness: Efforts should be made as part of the NCD
programme as well as the RMNCH+A programme to enhance health awareness on GDM
at various levels: the household, the school and the community.
Building capacity of front-line health workers to play an effective role in the
prevention and management of GDM
Frontline health workers such as the Junior Public Health Nurses, the ASHAs and the
Anganwadi workers and Male Health Workers should receive the appropriate training to
play an effective role in the prevention and management of GDM, as detailed below.
Asking about GDM as a part of routine history taking at the time of antenatal
registration: There should be special emphasis while registering an antenatal case both in
the public and private sector to ask about past history of GDM and family history of
diabetes mellitus. There should be a separate item in the registration system to fill this
detail.
Regular tracking and a system of monitoring GDM patients after delivery: All
pregnant women affected with GDM should be tracked through the local health facility
72
(sub-centre, PHC or other) and be registered under the government‘s Non Communicable
Disease Control programme.
Availability of testing at the PHC level: Postpartum screening through PHC and if
possible at sub-centre level. To promote healthy diet and exercise, demonstration at sub
centre level through health workers.
Availability of drugs at the subcentre and PHC level: Availability of drugs and
screening tests closer to home may be helpful for the GDM mothers. We need to set up a
system of regular monitoring similar to the DOTS programme of RNTCP.
Development and validation of a risk screening tool for GDM, and targeted testing
of women found to be high risk based on the tool: To prevent future diabetes in young
women, it is very important to develop an appropriate risk assessment tool, strengthen
screening practices for GDM during pregnancy and take actions for primary prevention.
Encourage studies on GDM and possible interventions to reduce progression to
T2DM.
The present study has identified associated factors and barriers to timely postpartum
diabetes screening. We need intervention studies to evaluate various context-specific
approaches to effective screening.
73
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Annexure I
Patterns of and factors associated with postpartum diabetes
screening in women diagnosed with Gestational Diabetes
Mellitus (GDM) in Malappuram district, Kerala
Serial number (for personal use only):
Interview Schedule for the survey
Code For personal use only Main code-M
M1 Participant’s ID
M2 Date of interview
M3 Start time
M4 End time
M5 Number of revisits made to
complete the interview
M6 Contact number of the
participant
Section 1: Background characteristics main code -B
I would like to ask you some questions about yourself and your health
Serial
number
Sub
code
Questions Response
1 B1 How old were you on your
most recent birth day?
DD MM YY
HH MM AM/PM
HH MM AM/PM
2 B2 What is your educational
qualification?
1 No schooling
2 1-7th standard
3 8-10th standard
4 Higher secondary
5 Post higher
secondary
diploma /
certificate
6 Graduate and
above
7 Others ,specify
3
B3
BMI
1
2
Height in cm
Weight in Kg
4 B4 What is your working status 1 Home maker
2 Daily wage earner
3 Salaried
employment
4 Self-employment
5 Student
6 Others , specify
Section2:Past Reproductive History(excluding the most recent delivery)
-Main code A
Q5:Order of pregnancy (A1)
Q6:Whether GDM diagnosed (A2) (Yes=1 No=2 )
Q7:Whether miscarriage/ abortions (A3) (Yes=1 No=2 )
Q8:If yes, month of gestations (A4)
If delivered If live birth Remarks Q9:Period of gestation in months (A5)
Q10:Mode of delivery (A6) (Normal=1 C-section=2 Assisted deliver=3)
Q11: Outcome (A7) (Live birth=1, Still birth=2)
Q12:M/F (A8) (male=1,female=2)
Q13:Current status (A9) (Alive +good health=1, Alive+ health problems =2, not alive=3
Q14: (A10)
Section3:Most recent pregnancy and delivery Main code-D
15 D1 Did you have any health
problems during your most
recent pregnancy?
1 Yes
2 No
16 D2 If yes,
explain……………………………………………….
17
D3 What type of delivery did
you have?
1 Normal delivery
2 C-section
3 Assisted delivery
18 D4 How many months pregnant
were you when you
delivered?
1 Pre term(less
than37weeks)
2 Term(37-41wks)
3 Post
term(>41wks)
19 D5 Did you suffer from any
complications
1 Yes
2 No
20 D6 If yes, what were they?
Section 4 Child characteristics Main Code: P
21 P1
Birth weight of the child in
kg
22 P2 Sex of the child 1 Male
2 Female
23 P3 *Cried just after delivery 1 Yes
2 No
24 P4 Breast feeding started 1 Less than one hour
2 Less than 24 hours
3 More than 24
hours
4 Others, specify
25 P5 Were there any difficulties in
initiating breast feeding?
1 Yes
2 No
26 P6 Did the child have jaundice
within one week of birth?
1 Yes
2 No
27
P7 Was the child admitted in
ICU before discharge?
1 Yes
2 No
28 P8 Was blood testing done,
before discharge?
1 Yes
2 No
3 don’t know
29
P9 If yes, for what 1 for routine
screening
2 to test blood
glucose level
3 As part of
investigation
while she/he was
ill
4 Don’t know
5 Any other, specify
30 P10 Is the child immunized for
age?
1 Yes
2 No
31 P11 Has the baby had any health
problems?
1 Yes
2 No
32 P12 If yes, describe ……………………………………….
Section5:Management of GDM in Most Recent Pregnancy
Main code: S
33 S1 Do you have a family history
of diabetes mellitus?
