Phase II

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PROJECTS

Supporting Uttar Pradesh state NCD response: Maternal care and diabetes in the public health system. Phase 2:WDF15-951.

OBJECTIVES

The goal of this project is to improve detection and management of gestational diabetes by building capacity in the public health system, whereby the area of NCD prevention anc area shall become closer integrated with maternal care/RCH.

APPROACH

This project will be implemented by Jain Hospital and MAhavir Shikshan Sansthan, in collaboration with the Ministry of Health & Family Welfare of the government of Uttar Pradesh and NHM, India, and under the framework of a MoU between Jain Hospital and the National Rural Health Mission of Uttar Pradesh State (NRHM), a federal level programme implemented in all states of India.
The WDF support towards the programme consists of phase 1 which has been completed (WDF grant ref WDF12-678) and phase 2 (WDF grant ref WDF15-951, from october 2016 to september 2019).

PHASE II

Goal: The Project seeks to create awareness, screening, Prevention, control and management of Gestational diabetes mellitus (GDM) and to build Technical expertise, knowledge and skills in the Government Public health care delivery system, to Develop capacity, Technical Manpower ,Training of HCPs & to implement State GDM surveillance in all 28 Districts & therefore reduce Complication of GDM ,outcome of Pregnancy ,prevent and control diabetes in future generation.

Objectivies:

  • Total of 300,000 Pregnant women screened for gestational diabetes, Diagnosing around (14%) 42,000 GDM women & 30,000 at Risk for GDM (10%) in Urban, Periurban and rural in 28 Districts, all GDM & at Risk were given adviced about Lifestyle and Diet and Diabetes Diagnosed treated with Insulin including OHA.
  • 1237 health care facilities NCD (Non Communicable Disease) clinic for Women & (MCH-Maternal child health Clinic) were upgraded for GDM Diagnosing, Prevention & Control with the aim to Management in 28 Districts of Uttar Pradesh.
  • Project Trained 3000 Doctors and 6000 ANM,GNM & staff Nurse in 2 days of Training involving HCPs from 1237 Public health facilities in 28 Districts of Uttar Pradesh ..
  • 456 Districts Workshop conducted in 28 Districts.

Target group(s):

Intended project results

  •  300,000 Screening of Pregnant women in Govt. PHC(Primary health Center)/CHC(Community health centre)/Urban health centre/Dist Hospital to be completed and routine part of ANC at 12-16,24-28 wks(Two Screening) and Post Partum Screening after delivery.
  • NCD Clinic for Women & MCH Clinic at CHCs, UHC (Urban health Centre), PHCs and Districts Hospitals (1237 health facilities) Upgraded for GDM Screening in 28 Districts.
  • An estimated 3,000 Doctors & 6,0,00 ANM, GNM ,health care staff, including doctors, nurses, dieticians and extension educators trained directly or indirectly on symptoms, treatment and preventive/control measures/Management of Gestational Diabetes.
  • 2 State level Workshop and 56 District level workshop in 28 Districts one each year for 2 year conducted.

Planned activities to reach objectives:

All the CHCs,UHC,PHCs and District hospitals male and female is our screening Centre, supplied with glucometer, strips,lancets,spirit swab,75 gm Glucose Packets,Paper Glass, Format s,Register, Diet chart and exercise schedule etc , Everything to Patients or Person with Diabetes is free of cost and supplied by State under NRHM & State Budget sectioned. WDF to support for Training of HCPs, State and District workshops, monitoring, evaluation etc.

