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More Sanitation, Literacy = Fewer Anaemic, Pregnant Women

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The proportion of anaemic, pregnant women dropped 12 percentage points over a decade to 2015, government health data show, but India still has more anaemic women than any other country and a prevalence rate above the global average.

All 14 states surveyed for the National Family Health Survey 2015-16 (NFHS-4) showed a decline in anaemic, pregnant women, the proportion dropping to 45 per cent from 57 per cent a decade ago.

The decline in anaemia among pregnant women (15 to 49 years) is correlated with improved sanitation and female education, according to an IndiaSpend analysis of NFHS-4 data. An anaemic, pregnant woman is more likely to die or deliver a baby lighter than normal, increasing chances of the infant's death.

In 2011, 54 per cent of pregnant women in India were anaemic, worse than Pakistan (50 per cent), Bangladesh (48 per cent), Nepal (44 per cent), Thailand (30 per cent), Iran (26 per cent), Sri Lanka (25 per cent), and Vietnam (23 per cent), according to World Health Organisation (WHO) data. The trends suggest that, in 2015, India was still doing worse than neighbouring countries, even relatively poorer ones.

Mainly caused by blood loss, anaemia results from the lack of healthy, red blood cells or haemoglobin, a protein that binds oxygen. Common symptoms include light-headedness and fatigue.

The largest decline in the 14 states surveyed was reported in the north-eastern state of Sikkim -- a decline of 39 percentage points over a decade; 24 per cent of pregnant women are now anaemic in Sikkim. The state was the third in the use of improved sanitation in 2014-15 and reported the second-largest increase in female literacy over 10 years from 2005-06 to 2014-15.

The eastern state of Bihar had the largest proportion of pregnant, anaemic women (58 per cent); it also had the lowest literacy rate and improvement in sanitation, according to NFHS-4 data. In 2005, five states had a greater proportion of pregnant, anaemic women than Bihar, which has now displaced Assam to occupy the top spot after improvements in other states. The decline in Bihar was two percentage points over the decade to 2015.

Bihar is followed by Madhya Pradesh and Haryana, both with 55 per cent of pregnant women anaemic.

At the other end, Sikkim is followed by Manipur (26 per cent) and Goa (27 per cent).

"The government should implement the universal Rs 6,000 cash transfer to pregnant women that was legislated by the 2013 National Food Security Act," Diane Coffey, visiting researcher at the Indian Statistical Institute, Delhi, told IndiaSpend. The money was supposed to allow pregnant women to access an "adequate quantity of quality food", as stated in the Act, hopefully leading to more nutrition in the diet.

The 14 states surveyed also witnessed a 20 percentage-point increase in households using improved sanitation facilities, according to NFHS-4 data -- toilets connected to a sewer system, septic tank, pit latrine, ventilated improved pit/biogas latrine, pit latrine with slab, or twin pit/composting toilet not shared with other households. These facilities are now used in 57 per cent of homes, up from 37 per cent a decade ago.

Only 25 per cent households feature these improvements in Bihar, a 10 percentage-point increase since they were surveyed in 2005-06, but lowest among all states.

Madhya Pradesh, with 34 per cent households using improved facilities, is the next worst state for sanitation improvements, as it is with anaemia. Assam is the third worst, with only 48 per cent households using improved sanitation facilities.

Poor sanitation can lead to environmental enteropathy, an intestinal disease preventing people from absorbing nutrition in their food, a cause of anaemia, according to this 2014 study. The intestinal disease is caused by exposure to faecal pathogens that result from poor sanitation.

Up to 88 per cent of households now use improved sanitation in Sikkim. Haryana saw the largest increase (39 percentage points) of households with improved sanitation.

Despite the increased usage of improved sanitation facilities, open defecation is still relatively high. As many as 54 per cent Indians defecate in the open, according to Census 2011. The open-defecation rate was 35.5 per cent in Nepal and 4.6 per cent in Bangladesh, poorer developing countries, the same year.

Open defecation, argued Coffey, can lead to both environmental enteropathy and worms, closely linked to anaemia.

"The government should invest in teaching rural people about how affordable latrines work, and convincing people to use them, rather than simply building the kinds of latrines that rural people don't want because they are concerned about pit emptying, a task they believe only untouchables can do," Coffey said.

As many as 76 per cent of Indian women are now literate, and the 14 states surveyed witnessed a 12 percentage-point average increase in female literacy.