1 Yes
2 No
34 S2 If yes, who has /had
diabetes?
1 Mother
2 Father
3 Siblings
a)During pregnancy Main Code: SP
35 SP1 I understand that you had
been diagnosed with diabetes
during your pregnancy. Can
you describe how you came
to be diagnosed as having
diabetes during your
pregnancy?
……………………………
…………………………
36
SP2 At which month of gestation
were you diagnosed with
GDM (Prameham)?
1 First trimester
2 Second trimester
3 Third trimester
4 Before pregnancy
37 SP3 Was there a reason for testing
your blood?
1 Routine test
2 One of my
parents/both have
diabetes
3 Previous history
of GDM
4 Previous history
of big baby
(macrosomia)
38 SP4 Did you receive any advice
on this?
1 Yes
2 No
39 SP5 If yes, from whom? 1 Doctor
2 Nurse(from the
hospital)
3 Friend
4 Others, specify
40 SP6 How did they manage your
condition?
1 Started oral
medicine
2 Advised diet
control
3 Advised exercise
4 Started injection
insulin
5 Any other, specify
41 SP7 What was the reaction of your family members when
you were diagnosed as GDM? Explain
………………………………………………………
b)After delivery Main code :SA
42 SA1 Do you think that blood
glucose testing is necessary
after delivery?
1 Yes
2 No
If no, go to Q:SA4
43 SA2 If yes, why?
44 SA3 Who told you about this? 1 Doctor
2 Health worker
3 AWW/ASHA
3 Media
5 Others, specify
45 SA4 Have you tested your blood
after delivery to check blood
glucose level?
1 Yes
2 No
(if ,no to Q no:PB1)
46
SA5 If yes, when did you conduct
the test?(period after
delivery)
47 SA6 From where? 1 Public hospital
2
Private hospital
3 Laboratory(self-
referred)
4 Self(at home)
If answer to SA 6 is 1 or 2 go to SA 10
48 SA7 What was the result of your
blood sugar test?
1 Blood sugar level
was high
(hyperglycemia)
2 Normal
If answer to Q; SA 6, is3 or 4 , then answer SA 8&9.
49 SA8 Did you consult a
doctor(after doing the blood
test- self)
1 Yes
2 No
50
SA 9 If you self-tested, but did not
go to a doctor .What was the
reason?
1 Lack of time
2 No one to
accompany
3 Family does not
support
4 Lack of money
5 Others, specify
After this question go to FP1
51 SA10 If blood sugar test was
normal and you consulted a
doctor, what did she/he say?
1 Nothing to worry
now
2 Do blood glucose
test at 6 weeks
after delivery
3 Do yearly
screening
4 Any other,
specify?
52
SA11 If the blood glucose level was
high, what did your doctor
advice?
1 To start medicine
2 Diet control
3 Exercise
4 Continue breast
feeding
5 Regular follow-up
6 Any other,
specify?
53 SA12 (a)
Which among the doctor’s advice were you able to
follow?
54 SA12 (b) Which among these were you
not able to follow?
55 SA12 (c) Why?
If answer to SA 11 is 1,go to SA 14,if not go to FP1
56 SA14 If started medicines , could
you please tell me what these
medicines are ( check
prescriptions)
1 Tablets (Oral
hypoglycemic
agents)
2 Insulin
57 SA15 Are there any difficulties for
you to get medicines
continuously?
1 Yes
2 No
58 SA16 If yes, could you explain me what the difficulties are?
..........................................................................
To be answered by those who have had no postpartum screening
Section 6:Personal Barriers Main code: PB
59
PB1 Why have you not got
yourself tested after delivery
for diabetes mellitus?
1 Lack of time
2 No one to
accompany
3 Family does not
support
4 Lack of money
5 Others, specify
60 PB2 Have you considered getting 1 Yes
tested anytime in the near
future for diabetes mellitus?
2 No
61 PB3 If yes, when?
Section7:Spacing/family planning Main code: FP
62
FP1 Are you using any
contraceptive methods?
1 Yes
2 No
63 FP2 If yes, what type? 1 IUD
2 Condoms
3 Oral contraceptive
Pills
4 Sterilization
(Vasectomy/
tubectomy)
5 Others, specify
64 FP3 Who told you about this? 1 Doctor
2 Nurse
3 JPHN
4 Husband
5 Friend
6 Self-decision
7 Any other
Section8:Risk Perception Main code: R
65 R1 Women who had developed 1 Yes
diabetes mellitus during pregnancy are more likely to get diabetes in their life time when compared to those who did not get diabetes mellitus during pregnancy/pregnancies. Do you think you have a higher chance of getting diabetes mellitus in your lifetime? (if No skip Q66 )
2 No
66 R2 If yes, who has told you
about this?
1 Doctor
2 Health worker
3 AWW/ASHA
4 Family members
5 Media
6 Health education
class
7 Others, specify
Section9:Postpartum health Main Code -T
Now I would like to ask you some questions about your health after delivery
67 T1 Have you had any health
problems after delivery(post
discharge)
1 Yes
2 No
68 T2 If yes, describe
69
T3 Have you ever had a feeling
of having little interest or
pleasure in doing things, after
the delivery
1 Yes
2 No
70 T4 Have you ever had a feeling
of feeling down or having
little energy?
