Post-Partum Screening of Gestational Diabetes: Opportunities for Integration with Existing Public Health.

Sir,

India has an extensive network of public healthcare centers, spread over the country. Concerted efforts by the government have helped the country achieve significant progress in the field of public health. The eradication of smallpox, guinea worm, and polio are a few examples of success in infectious disease control which have been achieved in recent decades.

India now faces new challenges in the form of non-communicable diseases (NCDs), such as diabetes mellitus.(1) Various national programs have been rolled out to detect, prevent, manage, and limit the negative impact of these diseases.(2) NCD control, though, is a different ball game. Infectious diseases are characterized by an acute, monophasic course, and are usually amenable to prevention and cure. NCDs are chronic and indolent, associated with suboptimal lifestyle, and often cannot be cured. Long-term follow-up, including investigations and management, are needed for effective control.

It makes sense, however, for a resource-constrained nation, such as India, to integrate NCD control programs with existing systems for acute illness prevention and management. The Indian Public Health Standards (2012) acknowledge this in their recommendations for various levels of healthcare facilities.(3) Utilization of pre-existing systems not only improves cost-efficiency but also enhances acceptance of NCD control measures by healthcare professionals, and by members of the public.

Post-partum screening (PPS) of women with gestational diabetes mellitus (GDM) is an important strategy for prevention of diabetes. Effective PPS is able to detect diabetes in a high risk cohort at an early stage, allow timely institution of lifestyle measures and pharmacological therapy, and prevent or delay onset of complications due to poor glycemic control.(4) This, however, is easier said than done. One-third of the women with type 2 diabetes mellitus have history of gestational diabetes mellitus. The conversion rates are high and occurs early particularly in Indians.(5) Therefore, the window of opportunity as well as action is narrow for Indian women. As per recommendations by American Diabetes Association, women with GDM should be screened after 6 weeks of post-partum for persistent dysglycemia. Woman with normal oral glucose tolerance test (OGTT) can be screened every 3 years, and with impaired OGTT, annually. However, current evidence shows that PPS rates are below optimal levels, not only in India but also in developed countries as well.(6)

Various methods have been utilized to improve the follow up of women with GDM.(67) However, these resource-intensive strategies cannot be replicated on a mass scale, especially in resource-poor countries.

There is a need, therefore, to integrate PPS and motivational strategies for PPS, in the existing healthcare system. Thankfully, such opportunities for integration do exist [Table 1]. Table 1 lists various windows of opportunity, available in standard Indian obstetric and pediatric care,(3) which can be used to promote PPS. PPS can easily be integrated in existing national health programmes, instead of creating a new scheme for it. Facilities (glucose testing, trained healthcare workers) required to carry out PPS exist from primary health centers onwards. The woman should be asked, and her discharge card should be checked, whether she had gestational diabetes during pregnancy. Seventy-five gram OGTT is the gold standard test which is recommended for diagnosis. However, fasting plasma glucose can be done by venipuncture, if OGTT is not feasible. Though we have based this discussion upon the Indian health system, other countries offer similar opportunities for patient-provider contact, in which PPS can easily be included.

Table 1

Windows of opportunity