  • 0.3 million pregnant women screened and Diagnosed 42,000 GDM of 28 Districts and received at least 1 follow up monitoring of blood sugar, Post prandial in 90% cases during pregnancy and Postpartum screening after 6 weeks of delivery to All Pregnant detected for GDM( OGTT 75 gm Glucose, 2 hr>=140 Mg/dl diagnostic for GDM in Pregnancy & Postpartum Criteria as per Type II Diabetes in Non Pregnant Women. Diagnosing & screening gestational diabetes during 12-16 and 24-28 wks of Pregnancy,after Diagnosis & identifying high risk for GDM and post delivery Diabetes following intervention like medical nutrition therapy(MNT),Exercise, MNT+ insulin Titration and at least one follow up to be insured for better pregnancy outcome. DIPSI Guidelines will be followed for Diagnosing GDM (Govt GDM Guidelines 2014). Diagnosing GDM single step WHO test with 75 gm of Glucose ingestion Post 2 hr blood glucose value =>140 mg% will diagnose Pregnant women as GDM(National guidelines GOI). Post partum screening of Post delivery women after 6 weeks to be insured in Immunization clinic with the Immunization card or at MCH clinic.
  • All the 1237 health care facilities upgraded for GDM Screening and management gradually in 3 years which will include PHCs(Primary health centre),CHCs(Community health Centre),UHC(Urban health Centre) and District hospital of 28 Districts..
  • 3000 Doctors and 6000 Nurses from 1237 health care facilities from Public system given 2 days trainings through 100 trainers trained at TOT.100 Trainers trained from 28 Districts trained by National level master trainers under TOT in Two places at Capital Lucknow and Agra , this will be full day training from 9 AM to 8 PM. IDF curricula for training taken as standard,National level Trainers from across the nation called for, who have more than 20 years experience and worked at national & International level in Diabetes. National Trainers includes in all segment of Gestational Diabetes called & other type of Diabetes
  • 2 states Workshop at the state headquarter involving keys health officials and 28 Districts Chief Medical officers(CMO) included each workshop in one year conducted. Districts Workshop in 28 Districts headquarter each year conducted including Doctors from Community health Centres(CHCs), Urban health centre(UHC)and Districts hospitals .


This Project is for 3 years implemented in 28 district comprising 125 million population (58% Population of state)including 75% Population in Rural Area and state planed to Implement in 28 districts and then accelerate to all the 75 Districts of state by 2018 ,Nov under NRHM of Govt of India..

Presently Project Implementation Plan with Govt .

GDM : total of 300,000 Pregnant women screened for gestational diabetes, Diagnosing around assuming (14%) GDM, 42,000 GDM women received follow up and treatment,42,000 Diagnosed GDM and at least one follow up to All patients detected for GDM ( OGTT 2 hr 75 Glucose test as per DIPSI Guidelines(Govt of India Guidelines for Gestational Diabetes,2014>=140 Mg/dl and High Risk GDM(where BSPP after 2 hr >120 mg/dl- <140 mg/dl).all the Pregnant women attending Antenatal Clinic(MCH clinic)in PHCs,CHCs,UHCs and District hospitals screened for GDM after 2 hour of taking 75 gm of Glucose irrespective of fasting in OPDs on all working days .

GDM

Protocol for investigation:

Intended project results

  1. Testing for GDM is recommended twice during ANC.The first testing should be done during first antenatal contact as early as possible in pregnancy.
  2. The second testing should be done during 24-28 weeks of pregnancy if the first test is negative
    There should be at least 4 weeks gap between the two tests.
  3. The test is to be conducted for all PW even if she comes late in pregnancy for ANC at the time of first contact.
    If she presents beyond 28 weeks of pregnancy, only one test is to be done at the first point of contact.
    If the test is positive at any point, protocol of management should be followed as given in this guideline.
    At M C (Maternal clinic/DH(District hospital/other Centres, availability of glucometer must be ensured at all ANC clinics with facility for collection of sample and interpretation of result there itself (by training of personnel).

At all other facilities upto PHC level, there should be an in-house arrangement for conducting the test & giving report immediately so that necessary advice can be given on the same day by the treating doctor.

Methodology: Test for diagnosis:

Single step testing using 75 g oral glucose & measuring plasma glucose 2 hour after ingestion.
75g glucose is to be given orally after dissolving in approximately 300ml water whether the PW comes in fasting or non-fasting state, irrespective of the last meal. The intake of the solution has to becompleted within 5 min. Test (OGTT) is to conducted two times during 14-16 and 24-28 weeks of Gestation. If the Pregnant women comes Ist times after 28 wks for ANC check up, test to be conducted to know the status of GDM.
National Guidelines for Diagnosis & Management of Gestational Diabetes Mellitus:
A plasma standardised glucometer should be used to evaluate blood glucose 2 hours after the oral glucose load.If vomiting occurs within 30 min of oral glucose intake, the test has to be repeated the next day, if vomiting occurs after 30 minutes, the test continues. The threshold plasma glucose level of ≥140 mg/dL (more than or equal to 140) is taken as cut off for diagnosis of GDM.