1 Yes
2 No
71 T5 Did you ever experienced
Poor appetite or over eating
1 Yes
2 No
72 T6 Have you ever experienced
feeling bad about yourself or
that you’re a failure or let
yourself or your family down
1 Yes
2 No
*Prolonged labour, especially if macrosomia may lead to foetal distress.
Thank the respondent;take permission to conduct again, if required.
Signature of the PI
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]©kmcbpsS
Afhv
]cntim[n¡m³
thn
3 tcmK_m[nXbmbn
cn¡pt¼mÄ
]cntim[\bv¡m
bn
4 AdnbnÃ
5 asäs´¦nepw
30 P10 Ipªnsâ Ct¸mgs¯
hbkn\\pkcn¨pff FÃm
Ip¯nhbv]pIfpw
FSp¯n«ptm?
1 Dv
2 CÃ
31 P11 Ipªn\v Fs´¦nepw
BtcmKy
{]iv\§fpmbn«ptm?
1 Dv
2 CÃ
32 P12 Ds¦n hniZam¡pI
……………………………………….
Section5:KÀ`Ime {]tal \nb{´Ww þ C¡gnª KÀ`¯nepw {]kh¯nepw
Main code: S
33 S1 IpSpw_¯nemÀs¡¦nepw
{]talw Dtm? 1 Dv
2 CÃ
34 S2 Ds¦n AXmÀ¡v 1 Aѳ
2 A½
3 _Ôp¡Ä
a)KÀ`Ime¯v Main Code: SP
35 SP1 KÀ`mhØbnembncp¶
kab¯v \n§Ä¡v {]talw
Dmbncp¶sX¶v Rm³
a\knem¡p¶p.
{]talapmbncp¶psh¶v
\n§Ä F§s\bmWv
a\knem¡nbXv,
hniZam¡mtam?
………………………………
………………………
36
SP2 KÀ`mhØbpsS GXv
amk¯nemWv \n§Ä {]tal
_m[nXbmsW¶v
Is¯nbXv?
1 BZys¯ aq¶v
amkw
2 cmas¯ aq¶v
amkw
3 aq¶mas¯ aq¶v
amkw
4 KÀ`nWnbmIp¶Xn
\v apt¼
37 SP3 \n§fpsS càw
]cntimKn¡phm\pff 1 ]Xnhv ]cntim[\
2 amXm]nXm¡fnÂ
ImcWw? Hcmtfm / cv
t]tcm {]tal
_m[nXcmtWm?
3 ap³Ime KÀ`
{]talmhØ
4 ap¼s¯
{]kh¯nÂ
henb
Ip«nbmbncpt¶m?
(amt{Im-tkm-anb)
38 SP4 CXn\p thn \n§Ä¡v
Bcn \ns¶¦nepw D]tZiw
e`n¨ncpt¶m?
1 Dv
2 CÃ
39 SP5 Ds¦n Bcn \n¶v 1 tUmIvSÀ
2 \gvkv(Bip]{Xnbn
 \n¶pw )
3 kplr¯v
4 aäpffhÀ
40 SP6 \n§fpsS Cu AhØsb
AhÀ F§s\bmWv
]cn]men¨Xv?
1 Ign¡phm\pff
acp¶v
2 `£W \nb{´Ww
3
hymbma \nÀt±iw
4 C³kpen³
C³P£³
5 Asäs´¦nepw,
hyàam¡pI
41 SP7 KÀ`Ime {]talw Ds¶v Is¯nbt¸mÄ
F´mbncp¶p IpSpw_mwK§fpsS {]XnIcWw,
hniZam¡pI.
………………………………………………………
b){]kh tijw Main code :SA
42 SA1 {]kh tijw cà¯nse
¥qt¡mknsâ ]cntim[\
A\nhmcyamsW¶v \n§Ä
IcpXp¶ptm?
1 Dv
2 CÃ
D¯cw Cà F¶msW¦n tNmZyw SA4 te¡v t]mIpI
43 SA2 BsW¦n F´p sImv?
44 SA3 BcmWv Cu
]cntim[\sb¡pdn¨v
\n§tfmSv ]dªXv?
1 tUmIvSÀ
2 BtcmKy
{]hÀ¯I³
3 A¦-W-hmSn
hÀ¡À/Bi
3 ]{X am[ya§Ä
5 asäs´¦nepw
45 SA4 cà¯nse ¥qt¡mknsâ
Afhv Is¯p¶Xn\pff
cà ]cntim[\ {]kh
tijw \n§Ä
\S¯nbncpt¶m?
1 Dv
2 CÃ
(D¯cw Cà F¶msW¦n tNmZyw PB1te¡v t]mIpI)
46
SA5 Ds¦n Ft¸mgmWv
\S¯nbXv?({]kh
tijapff kabw)
47 SA6 sSÌv \S¯nbXv FhnsS
\n¶mbncp¶ppw? 1 Kh.Bip]{Xn
2
kzImcy
Bip]{Xn
3 em_v(kzbw sd -̂
dÂ)
4 kzbw(ho«nÂsh¨v
)
tNmZyw SA 6 sâ D¯cw Ht¶m1 ctm BsW¦n SA 10 te¡v
t]mhpI
48 SA7 \n§fpsS cà
]cntim[\bpsS ^ew
F´mbncp¶p?