Half of Bihar's women can now read and write, a 13 percentage-point increase over a decade. No more than 59 per cent of women are literate in Madhya Pradesh, making it the state with the second-worst female literacy rate. This is in spite of a 15 percentage-point increase in female literacy, the largest increase reported, alongside Haryana.

As many as 89 per cent of women are now literate in Goa, followed by Sikkim (87 per cent) and Manipur (85 per cent).

On average, the 14 states surveyed saw a 12 percentage-point rise in women studying for at least a decade; 38 per cent women now do so. The largest increase was 19 percentage points in Tamil Nadu, followed by 18 in Sikkim and Karnataka.

Education may help women stand up for themselves within their families and ask for better food during pregnancy, which would reduce anaemia, Coffey suggested.

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How Depression Is Linked to Diabetes During Pregnancy

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Depression in early pregnancy more than doubles the risk of gestational diabetes, which, in turn, increases risk of postpartum depression six weeks after giving birth, says a study.Gestational diabetes is a form of diabetes occurring only in pregnancy and, if untreated, may cause serious health problems for mother and infant.

"Our data suggest that depression and gestational diabetes may occur together," said study first author Stefanie Hinkle from US National Institutes of Health's Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

"Until we learn more, physicians may want to consider observing pregnant women with depressive symptoms for signs of gestational diabetes. They also may want to monitor women who have had gestational diabetes for signs of postpartum depression," Hinkle noted.

Although obesity is known to increase the risk for gestational diabetes, the likelihood of gestational diabetes was higher for non-obese women reporting depression than for obese women with depression, the study found.
The researchers analysed pregnancy records from the NICHD Fetal Growth Studies-Singleton Cohort, which tracked the progress of thousands of pregnancies, to understand the patterns of fetal growth.

The study enrolled 2,334 non-obese and 468 obese women in weeks eight to 13 of pregnancy.

The women responded to questionnaires on symptoms of depression when they enrolled in the study, again between the 16th and 22nd week of pregnancy, and then six weeks after giving birth.

The researchers found that women who had the highest scores for depression in the first and second trimesters -- about 17 percent -- had nearly triple the risk for gestational diabetes when compared to women who had lower depression scores.

Of the women who developed gestational diabetes, nearly 15 percent experienced depressive symptoms after birth, which was more than four times that of women who had not had gestational diabetes, showed the study published online in the journal Diabetologia.

The researchers believe that high blood sugar levels may lead to inflammation, hormonal, and other changes that could lead to symptoms of depression.

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How I Kept Running While I Was Pregnant

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Running is a huge part of my life. Most of my social life involves running. It's my preferred form of therapy. I almost always have a race on the horizon, and I get up early to log miles before work more often than not. In other words, I'm one of "those people" - the generally eccentric bunch of fitness nuts that make Colorado Springs a top running town.

When we found out I was pregnant with my first child in January, my husband and I were thrilled. After the initial excitement wore off, I began to think about the implications that held for my daily life, especially running. Every woman - and every pregnancy - is different, and my guess was as good as anybody else's on how my body would hold up through the nine months of creating a human. You hear about women having to stop exercise entirely, but there are also people running marathons with giant bellies.

It turns out, it really is an individual journey, and the best anyone can do is listen to her body and her doctor.

When I talked to my OB/GYN early on, she recommended modifying my pace by tracking my heart rate, keeping my exertion below 140 beats per minute. Through a bit of online research, I learned that the American College of Obstetricians and Gynecologists had removed the specific heart rate recommendation from their exercise guidelines several years ago. Instead, they encourage training by perceived exertion level: keeping all efforts to a pace where it's easy to carry on a conversation.

However, because my doctor was insistent on the heart rate monitoring, I decided to give it a try. I bought a chest strap monitor to pair with my GPS watch and learned just how little effort it took me to get up to 140 beats per minute. My 9- or 10-minute-mile pace ballooned to 11 or 12 minutes. Speed workouts were a no-go. For the rest of my pregnancy, I used 140 bpm as a guideline, but I wouldn't freak out if it spiked a little higher but I could still carry on a conversation.

During the first trimester, your body goes into overdrive, and your circulation system is producing extra blood to support your baby. I found that my heart rate would spike and I would get winded going up stairs, let alone running up a hill. My favorite running routes are on the trails through the mountains and hills surrounding Colorado Springs, so the 140 bpm limit seemed oppressive at first. My body wasn't much different externally, but I had to slow down a lot to keep my effort level moderate. It took me a little time to get my head around this new physical challenge I was "training" for.