Intended project results

  1. For this programme, it has been decided that a plasma calibrated glucometer should be used for diagnosis of GDM instead of a semiauto- analyser or auto-analyser or any other testing methodology as it may lead to delay in getting the results immediately.
  2. Since it will be difficult for PW to come another day just to collect the result, testing facility with a glucometer should be available at all facilities in the ANC clinic itself. This facilitates getting the result immediately so that necessary advice may be given the same day.
  3. A glucometer should also be available in the labour room for close monitoring of GDM cases during labour.
  4. Calibration of Glucometer recommended after 20 measurements using calibration test strips, provided with glucometers.

Methodology: Test for diagnosis:

All PW who test positive for GDM for the first time should be started on Medical Nutrition Therapy (MNT) for 2 weeks.After 2 weeks on MNT, a 2 hrs PPPG (post meal) should be done.niversal testing for GDMThus, GDM is managed initially with MNT and if it is not controlled with MNT, insulin therapy is added to the MNT.

Mediacal Management

Insulin

Post Partum Screening for Diabetes after 6 weeks of delivery to be done in Immunization clinic or MCH clinic, both the facility link through training of staff,this is mandatory for GDM,Post Prandial Blood sugar is to be done and diagnosed Type II Diabetes if blood sugar >=200 mg/dl and treated for Type II diabetes in NCD clinic.

Post Partum follow up of Pregnant Women with GDM

  • Immediate postpartum care women with GDM is not different from women without GDM but these women are at high risk to develop Type 2 Diabetes mellitus in future.
  • Maternal glucose levels usually return to normal after delivery.Nevertheless, a FPG & 2 hr PPPG is performed on the 3rd day of delivery at the place of delivery. For this reason, GDM cases are not discharged after 48 hours unlike other normal PNC cases.
  • Subsequently, ANM to perform 75 g GTT at 6 weeks postpartum to evaluate glycemic status of woman.
  • Cut offs for normal blood glucose values are:
  1. Fasting plasma glucose: ≥ 126 mg/dl
  2. 75 g OGTT 2 hour plasma glucose
  3. Normal: 140 mg/dl
  4. IGT: 140-199mg/dl
  5. Type II Diabetes: ≥ 200 mg/dl
  6. Test normal: Woman is counselled about lifestyle modifications, weight monitoring & exercise.
  7. Test positive: Woman advised to consult a physician/NCD Clinic.
  8. PW with GDM and their offsprings are at increased risk of developing.
    Type II Diabetes mellitus in later life. They should be counselled for healthy lifestyle and behaviour, particularly role of diet & exercise.
  9. GDM should be a part of NCD (Non communicable Disease) programme.

Health Facility upgraded for Gestational Diabetes:

1237 Health care facilities including 34 Districts hospitals,432 CHCs(Community health cantre) and 771 PHCs(Primary health Centre) upgraded for GDM screening, Treatment and Management, Districts hospitals and CHCs have adequate Infrastructure logistic, manpower for Diabetes Treatment and Management ,771 PHCs in 28 Districts upgraded for Gestational Diabetes Screening and Treatment with Support and grant sanctioned under NRHM funds to state, SPMU(State Project Management unit) have agreed to Implement Diabetes Programme in all these centres and agreed to support with trained manpower and Logistics.
Treatment of all the Patients Diagnosed with GDM is free of cost and Medicine & Insulin supplied through all such facilities.