1 cà¯nse
]©kmcbpsS
Afhv IqSpXÂ
(ssl¸À
Kvssfko-anb)
2 km[mcWw
tNmZyw SA 6 sâ D¯cw, aqt¶m \mtem BsW¦n tNmZyw SA 8 sâbpw
9sâbpw D¯cw ]dbpI
49 SA8 cà ]cntim[\bv¡v tijw
\n§Ä tUmIvSsd
Incpt¶m? (cà
]cntim[\bv¡v tijw)
1 Dv
2 CÃ
50
SA 9 \n§Ä tUmIvSsd ImWmsX
kzbw ]cntim[\
\S¯pIbmbncp¶pthm? F¦n F´mWv ImcWw?
Cu tNmZy¯n\p tijw FPI te¡v t]mhpI
1 kab¡pdhp aqew
2 IqsS hcm³
BcpanÃm¯Xv
sImv
3 IpSpw_¯nsâ
klmbw
CÃmXncp¶Xv
sImv
4 ]WanÃm¯Xp
sImv
5 asäs´¦nepw,
hyàam¡pI
51 SA10 ]cntim[\m ^ew t\mÀaÂ
Bbncn¡pIbpw tUmIvSsd
ImWpIbpw sNbvXp,
F´mWv tUmIvSÀ ]dªXv?
1 Ct¸mÄ
t]Snt¡
ImcyanÃ
2 {]kh¯n\v
BdmgvNbv¡v
tijw hopw
càw
]cntim[n¡pI
3 hÀjmhÀjw
càw
]cntim[n¡pI
4 asäs´¦nepw,
hyàam¡pI
52
SA11 cà¯nse ¥qt¡mknsâ
Afhv IqSpXembncn¡pIbpw
tUmIvSsd ImWpIbpw
sNbvXp, tUmIvSdpsS
D]tZiw F´mbncp¶p ?
1 acp¶v
Bcw`n¡pI
2 `£W
\nb{´Ww
3 hymbmaw
4 apebq«p¶Xv
XpScpI
5 IrXyamb
]cnNcWw
6 asäs´¦nepw,
hyàam¡pI
53 SA12 (a)
tUmIvSdpsS GXv D]tZiamWv \n§Ä¡v ]n´pScm³
IgnªXv.?
54 SA12 (b) GXp]tZiamWv \n§Ä¡v
]n³XpScm³
IgnbmXncp¶Xv?
55 SA12 (c) F´psImv?
SA 11 sâ D¯cw 1 BsW¦n tNmZyw SA 14 Asæn FP1te¡v
t]mhpI
56 SA14 acp¶v Bcw`n¨ncp¶psh¦nÂ
GsXms¡bmbncp¶psh¶v
]dbmtam (No«v
]cntim[n¡pI)
1 KpfnIIÄ(HmdÂ
sslt¸m
ss¥koanIv
GPâvkv)
2 C³kpen³
57 SA15 XpSÀ¨bmbn acp¶v
e`n¡p¶Xn Fs´¦nepw
_p²nap«pmbncpt¶m ?
1 Dv
2 CÃ
58 SA16 Dv F¶msW¦n F´mbncp¶p _p²nap«v F¶v
]dbmtam?
..........................................................................
{]k-hm-\-́ -c-c-à-]-cn-tim-[\ sN¿m-̄ -hÀ am{Xw D¯cw \ÂIpI
Section 6:hyàn]camb XS椀 Main code: PB
59
PB1 {]kh¯n\p tijw
{]tal¯n\v ]cntim[\
tXSmXncp¶Xv F´p
sImv?
1
kab¡pdhp aqew
2 IqsS hcm³
BcpanÃm¯Xv
sImv
3 IpSpw_¯nsâ
klmbw
CÃmXncp¶Xv
sImv
4 ]WanÃm¯Xp
sImv
5 asäs´¦nepw,
hyàam¡pI
60 PB2 kao] `mhnbn {]tal
]cntim[\ \S¯phm³
Dt±in¡p¶ptm?
1 Dv
2 CÃ
61 PB3 Dv F¦n Ft¸mÄ?
Section7: {]kh§Ä X½n AIew/ IpSpw_mkq{XWw Main code: FP
62
FP1 \nehn GsX¦nepw
KÀ`\ntcm[\ amÀK§Ä
kzoIcn¡p¶ptm?
