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NIROGI Lanka - Phase 2 - NIROGI Maatha

National Initiative to Reinforce and Organize General diabetes care In Sri Lanka

NIROGI MAATHA - GESTATIONAL DIABETES CARE

Objectives

To initiate a national programme with cost-effective evidence based approach to gestational diabetes care through the Family Health Bureau

  • To initiate a comprehensive training program for capacity building of field staff on the management of GDM/DM during pregnancy in the country
  • To produce and disseminate IEC material on GDM/DM during pregnancy for patients and their families
  • To develop a nationally relevant low cost screening test for GDM in Sri Lanka by developing cut-off values of the 2hPPBS test in accordance with international criteria for universal application in the MCH service programme
  • To develop a centre of excellence for training and developing a long term package of follow up of diabetic mothers and babies

Justification

Gestational diabetes mellitus (GDM) is emerging as a common medical complication of pregnancy, with a parallel increase to the pandemic of DM. Currently GDM affects approximately 7% of all pregnancies and up to 14% of pregnancies in high-risk populations while pre-gestational DM is estimated to affect about 1.3%. The incidence of GDM in South India is reported to be 16.55%, while our own incidence in the community was 10.3% in 2003. A more comprehensive screening for GDM is planned to commence island wide in 2012.

In order to achieve better quality of care for pregnant women at risk of GDM and to ensure healthy offspring, the field staff (primary care) and hospital based staff (secondary and tertiary care) require a more focused capacity building to ensure a more conducive environment to deliver quality diabetes and cardiovascular care and for a more holistic, health promotion oriented maternal and child health care service. Further, unavailability of a proper screening test to identify GDM is a challenge for maternal care programme managers. Therefore, validation of a simple and low cost screening test is much in need. With more than 95% of pregnant women receiving their antenatal care from the government sector, it is envisaged that such screening incorporated into the existing MCH programme will ensure universal coverage and also enable accurate prevalence and pregnancy outcome data on gestational diabetes.

Project area

In conjunction with the Family Health Bureau (the main focal point of the Ministry of Health in managing MCH throughout the country

In order to achieve better quality of care for pregnant women at risk of GDM and to ensure healthy offspring, the field staff (primary care) and hospital based staff (secondary and tertiary care) require a more focused capacity building to ensure a more conducive environment to deliver quality diabetes and cardiovascular care and for a more holistic, health promotion oriented maternal and child health care service. Further, unavailability of a proper screening test to identify GDM is a challenge for maternal care programme managers. Therefore, validation of a simple and low cost screening test is much in need. With more than 95% of pregnant women receiving their antenatal care from the government sector, it is envisaged that such screening incorporated into the existing MCH programme will ensure universal coverage and also enable accurate prevalence and pregnancy outcome data on gestational diabetes.

Beneficiaries

  • MCH field staff in the state sector through the national coordinating centre (Family health Bureau) and childbearing female population of Sri Lanka
  • Pregnant women seeking antenatal services through the well planned state maternal and child health (MCH) system

Expected outcomes

To develop a centre of excellence for managing diabetes in pregnancy in long term

  • Capacity building of human and technical resources for screening, management and long term follow up of gestational diabetes at a national level
  • A national commitment to Universal Screening for GDM by Blood Glucose testing (as opposed to the existing method of testing random urine for reducing substances
  • Sensitize a life cycle approach to GDM – mother and baby long term follow up

Methods adopted

  • Development of a training module to train field staff on management of GDM/DM during pregnancy and training of field staff
    A group of experts on relevant fields (Diabetes and Endocrinology, medical education, curriculum development, public health) was identified and through a series of consultative meetings, a training module was developed under the following topics:
    • Burden of GDM worldwide, regionally and nationally
    • Clinical signs and symptoms and impact on pregnancy, infant, child and adulthood
    • Screening for GDM and confirmation
    • Management of GDM in the field setting
    • Management of GDM in the hospital setting
    • Follow up of a patient with GDM
    The module was pre tested and pilot tested, and revisions were done. The training module was translated into Sinhalese and Tamil languages, and printed in adequate numbers (1000 copies). In addition, a comprehensive document was prepared based on the training module to be used as a referral material for field health staff. This document was printed in adequate quantities (about 10,000 copies in three languages)

    Using the developed module, Training of Trainer (ToT) programmes was conducted. At least 5 trainers were identified from each district (cumulative of 150 trainers) and trained to cover whole country. In return, these trainers were expected to train the field health staff in the districts (i.e. approximately 6500 field staff).

