Very low rate of Thyroid Disorders screening during Pregnancy
Did you know that untreated hypothyroidism can progress and have devastating effect on women causing a multitude of disorders like birth defects, infertility, goiter, heart problems and mental health issues. Ankita Kothari, an industry analyst from Frost and Sullivan shares her research findings with the PatientsEngage community
What are the common risk factors for hypothyroidism?
Sex and age are the most common risk factors. Hypothyroidism is more common in women compared to men. Pregnant women are at a greater risk of developing hypothyroidism and pregnancy is a major factor for this higher risk of hypothyroidism in women. Similarly, risk of developing hypothyroidism increases with age. Genetic factors play a role too – one is at a greater risk if there is family history of hypothyroidism. Lifestyle factors such as stress, smoking and iodine deficient diet contribute to disturbances in thyroid function. There are also some medical conditions, presence of which makes a person more prone to hypohyroidism such as Type 1 Diabetes, Rheumatoid Arthritis, Down’s syndrome, etc.
Why are women more prone to hypothyroidism?
Women undergo frequent hormonal changes which make them more prone to hypothyroidism.
Can you explain the disparity in numbers for under-5 deaths in Assam vs UP, Bihar, MP and Rajasthan (page 29)?
Progress on improving the U5MR (Under 5 mortality rate) and child mortality rates has been really slow in few states. 8 states that performed the worst on this parameter - namely Assam, Madhya Pradesh, Orissa, Uttar Pradesh, Rajasthan, Bihar, Chhattisgarh and Jharkhand contribute to 57% of live births but have a burden of 70% of U5MR. State government’s which were progressive in nature and had a continuity in policy for 10-15 years fared better on IMR indicators than states which didn’t either have the stability or were marred by government having no progressive agenda for healthcare. Also, it needs to be understood that states which rank very high on corruption and embezzlement of public funds tend to score poorly on health indicators, case in point being siphoning of NRHM funds in Uttar Pradesh, a chunk of which was supposed to be spent on upgradation of maternal and child health infrastructure
Why is there a higher prevalence of hypothyroidism in inland cities vs the coastal cities?
The higher prevalence in inland cities is shooting up only because of alarming high prevalence of hypothyroidism recorded in Kolkata (21.67%). If I remove Kolkata off the equation of inland cities, the average prevalence in the 4 inland cities included in the particular study apart from Kolkata is close to that of the coastal cities. The high prevalence in Kolkata establishes that hypothyroidism is no more confined to iodine deficient hilly areas. Howsoever, this increased prevalence of hypothyroidism among the inland vs. coastal cities definitely leads us to wonder on the role of iodine deficiency in hypothyroidism.
What are some of the risk factors for thyroid disorders during pregnancy?
There are no other risk factors; pregnancy itself is a risk factor. Talking purely with respect to pregnancy, it is the hormonal changes during this period which puts pregnant women at a greater risk of developing hypothyroidism. As the risk of hypothyroidism increases with age, the risk probability of hypothyroidism increases significantly in women having late marriages and late pregnancy. Also, during the first trimester, the foetus depends on the mother for its iodine and thyroid hormones requirements.
Can you explain the association between miscarriage and hypothyroidism?
Miscarriage is an adverse impact of untreated hypothyroidism. Various clinical studies across the globe have established that untreated hypothyroidism or subclinical hypothyroidism puts the women at increased risk of miscarriage apart from other adverse impacts such as still birth, pre-term birth and low birth weight.
Most studies emphasize on a need for Universal screening in India. Is this being implemented and how ?
Around 85-90% of women are advised screening for thyroid disorders in private hospitals while only 5-10% women are advised in government set-ups. Disparity also exists as you move from metro cities to the rural regions – practice of advising screening and diagnostics is highest in metro cities and state capitals and reduces as you go beyond into the interiors.
How is the National Iodine Deficiency Disorder Control Program (NIDDCP) progressing? Is it an effective program (pg 43)?
Government of India launched the National Goiter Control Programme (NGCP), now the NIDDCP in 1962. There were a lot of set-backs that obstructed the progress of the programme in the initial period; however, in the last two decades the programme has made significant progress. 51% population were reported to consume adequately iodized salt in 2006 and currently around 71% of population consumes adequately iodized salt and 20% population is consuming salt with some iodine added. (2009 data). But, this data also means that we still have 350 million people who are at risk of developing IDD (Iodine Deficiency Disorder) since their iodine intake is inadequate. The program has definitely been effective but there is a long way to go to achieve the Universal Salt Iodization target (USI) and to eliminate Iodine Deficiency Disorders (IDD).
What steps are being taken to increase awareness amongst patients and clinicians?
There are hardly any awareness activities going around thyroid disorders from the government’s side. Clinical associations such as FOGSI (Federation of Obstetrics & Gynaecological Societies of India), Indian Academy of Paediatrics, and Indian thyroid Society have done significant work in this area and have recommended universal screening for thyroid disorders during pregnancy in their guidelines, thus creating awareness amongst their members and peer groups. Private players such as Abbott Healthcare and Thyrocare have been working on this for quite some time now and have been creating awareness around thyroid disorders through various campaigns targeted towards both patients as well as physicians. It is important to emphasize that thyroid disorders not only cause complications during pregnancy but also impact the mental and physical growth of the child. It is a burden - economic as well as emotional, which can be easily avoided with combined efforts from all stakeholders.
What were the findings that surprised you most?
The most surprising finding of the study was the very low penetration of thyroid screening even in the well off section of the society which gets treated in high and mid end private hospitals. This can be attributed to low level of awareness amongst the general population and the belief amongst majority of clinicians of hypothyroidism being non fatal in nature. Suspicion based testing is highly prevalent currently instead of universal screening. Another surprising finding of the study was from couple of government hospitals where the doctors wanted to screen pregnant women for hypothyroidism, but since its not a part of the current Reproductive and Child Health Program (RCH), all they could do was to verbally suggest the patients to get themselves screened. The central government's initiative towards introducing thyroid screening in high risk pregnancies is a welcome step and it is expected to serve as a stepping stone towards "Universal Screening for Thyroid Disorders in Pregnancy". There would be operational challenges of logistics and infrastructure for the same, howsoever once the government undertakes a commitment towards universal screening, these challenges can be resolved with the help on initiatives like public-private partnership, easy to use point of care thyroid testing devices and likewise.
What would you say to OBGYNs who think that screening should only apply to high risk women and not universal?
Good chunk of hypothyroid cases are subclinical and so do not show any symptoms which makes it even more necessary to screen all women for thyroid disorders. Studies have shown that as high as 35% of hypothyroid cases were missed out due to targeted/ high risk screening of thyroid disorders instead of universal screening.
Ankita Kothari, an industry analyst at Frost & Sullivan offers advisory services to pharmaceutical and medical technology companies. She focuses on topics which tend to impact public health and this is both her passion and part of her job. She strongly believes that interventions in the form of awareness campaigns can play a very important role in improving the health outcomes for India. For a country like India strengthening the primary healthcare with low cost interventions is the way forward. This is a small attempt of hers to spread awareness about how to make pregnancies safer and devoid of complications.