1 Dv
2 CÃ
63 FP2 Dv F¦n GXv? 1 IUD
2 tImw
3 HmdÂ
tIm¬{Smsk]väo
hv KpfnIIÄ
4 sÌdnssetkj³
(hmkIvSan/Syq_
IvSan)
5 asäs´¦nepw,
hyàam¡pI
64 FP3 \n§tfmSnXnt\¡pdn¨v
BcmWv ]dªXv? 1 tUmIvSÀ
2 \gvkv
3 sP.]n.F¨v.F³
4 `À¯mhv
5 kplr¯v
6 kz´w Xocpam\w
7 asäs´¦nepw
Section8:A]ISkm[yXsb¡pdn¨pff Aht_m[w/ Úm\w
Main code: R
65 R1 KÀ`n-Wn-bm-Ip¶ kab¯v {]tal _m[nXcmIp¶ kv{XoIÄ¡v XpSÀ¶v PohnX¯n {]talapmIphm\pff km[yX KÀ`n-Wn-bm-Ip¶ kab¯v {]tal _m[nXcmIm¯ kv{XoItf¡mfpw IqSpXemWv. \n§Ä¡v XpSÀ¶pff PohnX¯n {]talw _m[n¡m\pff km[yX IqSpXemsW¶v
IcpXp¶ptm? (CÃ
F¶msW¦n Q: 66
Hgnhm¡pI )
1
2
Dv
CÃ
66 R2 D¯cw Dv F¶msW¦nÂ
BcmWv CXns\¡pdn¨v
Xm¦tfmSv ]dªXv
1 tUmIvSÀ
2 BtcmKy
{]hÀ¯I³
3 AwK\hmSn
hÀ¡À/Bi
4 IpSpw_w
5 ]{X am[ya§Ä
6 BtcmKy
¢mÊpIÄ
7 asäs´¦nepw
Section9: {]khm\´c BtcmKyw Main Code -T {]khm\´capff \n§fpsS BtcmKys¯¡pdn¨pff tNmZy§fmWv C\n
67 T1 {]kh¯n\p tijw
Fs´¦nepw BtcmKy
{]iv\§fpmtbm?(UnkvNm
ÀPn\v tijw)
1 Dv
2 CÃ
68 T2 Ds¦n hyàam¡pI
69
T3 {]kh¯n\p tijw
Imcy§Ä sN¿p¶XnÂ
sNdnb kt´mjtam
Xm¸cytam am{Xta \n§Ä
ImWn¡p¶pÅpthm
1 Dv
2 CÃ
70 T4 ISp¯ \ncmitbm
DuÀÖkzeX¡pdthm
\n§sf Ae«p¶ptm?
1 Dv
2 CÃ
71 T5 hni¸nÃmbvatbm AanXamb
`£W {]nbtam \n§sf
Ae«p¶ptm?
1 Dv
2 CÃ
72 T6 \n§fpsS PohnXw Hcp
]cmPbamsWt¶m
IpSpw_s¯ \n§Ä
\ncmis¸Sp¯nsbt¶m
tXm¶p¶ptm?
1 Dv
2 CÃ
* kpZoÀLamb {]khw, {]tXyIn¨pw henb Ip«n BIpt¼mÄ izmk
XSʯn\pff km[yX hfsc IqSpXemWv.
]s¦Sp¯bmtfmSv \µn ]dbpI, X¶ hnhc§fn hniZoIcWw
Bhiyaps¦n hopw ImWm\pff A\phmZw tNmZn¡pI.
{][m\ At\zjIsâ H¸v.
Annexure III
Achutha Menon Centre for Health Science Studies,
Sree Chitra Tirunal Institute for Medical Sciences & Technology,
Trivandrum 695011
Patterns of and factors associated with postpartum diabetes screening in women diagnosed with Gestational Diabetes Mellitus (GDM) in Malappuram district, Kerala.
Research Subject Information Sheet for Mothers Who Had GDM
Namaskaram, I am ***, Master of Public Health student of Achutha Menon
Centre for Health Science Studies of the Sree Chitra Tirunal Institute for
Medical Sciences and Technology, Trivandrum. This study is being carried
out as a part of the course requirement for the Master in Public Health (MPH
course) that I am currently undertaking. This study is being done under the
supervision of ***, Professor of Achutha Menon Centre for Health Science
Studies. Please feel free to ask any questions or doubts related to this study.
Purpose of the study:
This study is being done to understand the kind of medical care that is being
provided to pregnant women who may have diabetes during their pregnancy
and their management afterwards. Understanding this may contribute to
preventing the development of diabetes mellitus in women. That is why we
want to learn about your experiences during pregnancy, child birth and after
delivery.
This study is being conducted in three private and one public hospital of
Malappuram district, and you have been chosen from the hospital delivery
register based on the eligibility criteria for participating in this study, as per
the procedure. A total of 200 participants will be included and interviewed in
this study.
Procedure:
The survey would take approximately 30-45 minutes of your valuable time.
You will be asked a few questions regarding your pregnancy experiences,
about your delivery, and the postpartum period. The collected data will be
used for research purpose only. If you will permit, I would like to contact
you for clarifications related to the information collected during the present
interview.
Benefits:
There may not be any direct benefit for you from this study. But the
information provided by you may prove to be of great importance with
respect to understanding the factors influencing postpartum GDM
management, the patterns of seeking care and your morbidity experiences as
well as the provider’s role in the management of care. As this is an important
public health issue, this study may contribute to policies that help to ensure a
standardized protocol for management of GDM and incorporation of GDM
management to the National programs for controlling non communicable
diseases.
Confidentiality:
Utmost priority will be given to protect the privacy and confidentiality of
your personal information. The collected information will not be shared with
anyone not involved in the study and reporting will be done in aggregate
form only. At no stage shall your identity be revealed for this. Complete
anonymity will be maintained and you will be assigned a participant
identification number. All hard copies of filled interview schedules and
consent forms will be kept under my custody and will be destroyed properly
when they are deemed no longer needed after one year of dissertation report
submission, whichever comes first.
Voluntary participation:
Your participation in this study is voluntary and you have the right to
withdraw your participation at any time during the interview without any
explanation. Refusal to participate will not involve any penalty or loss of
benefits to which you are otherwise entitled. There might be certain
questions which you may find stressful. You can choose to decline
answering these questions. If you have additional questions about this
research you may contact me, the supervisor or the
IEC Member Secretary.