    At the central level, a core group of resource persons were identified (from the resource persons participating for module development) which included Obstetricians, Physicians and Community physicians. This group trained a group of trainers from each district (5 from each district and Sri Lanka has 26 health districts, therefore ~150 trainers). The group from each district included an Obstetrician, physician and medical officers. In return these trainers will be expected to train the field health staff in the districts (i.e. approximately 6500 field staff). Medical Officers of Health facilitated the process to ensure that all the field staff members attached to each MOH area are oriented towards quality screening and care of GDM. The Hospital staff in an MOH area was also targeted.



    Field health staff consisted of medical officers, Public Health Nursing sisters and Public Health Midwives (~ 6500). National Practice Guidelines developed by the Ceylon College of Physicians on managing diabetes in 2007 have a component on GDM along these lines. This project and its outputs (evidence of outcomes on the developed algorithm) should effectively provide a forum for Ministry of Health to adopt a cost-effective approach to managing GDM.
  • Development and printing of the educational leaflets and flip charts on Diabetes during pregnancy and hypertension during pregnancy for patients and families
    A group of experts on relevant fields (diabetes and endocrinology, health education, curriculum development, public health) was identified for the development of educational leaflets for the public. The following topics were covered. - What is GDM/Hypertension during pregnancy? - Impact on the pregnancy and foetus - Signs and symptoms and danger signals - Emergency preparedness and response - Follow up after delivery The leaflets were pre tested and printing was done. At least 50, 000 leaflets were given to the pregnant women with DM or hypertension.
  • Identification of cut off value for 2h PPBS as a first contact screening tool for identifying those at risk of GDM in the Sri Lankan context
    After lengthy discussions, 2hr PBBS was identified as the initial screening test for GDM at antenatal booking in Sri Lanka. However, the Sri Lankan diet contains a large amount of fibre which has a direct impact on glucose absorption. Therefore, the conventional cut off values advocated by the WHO for 2h PPBS has limitations when used at field level. Therefore, a study was conducted to identify the optimal cut off values for this test. For this purpose, all pregnant women were screened at booking visit in the first trimester; if PPBS was more than 120mg/dl, 75g OGTT was carried out at a specialised unit; and all pregnant women with normal screening at booking underwent 75g OGTT at POA of 24-28 weeks in order to ensure universal screening for gestational diabetes at field level.


  • Developing a centre of excellence for maintaining a database of diabetic mothers and their offspring at Professorial Unit of De Soysa Hospital for Women (DSHW), Colombo
    There is insufficient awareness amongst the health care fraternity on the need for long term follow up of women with GDM, as their risks of developing chronic T2DM. Furthermore, little data exists to determine the proportion of women with previously undetected PGDM and its impact on foetal development and anomalies. Furthermore little data exists on the long term risks of obesity and metabolic disease among the offspring of diabetic mothers. Hence utilizing the services of the four trained DENOs at DSHW and under the supervision of diabetic physician and endocrine paediatrician (from the relevant departments of the Faculty of Medicine, Colombo) regular long term review of these mothers will be ensured. The existing services for pregnant women will be extended in this project with a more focused attention on long term problems and their solutions.