Training of HCPs:

  • 10 National level trainers selected, trainer from different Part of country ,selected from Govt and Private Institutions who had experience more than 20 yrs in Diabetes and GDM with National & internationally Proven work in Diabetes,one of our expert will be a Certified Diabetes Educator(CDE) who has worked more then 10 years in Diabetes Education. Other expert Communication for behaviour change in health of National level called for, Scheduled at places of state Capital lucknow and Agra,in uttar Pradesh.
  •  100 District level(3-5 District level Trainer selected from private and Govt sector from each district) trainer trained in 1 full day training at each place lucknow and Agra in Batches of 50 trainers. All the aspect of Gestational Diabetes covered as per IDF Module for Gestational Diabetes and Indian Guidelines recently Introduced by Govt,India 2014
  •  IDF 6th Edition 12 Training Module will be used as standard of care. 6 Diabetes Module for training prepared including GDM.These 3-5 Doctors received Training in TOT will take training in their respective districts atleast one Obstetrician included as trainer, in case of small Districts,Trainer from adjacent district can manage.Expenses for transportation and per diem will be provided to trainer.
  •  3,000 Doctors and 6,000 Para Medical Professonal trained in 3 years in batches of 25 Doctors and 40 Para Medical batches, therefore 120 batches of Doctors and 150 batches of Paramedics (ANM, Nurses, GNM) trained in 2 Days training in 3 years. All the Training conducted in District hospital and CHCs (Community health Centre) in a Training hall.
  •  120 Batches of 25 Doctors each with 2days trainings and 150 Batches of Paramedical with 2 days training 40 participant per batch conducted in 3 years.
  •  Each participants received 2 Days of training consecutive days ,each full day 6 hours from 10 AM to 5 PM including 1 hour lunch, Perdiem for Participants to attend Training given.Training given by Trainer trained at TOT by State trainers, at least 2 Trainers conducted training each day.
  •  Whole day training session evaluated by Trainer through 20 Question (MCQ) each day. 

New Training Materials

  • for Education of ASHA/ANM/Paramedical GDM Manual developed for GDM Education in local hindi language from IDF(International Diabetes Federation) Module for health educator 2012 & Gestational Diabetes.
  •  Diabetes Self management Education(DSME) Manual Prepared as per IDF Guidelines For Education of Diabetes & Gestational Diabetes patients, 2012.
  •  Training Module for health care Professional IDF 2012 Module taken as Gold standard for education of Doctors & Paramedical staff for training Purpose with changes done according to local conditions.
  •  A Manual for Doctors developed on Gestational diabetes covering all the aspect of Gestational diabetes including Govt of India Guidelines,2014 with Expert from diabetes & FOGSI(National level Gyanecologist).
  •  IDF published “Peer Leader Training Manual” for training for health professionals used.
  •  IDF 2014 Atlas 6th updated Edition covered to highlight the status of Diabetes in Globe & Gestational Diabetes Prevalence of gestational Diabetes Highlighted.

Workshops:

  • 2 State Workshops at State conducted under the Chairmanship of NRHM Mission Director and Principal Secretary ,Ministry of health & family Welfare,Govt of Uttar Pradesh, Ist Workshop Where the Project will be Inaugurated officially by our Chief Guest Chief Minister of Uttar Pradesh Mr Akhilesh Yadav as Discussed with Special Secretary to Chief Minister ,All the SPMU officials ,consultants(State Project Management Unit officials around 100,Director General Medical health,CMO(Chief Medical officer) of 28 Districts and National,International NGOs state coordinator attended the workshop, A full day workshop from 10 AM to 5 PM with Speakers from state NCD cell . It will be Mini Conference bringing NGOs, Private hospitals and Govt top health planer in one place every year in capital including Diabetologist, Gynaecologist and top physician to chalk out plan for diabetes.
  •  District Diabetes Workshop organized under the Chairmanship of DM (District Magistrate) in all 28 Districts in a year, where all the Govt health officials,Members of District health society and Key Govt Functionaries like CDO(Community Development officer,CDPO(child development Project officer under ICDS (intergrated child development scheme, SDM (subdivisional megistrate),CMO,,ACMOs,Commissoner, NGOs like Care,UNICEF,Rotary,WHO,local NGO,PRI (panchati raj institution member,Civil defence head invited,conducted 2 hrs workshop where Diabetes Epidemic and project activities discussed in details.

One District Workshop planned with media personnel from print and Audio-visual conducted to brief them about this programme from the leading newpaper and channels. Local NGO’s,IMA,FOGSI,Physician forum and various professional bodies sensitised about the programme.Local channel,state regional channels used for Diabetes Awareness and publicity.