*** ******* ******* Contact details of guide Contact details of the (Principal investigator’s IEC Member Secretary contact details)
Signature of Principal investigator
Annexure IV
ANyp-X-ta-t\m³ skâÀ t^mÀ sl¯v kb³kv ÌUo-kv,
{ioNn{XXncp-\mÄ C³Ìn-äq«v t^mÀ saUn-¡Â kb³kkv
& sSIvt\m-f-Pn, Xncp-h-\-´-]p-cw, 695011, tIcfw
KÀ`Ime {]taltcmKapmbncp¶ A½-amÀ¡pÅ hnh-cW ]{XnI
KÀ`Ime {]taltcmKapmbncp¶ kv{XoIfn {]khm\´c {]taltcmK (Pn.Un.Fw) ]cntim[\bpsS coXnIfpw klmbn¡p¶ LSI§fpw þ ae¸pdw PnÃ, tIcfw
\akvImcw,
Rm³ tUm. k¡o\ {io Nn¯ncXncp\mÄ C³Ìnäyq«v Hm^v saUn¡Â kb³kkv Bâv sSIvt\m-f-Pn, {Snhm³{U-̄ nsâ Iognse ANypXtat\m³ skâÀ t^mÀ sl¯v kb³kv ÌUoknÂ, amÌÀ Hm^v ]»nIv sl¯v hnZymÀ°n\nbmWv. Fsâ _ncpZm\´c _ncpZ tImgvkn\v Bhiyamb {]_Ôw kaÀ¸n¡p¶Xnte¡mbn«mWv {]kvXpX KthjWw \S¯p¶Xv. Cu ]T\w ANypX tat\m³ skâÀ t^mÀ sl¯v kb³knse s{]m^. kpµ-co-c-ho-{µsâ t\XrXz¯nemWv \S¶p hcp¶Xv.
Cu ]T\s¯¡pdn¨v Fs´¦nepw kwib§tfm tNmZy§tfm Ds¦n tNmZn¡m³ aSn¡cpsX¶v A`yÀ°n¡p¶p.
]T\¯nsâ Dt±iyw
KÀ`Ime {]tal tcmKnIÄ¡v KÀ`mhØbnepw {]kh tijhpw \ÂInb NnInÕsb¡pdn¨v a\knem¡p¶Xn\mWv Cu ]T\w \S¯p¶Xv. CXvv a\knem¡p¶Xv kv{XoIfn {]talw XSbp¶Xn\v klmbn¡pw. AXpsImmWv KÀ`Ime {]talapffhcpsS KÀ`mhØbnepw {]kh kab¯pw {]khm\´capff ]cnNcW§fn \n§fpsS A\p`h§Ä Rm³ ]T\hnt[bam¡m³ Dt±in¡p¶Xv.
ae¸pdw PnÃbn 3 kzImcy Bip]{Xnbnepw Hcp kÀ¡mÀ Bip]{XnbnepamWv Cu ]T\w \S¯p¶Xv. Bip]{XnIfnse enÌn \n¶pamWv \n§sf R§Ä XncsªSp¯Xv. GI-tZiw 200 t]scbmWv Cu ]T-\-̄ n DÄs -̧Sp-̄ n-bn-cn-¡p-¶Xpw CâÀhyq-\-S-̄ p-¶Xpw.
]T\ coXn
30 apX 45 an\n«mWv \n§Ä Cu kÀthbv¡mbn Nnehgnt¡Xv. A`napJ kw`mjW coXnbn \n§fpsS KÀ`Imes¯bpw {]khImes¯bpw {]khm\´c Imes¯bpw A\p`h§Ä tNmZn¡p¶Xmbncn¡pw. {]kvXpX hnhc§Ä KthjW Dt±i§Ä¡v am{Xambncn¡pw D]tbmKn¡p¶Xv F¶v Dd¸v Xcp¶p. \n§fpsS k½Xw Ds¦n Cu hnhc§sf Ipdn¨v kwibw Dmhp¶ ]£w \n§sf XpSÀ¶v _Ôs¸Sp¶Xmbncn¡pw.
KpW§Ä
{]kvXpX ]T\¯neqsS \n§Ä¡mbn am{Xw bmsXmcp hn[ B\pIqey§tfm KpW§tfm e`n¡p¶Xmbncn¡nÃ. F¶m \n§Ä Xcp¶ hnhc§Ä {]tal _m[nXcmb KÀ`nWnIfpsS NnInÕsb¡pdn¨pw AhÀ¡v e`n¡p¶ ip{iqjsb¡pdn¨pw Adnbphm³ klmbn¡pw. Hcp s]mXpP\mtcmKy hnjbsa¶ coXnbn Cu ]T\w {]tal_m[nXcmb KÀ`nWnIÄ¡p anI¨ ip{iqj e`n¡p¶Xn\mhiyamb ]²XnIÄ cq]s¸Sp¯p¶Xnt\m {]tXyI Kh¬saâv ]²Xn cq]s¸Sp¯p¶Xnt\m klmbnt¨¡pw.
kzImczX
\n§Ä Xcp¶ FÃm hnhc§fpw kzImcyambn kq£n¡p¶XmWv. {]tXyIn¨v \n§fpsS hyàn]camb hnhc§Ä ]T\hpambn _ÔanÃm¯hÀ¡v bmsXmcp ImcWhimepw \ÂIpIbnÃ. IqSmsX hnh-c-§Ä dnt¸mÀ«v sN¿p¶Xv kw{K-l-cq-]-̄ n-em-bn-cn-¡pw. \n§fpsS A`napJ¯nsâ tcJIfpw k½X]{Xhpw Rm³ `{Zambn kq£n¡p¶XmWv. KthjW Bhiyw Ignªm AX-sÃ-¦n ]T-\-dn-t¸mÀ«v kaÀ¸n-̈ mÂ, GXmWv BZyw hcp-¶Xv F¶-X-\p-k-cn-̈ v, Hcp hÀj¯n\p tijw icn-bmb coXn-bn \in¸n¡p¶-Xm-Wv.