Once I accepted my new parameters, though, I was able to stay fairly consistent, running four to five days a week at a slower pace. I was fortunate enough to avoid many of the discomforts of early pregnancy, such as consistent morning sickness. (I imagine a large chunk of people just stopped reading right there.) Trust me, I consider myself extremely lucky.

Maybe being fit to start out with helped, or maybe my body just handled this burden really well. As my belly began to expand in the second trimester, I noticed pain in my round ligaments, which run on either side of the belly, supporting the abdomen. I bought a support belt that I wore for a while, but I found that into the third trimester the pain decreased and the belt didn't make a whole lot of difference anymore, so I started leaving it behind.

As the third trimester wore on and the baby began exerting more internal pressure downward, I began requiring numerous midrun bathroom breaks on even the shortest of runs. I could draw a map from memory of the port-a-johns and favorable bushes in the local parks I was frequenting. I also noticed that the extra weight was taking a toll on my joints and muscles. I'd feel as tired after four miles as I used to be after eight. Another unfortunate side effect of carrying extra weight on the front of one's body is a lack of balance: I took a couple of spills and bloodied my knees pretty well, not expecting the tug of gravity to be so strong.

My biggest accomplishment was finishing a 10K race at 38 weeks. It wasn't pretty: I used every bathroom opportunity available and had to walk up the "hills" on the course. I joked with my friend Carrie, who ran with me, that she had to be ready to call 911, catch a baby or provide cover if I had to duck into the bushes - it was a big job!

I think all this activity will pay off: using endorphins to weather the emotional roller coaster of pregnancy hormones, being fit and healthy to undertake the marathon of labor and delivery and being able to bounce back faster afterward. As a bonus, I've already shared so much with my unborn child (about 700 miles' worth of experiences, if we are keeping score). My husband and I want to set the example of a healthy, active lifestyle right from the beginning. Plus, someone has to be able to keep up with this kid.

Since the 10K, I've slowed down quite a bit, but I still think about running all the time. I worry about what postpartum running will be like, both physically and from a time-management perspective. Right now I'm pretty eager to get back at it for many reasons (go ahead and Google "maternal fat stores"), but I know I'll need to temper that enthusiasm and follow my doctor's recommendations about when it's safe to start. I plan to ease back in, building mileage slowly (we've already bought a jogging stroller) and making sure to incorporate plenty of yoga, stretching, cross-training and strength training. I've learned through years of running what it takes for me to stay injury-free; I'll just have to be even more aware of what my body tells me as we all adjust to our new family member.

I feel lucky to have run as long as I did, but now I imagine what it will feel like to be able to run at a faster pace, to actually push myself. I picture the freedom of bombing down a rocky mountain trail, feeling the sun on my face and the wind in my hair.

And perhaps most of all, I dream of being able to cover more than 2 miles between bathroom stops.
Miles run (or hiked) while pregnant: Just over 700
Farthest distance: 13.1 miles at eight weeks along
Average weekly mileage: About 20 (until the last month, when it dropped to 10 or so)

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Younger Pregnant Women More Prone to Strokes

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According to a study, pregnancy in young women may increase the risk of stroke as compared to their older counterparts of childbearing age.
The findings showed that stroke risk was more in women aged 12 to 24 years and increased significantly by 60 per cent in women 25 to 34 years during pregnancy or post partum period up to six weeks after delivery. However, there was no difference in stroke risk in women who were 35 years or older.

"We have been warning older women that pregnancy may increase their risk of stroke, but this study shows that their stroke risk appears similar to women of the same age who are not pregnant," said lead author Eliza C. Miller from Columbia University Medical Centre (CUMC) in New York, US.

"But in women under 35, pregnancy significantly increased the risk of stroke. In fact, one in five strokes in women from that age group were related to pregnancy," Miller added.

Previous studies suggested that the risk of pregnancy-associated stroke is higher in older women than in younger women.

"The incidence of pregnancy-associated strokes is rising, and that could be explained by the fact that more women are delaying childbearing until they are older, when the overall risk of stroke is higher," noted Joshua Z. Willey, Assistant Professor at CUMC and neurologist at New York-Presbyterian Hospital in the US.

In the study, the team examined 19,146 women, aged 12 to 55 years. Of these, 797 (4.2 per cent) were pregnant or had just given birth.

They found that the overall incidence of stroke during or soon after pregnancy increased with age (46.9 per 100,000 in women age 45 to 55 vs 14 per 100,000 in women age 12 to 24).

