Where it all began: The Tamil Nadu gestational diabetes project

2009. It was called the first of its kind when in 2004, Dr. Seshiah’s Diabetes Care and Research Institute initiated a project to prevent and control gestational diabetes among women in rural and urban areas of Chennai in India. Besides support from WDF, the Health Department of the Government of Tamil Nadu partnered in from the beginning and supported the initiative. In 2007, the methods initiated by Dr. Seshiah were echoed throughout the state and screenings made compulsory for all pregnant women in the entire state of Tamil Nadu.

Creating documentation

The motivation for initiating the project on gestational diabetes was to collect data and verify the situation. Without proper data, health professionals only had assumptions to work from. Dr. Madhuri S. Balaji, endocrinologist and member of the project team, explains: “We wanted to establish a surveillance system to determine the incidence rate of gestational diabetes among pregnant mothers in the project area. And we wanted to use the results to evaluate the public health measures to determine the success of the intervention methods.”

Both objectives have been met to such a degree that this project is often cited in international journals for establishing screenings for gestational diabetes; for the high prevalence rate found; and for the important work with prevention and lifestyle modifications among the pregnant women.

Alarmingly high prevalence rate

Compared to an estimated global prevalence of gestational diabetes between 3 and 15%, the findings among 12,056 women screened in rural, semi-urban and urban areas around Chennai were all in the higher end of the scale. The highest prevalence was found in an urban environment with 17.8%, followed by 13.8% in a semi-urban environment and 9.9% in a rural area. The determination of the alarmingly high incidence rate documented the need for establishing screening and follow-up procedures for pregnant women in the state.

Fortunately, the government of Tamil Nadu recognises diabetes as a serious health problem. The evidence and screening methods used by Dr. Seshiah’s team convinced the government of Tamil Nadu to issue an order that effective from 2008, mandatory screening for GDM in all antenatal women should be offered free of charge at all 1,417 public health clinics in the state, covering a female population of 33 million. Furthermore, the government has sanctioned 3,000 Rupees (USD 75) to each woman before and after delivery to ensure adequate nutrition and support in this important period.

Better delivery and healthier babies

One of the risks of untreated gestational diabetes is abnormal birth weight of the baby. A birth weight below 2.5 kg is referred to as Small for Gestational Age (SGA) and a birth weight above 3.5 kg is referred to as Large for Gestational Age (LGA), or macrosomia. The latter is known to cause shoulder dystocia and related birth injuries for both mother and the newborn, and reducing the number of large babies is therefore equal to reducing birth injuries. Both SGA and LGA babies have higher risks of morbidity and mortality as well as future risk of diabetes, hypertension, heart disease and strokes.

National Health Surveys conducted in the entire state of Tamil Nadu showed that 17% of babies were born with low birth weight and 19% as big babies. In comparison, among the 8,731 pregnant women followed-up upon in the project, only 10% of the babies were born with low birth weight and 7% were born as large babies. “This is a significant reduction,” says Dr. Madhuri S. Balaji who has worked closely with the women since the beginning of the project. “For me as a clinician, the biggest change has been the reduction in numbers of large babies. It has been very gratifying to see an immediate result for the women and know that the service we provide – and which is now provided for all women – is a good service for the mother,” she says.

A call from the community

As an integral part of the project, pregnant women and women ranging from adolescent girls to elderly women in selected urban and rural communities have been informed about GDM symptoms, risk factors and complications through posters, public announcements and awareness campaigns. In many villages in India, illiteracy is widespread, calling for a unique approach in reaching out to the target group. The project team has mobilised and established self-help groups consisting of volunteers from the local communities who reach out to the populations in live street plays and mobile public announcements through loudspeakers or megaphones attached to auto rickshaws. All the awareness activities have directly encouraged women to show up for free screening at the participating health posts.

The training of health care personnel included all levels from medical professionals at the primary health centres to health nurses, health educators and women’s self help groups to ensure contact to families and community. Fortunately, a lot of encouragement also came from the village heads, the Health Department of the Government of Tamil Nadu and several others involved at various levels when they started noticing the positive impact of the project. The villagers and their heads were very pleased to note that the women benefited from the project. 

Better health now and in the future

Project Coordinator at the World Diabetes Foundation, Mr. Ulrik Uldall Nielsen is proud of  the Foundation’s support to such an important project. “We look upon this project as the flagship project within gestational diabetes, because it was the first endavour for us to support, but more importantly because it has had such an immediate and positive impact,” he says. As of August 2008, the project entered a second phase which runs for three additional years. “The extension goes hand in hand with the Tamil Nadu Government decision to make screening for gestational diabetes compulsory throughout the state. Our support is targeted at training the health care personnel who work in the primary health care facilities where the women are screened,” he explains.

While improved health is the immediate and measurable result of the project, the awareness work done in the communities also seems to bear fruit. According to Dr. Madhuri S. Balaji, the project has empowered women to take action with their own and their families’ lives when it comes to nutrition and health. These women have changed their attitude towards general health and wellbeing which may prevent them from developing diabetes and non-communicable diseases in the long term.  

Dr. Madhuri S. Balaji is very content with the project impact: “This project helped us to educate not only ante-natal mothers but also their entire family to make sensible changes in order to improve their diet and lifestyle. A large number of ante natal mothers benefitted from this project. Most of all, the satisfaction gained when treating an ante-natal mother and seeing her deliver a healthy baby finally, is incomparable. We are proud that this project helped us to touch the lives of so many unborn children and their mothers. With every normal delivery without any complications, our joy and satisfaction grew,” she says with her happy smile.

Project Director Dr. V Seshiah is pleased with recent developments. The Ministry of Health of the Government of India has called for a meeting in late October 2009 where key officials from state and central ministries of health nationwide will meet to discuss a diabetes prevention program focusing on gestational diabetes. He has been invited to coordinate the activities. In addition the Committee of Medical Disorders in Pregnancy of the Federation of Obstetrics and Gynecology Society of India [FOGSI], actively participated in preparing the guidelines for gestational diabetes which were released in June this year. Also a national training program to train the trainers on the guidelines was initiated. “Years of hard work to get attention about the problem is finally bearing fruit and there is good reason to be pleased”, says Dr. Anil Kapur, Managing Director of  the World Diabetes Foundation who has worked closely with Dr. Seshiah for many years.

Article written in 2009