Impact assessment and evaluation

  • 325 Medical Officers of Health (MOH), 400 Public Health Nurses (PHN), 6700 field midwives (PHM) received appropriate training on the core subject of GDM and its importance and were enabled to deliver the necessary health education of women of reproductive age in Sri Lanka.
  • Training modules available for future training of MCH staff will ensure sustainability of project objectives
  • Universal screening of all pregnant mothers were done in 5 piloting MOH areas(Piliyandala, Pitakotte, Kaduwela,Hanwella, padukka)
  • Cohort study on follow up of mothers with GDM and their off springs were carried out at professorial unit at De soysa hospital for women

Key achievements

  • Developed a training module pack (linked to the practice guidelines) to train field staff on GDM at national level in collaboration with the Family Health Bureau
  • 1000 copies printed of the Training module to train field staff on management of GDM/diabetes during pregnancy
  • Capacity building of 6490 field staff on the core subject of Gestational Diabetes Mellitus & its importance (150 trainers, 325 MOHs, 45 PHNSs, 5757 PHMs and 213 SPHM) Training of 150 trainers of training programs conducted (4 sessions) 5757 public health midwives trained
  • Developed a national screening and management guideline through the Family Health Bureau with all stakeholders (professional bodies representing obstetrics, physicians, endocrinologists and GPs).
  • 2h PPBS test was tested for its suitability as an initial screening test for detecting GDM at booking visit in the first trimester through a population-based study of 1600 pregnant women in a defined suburban health area. 1600 mothers were screened for GDM using 2hPPBS in 1 MOH area in Gampaha district: (67 were non-respondents; 40 had PPBS >120; 4 had PPBS >200 mg/dl; 36 underwent OGTT before 16 weeks POA and 15 had abnormal OGTT). Of those eligible for OGTT at 24-28 weeks (n= 1381): 150 had GDM (10.86%). In total, 169 developed GDM before 28 weeks POA (12.07%).
  • Screened 15,000 for 2h PPBS as a first contact screening tool for identifying those at risk of GDM.
  • Developed a booklet on diet in all three languages for pregnant women especially for women with GDM or PGDM to be applied through the field midwives.
  • 10,000 educational booklet on Diabetes during pregnancy and hypertension during pregnancy for patients and families


  • Developed a centre of excellence for diabetic mothers and their offspring by upgrading the medical clinic at Professorial Unit of De Soyza Hospital for Women - Approx. 50-75 women with GDM per week attended to by 3 DENOs and 5 doctors. - Long term follow up of 312 mothers with GDM, PGDM and their baby pairs was initiated through consultant paediatrician conducted clinic for the babies where DENOs screen and advice mothers
  • Five piloting MOH areas (Padukka, Hanwalle, Pitakotte, Piliyandala and Kaduwela) sent returns of universal screening by DIPSI method (n= 3109)
  • Successfully developed a DVD in physical activities during pregnancy


Lessons learnt

  • Sustainability is very strong for universal screening and formal GDM related education through the standard island wide MCH programme with the Family Health Bureau as the national focal point.
  • For specific data collection of affected mothers and their offspring, DMH provides an ideal centre of excellence for all pregnant mothers with diabetes in pregnancy and GDM, where the project based development of a national management model is applied.

Technical group

  • Prof Chandrika Wijeyaratne (Professor in Reproductive Medicine, University of Colombo) - Coordinator
  • Dr Piyasena Samarakoon (Dep. Director General of Health-Medical Services I, Ministry of Health)
  • Dr Ananda Gunasekera (Dep. Director General of Health-Medical Services II, Ministry of Health)
  • Dr Jayasundera Bandara (Dep. Director General of Health-Education Training and Research, Ministry of Health)
  • Dr Deepthi Perera (Director, Family Health Bureau, Ministry of Health)
  • Dr Nilmini Hemachandra (National Programme Officer, Maternal Care, Family Health Bureau)
  • Dr Chitramalee de Silva (Consultant Community Physician, Maternal Health, Family Health Bureau)
  • Prof Shamya de Silva (Professor in Paediatrics, University of Colombo)
  • Dr Mahesh Harischandra (Consultant Physician, De Soyza Hospital for Women)
  • Dr Dhanapala Dissanayake (Consultant Physician, Castle Street Hospital for Women)
  • Dr Priyankara Jayawardhena (Consultant Physician, National Hospital of Sri lanka)
  • Prof Hemantha Senanayake (Professor in Obstetrics and Gynaecology, University of Colombo)
  • Dr Mahinda Rajapakse (Director, De Soyza Hospital for Women)