However, pregnant and postpartum women in the youngest group (age 12 to 24) had more than double the risk of stroke than non-pregnant women in the same age group (14 per 100,000 in pregnant women vs 6.4 in non-pregnant women).

"We need more research to understand the causes of pregnancy-associated stroke better, so that we can identify young women at the highest risk and prevent these devastating events," Miller said.

The results appear in the journal JAMA Neurology.

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Poverty, Instability Linked to Poor Control of Pregnancy Diabetes

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Pregnant women with pregnancy-related diabetes are less likely to achieve blood sugar control if they rely on food stamps or have a generally chaotic lifestyle, according to a U.S. study.

These kinds of factors may be modifiable, the authors write in Obstetrics and Gynecology.

“Many social factors have a major impact on overall pregnancy health,” said Dr. Laura Colicchia, who led the study at the University of Pittsburgh and is currently in Maternal-Fetal Medicine at Abbott Northwestern Hospital in Minneapolis.

About 200,000 U.S. women develop diabetes during pregnancy each year, Colicchia said, and they must follow a strict diet, prick their fingers four times daily to check blood sugar, report their blood sugars to the doctor weekly, have frequent office visits and ultrasounds, and in many cases take insulin or medications several times daily to control their sugars.

“Gestational diabetes impacts every aspect of a woman's life including eating with and cooking for her family, scheduling her blood sugar checks and meals at work, where she obtains the food to follow the diet and how she creates time for everything,” she said.
“Because of this, barriers to management of diabetes can come from any part of her life including her family, her neighborhood, her daily routine or her employer,” she told Reuters Health by email.

Women who are obese, have limited access to food or are from marginalized communities are at higher risk for gestational diabetes and often have higher blood sugar levels when diabetes is diagnosed making it harder to control, Colicchia noted.

The researchers surveyed 111 women with gestational diabetes at clinical visits, using questionnaires designed to measure social support and degree of life “chaos,” which includes organization, stability and the ability to plan and prepare for the future.

They later analyzed medical records for blood sugar control and pregnancy outcomes, including infant size, maternal weight gain, cesarean delivery and newborn health.

Women were rated as having good blood sugar control if at least 70 percent of their blood sugar assessments were at goal level or better.

Overall, 86 of the 111 women achieved good glycemic control, either by diet changes alone or with the help of medication and insulin treatment. These women were more likely to be married, have higher household income and exercise three times a week, and less likely to have public insurance or a history of depression or anxiety.

In general, food access and social support were not related to blood sugar control, though women receiving Supplemental Nutrition Assistance Program (SNAP) benefits tended to have worse blood sugar control.

Women with poor blood sugar control had higher scores on the chaotic lifestyle scale than those with good control, the authors also found.

“Women are not always able to change many things that make life chaotic such as unstable housing, unpredictable work schedules, poverty and family stressors,” Colicchia said. “However, the gestational diabetes regimen in many cases can be adjusted to accommodate some of these factors, such as adjusting mealtimes or medication times to the woman's new schedule, or giving suggestions for healthy meals that can be eaten on the go or can be cooked ahead.”

Women who lack material resources and live amidst hubbub and chaos brought on by caring for children and working and the absence of a partner may have more trouble controlling their blood sugar, said Nancy Ross of McGill University in Montreal who was not involved in the study.

“It seems like these women need help to lessen the ‘hubbub and chaos’ - perhaps shorter working hours, some breaks from caring for children to focus on shopping and meal preparation and having time to exercise,” Ross said by email.

Doctors should ask women about the social factors relevant to diabetes care, and women should be honest with their doctors about the limitations they face, Colicchia said. ‘

“If doctors and nutritionists know in advance that a woman will not be able to eat breakfast because she has to get her kids on the bus, or that her employer won't let her check her sugar after lunch we can make suggestions and adjustments to accommodate some of these factors,” she said.

Dr. D. Malekar
Dr. D. Malekar
MBBS, Family Physician, 21 yrs, Pune
Dr. Pallavi Joshi
Dr. Pallavi Joshi
BHMS, Family Physician Homeopath, 1 yrs, Pune
Dr. Richa
Dr. Richa
BAMS, Mumbai Suburban
Dr. Sanjeev Parmar
Dr. Sanjeev Parmar
MBBS, Gynaecologist Infertility Specialist, 16 yrs, Pune
Dr. Anup Gaikwad
Dr. Anup Gaikwad
BHMS, Family Physician Homeopath, 8 yrs, Pune
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