kzta[bm Dff ]s¦Sp¡Â
Cu ]T\¯n \n§Ä ]s¦Sp¡p¶Xv kzta[bm BWv. bmsXmcp ImcWhpw IqSmsX GXv kab¯pw ]T\¯n \n¶v ]n´ncnbm\pff kzmX{´yw \n§Ä¡v Dmbncn¡p¶XmWv. ]T\¯n ]s¦Sp¡mXncp¶Xv sImv Xm¦Ä¡v bmsXmcp hn[¯nepff \jvS§tfm ]ngtbm Dmbncn¡p¶XÃ. ]T\hpambn _Ôs¸«v A[nIambn Fs´¦nepw tNmZy§fps¦n \n§Ä¡v Fs¶tbm Asæn F¯n¡Â I½nän sk{I«dnbpamtbm _Ôs¸Smhp¶XmWv.
{][m-\-K-th-j-Isb _Ô-s¸tS hnh-c-§Ä
ssKUns\ _Ô-s¸tS hnh-c-§Ä
sF. C. kn saw¼Àsk-{I-«dn _Ô-s¸tS hnh-c-§Ä
{][m-\-K-th-j-IbpsS H v̧
Annexure V
Patterns of and factors associated with seeking postpartum health care
including diabetes screening in women diagnosed with Gestational
Diabetes Mellitus (GDM) in Malappuram district , Kerala
CONSENT STATEMENT
Participant’s Unique Identification (UID) Number:
I have read/been read the details of the information sheet. The nature of the
study and my involvement has been explained and all my questions
regarding the study have been answered satisfactorily. By signing /
providing thumb impression on this consent form, I indicate that I
understand what is expected from me and that I am willing to participate in
this study. I have also been informed as to whom I should contact for further
clarifications. I know that I can withdraw my participation at any time during
the interview without any explanations.
Name of the participant: ________________________________________
Signature / left thumb print:
Date of consent: D D M M Y Y
If the participant is willing to participate but unwilling to provide signature
or thumb impression
(Verbal consent):
Name of witness: ________________________________________
Signature of the witness:
Signature of the investigator:
Date:
Annexure VI KÀ`Ime {]taltcmKapmbncp¶ kv{XoIfn {]khm\´c {]taltcmK (Pn.Un.Fw) ]cntim[\bpsS coXnIfpw klmbn¡p¶ LSI§fpw þ ae¸pdw PnÃ, tIcfw
k½-X-]{Xw
]s¦-Sp-¡p-¶-bm-fpsS \w¼À
ta ]dª tcJbnse hniZmwi§Ä Rm³ hmbn¨p. ]T\¯nsâ coXnsb¸änbpw Fsâ ]¦mfn¯s¯¡pdn¨pw F\n¡v hniZoIcn¨v X¶n«pv. IqSmsX ]T\s¯¡pdn¨pff Fsâ FÃm kwib§Ä¡pw hniZoIcWw \ÂInbn«pv. Cu k½X ]{X¯n H¸nSpItbm/ hnceSbmfw ]Xn¸n¡pItbm sN¿p¶ ]£w Cu ]T\¯n ]s¦Sp¡m³ F\n¡v k½XamWv. kwibZqcoIcW¯n\v BscbmWv _Ôs¸tSsX¶v Fs¶ Adnbn¨n«pv. IqSn¡mgvN \S¯p¶Xn\nSbn hniZoIcWw IqSmsX Xs¶ ]T\¯n \n¶v ]n³amdm³ ]äpsa¶pw F\n¡dnbmw.
Xncn¨dnb \¼À………………………
]s¦Sp¡p¶ Bfnsâ t]cv : ……………………….
H¸v/ hnceSbmfw
XobXn: ……………………
]T-\-]-¦mfn ]T-\-¯n ]s¦-Sp-¡m³ k½-Xn-¡p-¶p-F-¦nepw Ht¸m hnc-e-S-bm-ftam \ÂIm³ hnk-½-Xn-¡p¶p F¦nÂ
(hm¡m-epÅ k½-Xw):
km£nbpsS t]cv:…………………………
km£nbpsS H¸v: …………………………
]T\w \N-̄ p¶ BfsSt]cv ……………………..
H¸vv: ………………………. XobXn: …………………………..
Annexure VII Achutha Menon Centre for Health Science Studies,
Sree Chitra Tirunal Institute for Medical Sciences & Technology,
Trivandrum 695011
Patterns of and factors associated with postpartum diabetes screening in women diagnosed with Gestational Diabetes Mellitus (GDM) in Malappuram district, Kerala.
Research Subject Information Sheet for Providers
Namaskaram, I am ***, Master of Public Health student of Achutha Menon
Centre for Health Science Studies of the Sree Chitra Tirunal Institute for
Medical Sciences and Technology, Trivandrum. This study is being carried
out as a part of the course requirement for the Master in Public Health (MPH
course) that I am currently undertaking. This study is being done under the
supervision of ***, Professor of Achutha Menon Centre for Health Science
Studies. Please feel free to ask any questions or doubts related to this study.
