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AAPI Journal • June 2009 SPECIAL ARTICLE Perinatal Outcomes Among Mothers of Indian Origin and Prenatal Testing In The United States by Neeraja Kambham 1 , Vinita Parkash 2 , Shenbagam Dewar 3 , Meenakshi Singh 4- Neeraja Kambham, M.D. Stanford, CA In 2002, Dr. Ashima Madan from Stanford University reported on the increased incidence of Low Birth Weight (LBW) infants in Asian Indian women (Madan et al., J. Perinatol. 2002). A subsequent study reviewed the birth records of 1,622,324 babies born in California from 1995-97 and further corroborated these findings (Gould et al., Pediatrics. 2003). Perinatal outcomes in Asian Indian women were compared to Hispanic and Caucasian women, and the data showed that Indian mothers were more likely to have an adverse pregnancy outcome. Termed as a ‘dual epidemiologic paradox’, this paper suggested that despite an improved socio-economic profile as measured by education and income, Indian mothers more frequently gave birth to LBW babies than Caucasian or even foreign born Hispanic mothers. In a follow up study examining the U.S Perinatal Mortality Data Files, the investigators showed that these findings persisted in the second generation Asian Indian women (Madan et al., J. Pedaitr 2006). In other words, both foreign born and U.S. born Asian Indian women remain at high risk for delivering LBW infants. Although the incidence of maternal diabetes was higher in Indian women in one of the studies, the other suspected risk factors such as pregnancy induced hypertension, pre-eclampsia or maternal anemia were not observed. The investigators then went on to examine morbidity in these infants. The data from this small, retrospective study showed that Asian Indian infants also have a higher incidence of admissions to the intensive care nursery (abstract – Society for Ped Res. 2009). These studies suggest that perhaps genetic and /or environmental factors compromise perinatal outcomes in Asian Indian women living in the US. Identification of these factors is essential to design directed testing and perinatal care programs to reduce such negative outcomes in these infants. Prenatal care and tests for carrier screening among Indian mothers The mothers of Indian descent get adequate and in fact, better prenatal care in comparison to their ethnic peers. However, current prenatal care protocols, developed largely based on studies conducted in predominantly Caucasian/African American and occasionally Hispanic groups, may not focus on the distinct susceptibilities and risks of this population subgroup. The current guidelines of the American College of Obstetrics and Gynecology recommend a prenatal care program, to monitor the well being of mother and baby, and to screen for genetic abnormalities. The latter include a variety of blood tests and ultrasound screenings to rule out genetic syndromes that occur sufficiently commonly in the general population. In high-risk settings, additional testing such as amniocentesis or chorionic villous sampling is advocated. The ACOG recommends genetic carrier screening for Cystic Fibrosis in ALL pregnant women, because of its relatively high prevalence in Caucasians. Additional tests are recommended in the setting of a strong family history of genetic disease or certain ethnic backgrounds (eg. Ashkenazi Jews). These genetic screening guidelines are invaluable in that they standardize protocols over different areas of the country and ensure a uniform level of care. However, by their very nature, these (broad and all encompassing) guidelines tend to disregard small population subgroups that may have different genetic profiles. For example, ACOG recommendations would subject Indian mothers to screening for Cystic Fibrosis, a disease that is very rare among Indians (
SPECIAL ARTICLE AAPI Journal • June 2009 Cross Country Biking and Campaigning for Chronic Disease Prevention by Rajan Dewar, M.D., PhD and Ramar Kannan, M.D. As already well highlighted in several articles, published books, forums and previous issues of the AAPI Journal, chronic diseases due to preventable lifestyle factors, are among the leading and rapidly rising causes for increased morbidity and mortality among Indian adults. Seen more in this era of globalization, sedentary lifestyles, unhealthy food and other yet unidentified factors has raised an alarming trend in these diseases that include hypertension, coronary artery disease, dyslipidemia, obesity and diabetes mellitus. These sets of diseases and their resulting complications are serious enough to merit immediate and urgent interventions in India. Consider the following statistics regarding the Indian population (in India) at risk: The prevalence of Coronary Heart Disease (CHD) is 11% among urban adults. The overall prevalence of hypertension is 28% in the 20-69 age group. Overall prevalence of overweight/obesity is 31%. Diabetics in India are expected to increase from 30 to 57 million by 2025. Death from chronic diseases is set to increase from 53 to 67 % by 2025. Accumulated loss in revenue as a result of chronic diseases from 2005 to 2015 is predicted to be US$ 236 billion. Screening measures by the AAPI and a few other organizations are highly commendable and go a long way in disease prevention and health education. We wanted to highlight yet another unique effort in this direction, to the attention of the AAPI readership. Sanjeevini trust is a relatively new organization formed by a practising Urologist in the United Kingdom. Members of this trust combine a direct public education campaign along with screening camps for these chronic diseases in selected communities. Dr. T.V. Seshagiri and his colleagues have been organizing cross-country bicycle trips mostly in South India educating the lay public about these chronic diseases and discussing simple ways of lifestyle modifications that can help with chronic disease prevention. These bicycle trips are typically long distance rallies. For example, the 2008 campaign covered 1100 kms in Northern districts of Tamil Nadu; this year the organisers have plans for a Bangalore-Pondicherry rally that is approximately 300 kms and lasts 3-4 days. The physicians start biking by 5:30 AM, bike for 2-3 hours, stop for breakfast, and bike again till about 10:30 AM. After a noon break to beat the heat, they restart by 3:30 or 4 and bike till sundown. The biking trip is punctuated by frequent stops – almost every 25-30 minutes: if they see a crowd of 5 people or so, say in a tea shop, they stop their bikes, introduce themselves and talk about chronic diseases, how sedentary life styles, smoking and malnourishment due to a carbohydrate or fat rich diet can cause diabetes, hypertension or heart disease. They explain the impact of these diseases on the individuals’ family, jobs, or their well being. The organisers feel that this direct health education, though targeting only a microscopic population is still very effective – people listen when they are visited by “foreign doctors”, those are biking for the public’s good. Through this ‘bottom’s-up’ approach and other publicity measures these ‘docs on bikes’ are able to reach out to many communities. The screening camps are organised as day long clinics with a point of care testing laboratory screening for diabetes and kidney diseases. They also screen for hypertension and cardiac symptoms. They target rural or suburban population with poor access to a low cost health clinic. The intent is to promote or work with a local doctor who will continue to care for the newly diagnosed patients. Identifying local doctors is possibly the most challenging aspect of these screening camps. Dr. T.V. Seshagiri is promoting the idea of “adopting communities by non-resident physicians”. Physicians can therefore identify a small village that they have been associated with, and arrange a screening camp, invite the ‘docs on bikes’, and co-ordinate continued care of the patients through local resources. Through a combination of education, local community involvement and charity, Dr. Seshagiri is able to reach out to the masses. Continued on page 32 29 www.aapiusa.org
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