Camps:

Community camps have the key to success of this whole project as during Community Camps ASHAS instrumental in bringing ANC for Screening of GDM during these camps nearby community brought wide publicity and awareness masses about Diabetes and Prediabetes, we registered our large number of ANC during these camps, which is complete check ups of ANC women by Govt Obstetrician, as location of camps is nearby accessible area where health facility is nonexistent, ASHA(Accredited Social health activist) which is available for 1000 population under NRHM(national rural health scheme of GOI) brought them in camps in huge numbers,camps organised with the help of Govt health Functionaries (funds for the camps provided by Rogi Kalyan Samiti under NRHM).1350 Camps 48 camps in each Districts conducted in 28 Districts,14-16 camps in each District in a year conducted in remote area for Diabetes for awareness and Community reach.In urban Areas this includes slums and underprivileged area where govt health functionaries are non functional but NGOs are active. Field Community Camps screening is random and difficult to diagnose,its is part of Awareness so that these Patients if suspected can be called for Screening in nearest health care facilities.

Monitering:

Project hired 16 temporary Field Block Monitors in 28 Districts supervised and Monitored Diabetes Screening and Training of HCPs, Monitors appointed with Minimum qualification BSc and Previous experience of working with reputed NGOs in the same District Monitored. One monitor allotted 1-2 Districts, One monitor for Big District and 2 Districts in case of small districts.
One monitor allotted 1-2 Districts, One monitor for Big District and 2 Districts in case of small districts

IEC:

  • The Population based awareness Campaign Introduced and Message tested before target group before mass Dissemination; then posters, handbills,Banners, pamphlets and stickers produced and Print media,FM radio,local channel used to Propagate the messages.
  •  IEC achieved in 11183 Subcentre areas through distribution of Posters,hand bills and Palmplets by 60,000 ASHAs Sensitised for Diabetes in their monthly meeting at CHCs. IEC is the Part of Govt Budget for NCD.
  • Expert agencies liasoned with Project Nodal person for the mass Publicity, National , International local NGOs like Unicef, Care,Rotary, Govt Health system involved.
  • National Importance of Programme: Our“Capacity Building for Gestational Diabetes Prevention & Control in Public health System” is 100% with State Govt health functionaries(SPMU) supported by grant under NRHM of “Ministry of health and family Welfare, Govt of India a Project of National Importance, MOU approved and recommended by Executive Committee, NRHM in its Meeting on 08.07.2015.
TARGET GROUP(S):

Gestational Diabetes: All the Pregnant women attending ANC clinic:first visit 14-16 weeks ,second times in 24-28 weeks , Post Partum Women Glucose Screening after 6 Wks of Delivery.

Beneficiaries:

  1. All the Pregnant women attending ANC check up.
  2. Gestational Diabetes Pregnant Women and foetus.
  3. Post Partum Screening (Post delivery Women after 6 weeks) gone under Post Prandial or OGTT test.
  • 80% Population BPL(Below Poverty line) goes to Public health care facilities because of poverty,its is important that all the BPL which constitute 75% of our Population in Uttar Pradesh gets free facilities for Diabetes Screening and Management under this Programme.All the OHA and Insulin is available in Govt Health care facilities under NRHM(Project Implementation Plan) and treatment initiated by Consulting Physician and Obstetrician in health care facility.
  • Our Project WDF-12-678 has shown that low birth is 35% in GDM compare with 14% in Non GDM, control of Blood sugar is key for prevention of LBW babies(LBW is a big Problem in poorest state of Uttar Pradesh).
  • GDM poses a risk to mother and child. Our Target is to safeguard outcome of Pregnancy which is translated into reduction in Prenatal & IMR and Prevention and Control of Diabetes after pregnancy in mother and infant both and further control of Diabetes in women& new generation.
  • The risk is largely related to high blood glucose levels and its consequences. The risk increases with higher blood glucose levels, Treatment resulting in better control of these levels can reduce some of the risks of GDM considerably.
  • GDM poses a risk to mother and child. Our Target is to safeguard outcome of Pregnancy which is translated into reduction in Prenatal & IMR and Prevention and Control of Diabetes after pregnancy in mother and infant both and further control of Diabetes in women& new generation.