Purpose of the study:
This study is being done among providers who give direct obstetric care and
manage women affected with gestational diabetes mellitus (GDM) during
pregnancy, delivery and postpartum period. Hence understanding their
perspectives regarding various aspects of gestational diabetes management
and postpartum diabetes screening and management based on their
experiences will help to guide future policy formulations. This will
contribute to improving postpartum screening status of GDM affected
women and reduce progression to Type2DM. This is why we would like to
interview you to learn about your experiences of management of gestational
diabetes mellitus (GDM) during pregnancy, child birth and after delivery. If
you will permit we would like to audio record the interview.
This study is being conducted in three private and one public hospitals of
Malappuram district, and you have been chosen from the available list in the
hospital for participating in this study. A total of 6-7 providers, who provide
direct obstetric care to the GDM affected mothers will be interviewed in the
study.
Procedure:
The survey would take approximately 20-25 minutes of your valuable time.
You will be asked a few questions regarding the management of GDM. The
collected data will be used for research purpose only. If you will permit, I
would like to contact you for clarifications related to the information
collected during the present interview.
Benefits:
There may not be any direct benefit for you from this study. But the
information provided by you may prove to be of great importance with
respect to understanding the factors influencing postpartum GDM
management, the patterns of seeking care and as well as the provider’s role
in the management of care. As this is an important public health issue, this
study may contribute to policies that help to ensure a standardized protocol
for management of GDM and incorporation of GDM management to the
National programs for controlling non communicable diseases.
Confidentiality:
Utmost priority will be given to protect the privacy and confidentiality of the
information given by you. The collected information will not be shared with
anyone not involved in the study. At no stage shall your identity be revealed
for this. Complete anonymity will be maintained and you will be assigned a
participant identification number. All audio recordings and transcripts of the
interview and consent forms will be kept under my custody and will be
destroyed properly when they are deemed no longer needed after one year of
dissertation report submission, whichever comes first.
Voluntary participation:
Your participation in this study is voluntary and you have the right to
withdraw your participation at any time during the interview without any
explanation. Refusal to participate will not involve any penalty or loss of
benefits to which you are otherwise entitled. There might be certain
questions which you may find stressful. You can choose to decline
answering these questions. If you have additional questions about this
research you may contact me, the supervisor or the
IEC Member Secretary.
*** ******* ******* Contact details of guide Contact details of the (Principal investigator’s IEC Member Secretary contact details)
Signature of Principal investigator
Annexure VIII
Achutha Menon Centre for Health Science Studies,
Sree Chitra Tirunal Institute for Medical Sciences & Technology,
Trivandrum 695011
Patterns of and factors associated with seeking postpartum health care
including diabetes screening in women diagnosed with Gestational
Diabetes Mellitus (GDM) in Malappuram district , Kerala
CONSENT STATEMENT
Participant’s Unique Identification (UID) Number: I have read/been read the details of the information sheet. The nature of the
study and my involvement has been explained and all my questions
regarding the study have been answered satisfactorily. By signing /
providing thumb impression on this consent form, I indicate that I
understand what is expected from me and that I am willing to participate in
this study. I have also been informed as to whom I should contact for further
clarifications. I know that I can withdraw my participation at any time during
the interview without any explanations.
Name of the participant: ________________________________________
Consent for interview Consent for audio recording Signature Date of consent:
D D M M Y Y
Annexure IX
Achutha Menon Centre for Health Science Studies,
Sree Chitra Tirunal Institute for Medical Sciences & Technology,
Trivandrum 695011
Patterns of and factors associated with postpartum diabetes
screening in women diagnosed with Gestational Diabetes
Mellitus (GDM) in Malappuram district, Kerala
Interview Guide-Provider
1. How often in your practice do you come across pregnant women
affected by GDM? 2. What do you do when one of your patient diagnosed with GDM comes to
you with the test results? (Probe if not mentioned: What information do
you give them, how do you manage them, information regarding future
risk of progression to T2 diabetes, advice to come frequently for
Antenatal check up, /postpartum screening/risk to baby).
3. Can you tell me about the management of GDM during labour and the
immediate postpartum period? (Probe if not mentioned about : any
special precautions like admissions before EDD, frequent blood sugar
level monitoring, delivery from a hospital with paediatrician & physician,
and facility to give advance life care support to both mother and child)
4. Can you tell me about the situation where you take decisions regarding C-
sections (probe-do you prefer C-sections to all or specific ones).
5. What advice do you give when a GDM patient is discharged after
delivery? (probe if not mentioned: regarding diet, breast feeding,
exercise(for normal delivery),about medicines ,about returning for
postpartum screening)
6. Do you prescribe any medicines for them while discharging them after
delivery from your institution?
7. In your experience, roughly what proportion of the GDM affected women
come for follow-up after delivery?
8. Out of this how many come for follow up even if you have not
specifically told them?
9. What according to you are the best methods to ensure follow up visits by
the patients?(probe if not mentioned :written advice along with discharge
card/message alert system/telephonic reminders)
10. In your experience, what proportion of the women diagnosed with GDM
progress to Type 2 DM in future? (Probe if not mentioned: about
possibility of conversion of these cases to type 2 DM in future? Is it
common or not?)
11. What is your practice regarding family planning advice for women
affected by GDM?
