02. Feb 2016

Thesis explores diabetes in pregnancy in Tamil Nadu

Gwendolyn Carleton
Despite the growing burden of diabetes related to pregnancy, evidence is lacking on how to implement and improve gestational diabetes services in developing countries, research finds.
Women at a gestational diabetes (GDM) screening in Tamil Nadu. New research investigates GDM services and hyperglycaemia in pregnancy in the south Indian state. Photo by Anders Kristensen.
On 29 January, Karoline Kragelund Nielsen explained the genesis of her PhD research topic to an audience of about 75 academics and colleagues at the University of Copenhagen’s Faculty of Health and Medical Sciences.
“Almost five years ago, I was doing a qualitative research study for the WDF, interviewing project partners implementing gestational diabetes projects in low and middle income countries,” she said. 
“The partners indicated lot of barriers to implementing GDM services. But there wasn’t a lot of information available. That was the beginning.”
The end was on display Friday, when Ms. Nielsen defended her thesis Screening for Gestational Diabetes Mellitus in Tamil Nadu, India – Determinants, Risks and Services.
The research objective was to examine the factors influencing GDM services, particularly the screening process, and the risk factors for developing hyperglycaemia in pregnancy. Ms. Nielsen chose to focus on pregnant women in Tamil Nadu, India, because of large number of women who die or are injured during childbirth in India, and because Tamil Nadu was the first state in India to introduce universal screening for GDM, she said.
Evidence still lacking
Ms. Nielsen’s research employed a systematic literature review, qualitative data collected in Tamil Nadu, and epidemiological data from pregnant women in Tamil Nadu.
“By combining different methods, it was possible to gain a richer and more holistic understanding of GDM services, particularly screening and diagnosis,” she said.
She explored three research questions:
1) What are the known determinants and barriers to GDM care and services in high, middle and low income countries? 
2) What factors hinder and promote timely initiation and completion of the GDM screening and diagnosis process in Tamil Nadu? 
3) What is the role of socio-economic factors (income and education) as well as more traditional risk factors for hypertension in pregnancy, and can any single or accumulated risk factor(s) be used to predict hyperglycaemic status among women attending GDM screening in Tamil Nadu? 
Her conclusion: 
- Despite the growing burden of diabetes related to pregnancy, evidence is lacking on how to implement and improve GDM services, particularly screening, and especially from low and middle income countries. 
- Pregnant women in Tamil Nadu are in general highly motivated to attend the GDM screening – which is reinforced by a strong social pressure for securing a healthy next generation of the family. Yet, completing the screening process requires a lot of ‘doing’ and there are several factors both within and outside the health system that influence the completion of the process.  
- Having two parents or a mother only with diabetes, age, and BMI were identified as risk factors for developing hyperglycaemia in pregnancy in the population. However, none were particularly good at discriminating between those with and without hyperglycaemia in pregnancy. 
- The finding that doubling income was associated with increasing risk at a rural healthcare centre, but not in two semi-urban centres, together with the finding that maternal but not paternal diabetes alone increased the risk, highlights the potential importance of socio-economic status and intergenerational impact in hyperglycaemia in pregnancy.
Ms. Nielsen’s thesis advisors were Prof. Ib Christian Bygbjerg, Prof. Peter Damm and Dr. Anil Kapur. At the end of her defence, she was awarded with her doctorate in Public Health.
The thesis was funded by the World Diabetes Foundation, the University of Copenhagen, and several other donors. It is based on three studies, one currently published in BMC Pregnancy and Childbirth and two in review. Once all three studies are published, the thesis will also be published online. 
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