Widespread non-adherence to evidence-based maternity care guidelines: a population-based cluster randomised household survey.

OBJECTIVE: To assess the quality of maternity care in an Indian metropolitan city. STUDY DESIGN: Three-stage cluster randomised cross-sectional survey. SETTING: Sixty selected colonies of Delhi. POPULATION: One thousand eight hundred and one subjects (of 2286 eligible) were enrolled from 118 446 houses. Women who had delivered a live viable birth in the past 6 months were selected for the study. METHODS: In stage 1, 20 wards (of 150) were selected using a probability-proportionate-to-size systematic method. In stage 2, one colony from each income stratum (high, middle and low) was selected from each ward by simple random sampling. In stage 3, a house-to-house survey was conducted to recruit 30 women for administering a peer-reviewed and pilot-trialled questionnaire. MAIN OUTCOME MEASURES: Caesarean section rate, induction rate and episiotomy rate. RESULTS: National health targets such as iron supplementation advice (>96%), tetanus vaccination (>81%), and ≥3 antenatal visits (>90%) were largely achieved across health care facilities but not in home deliveries. Interventions were lower in public than private hospitals: caesarean section [23.7% (20.2-27.7) versus 53.8% (49.3-58.3)], induction [20.6% (17.5-24.25) versus 30.8% (26.8-33.2)] and episiotomy [57.8% (52.3-63.1) versus 79.4% (71.0-85.9)]. Private hospitals achieved better labour support rates [1.1% (0.5-2.2) versus 14.6% (8.5-24.1)] and pain relief [0.9% (0.4-2.0) versus 9.9 (6.5-14.8)]. Pubic hair shaving [16.2% (11.5-22.5) versus 36.4% (29.9-43.4)], enema [20.2% (15.5-26.0) versus 57.3% (49.5-64.8)], and IV fluids during labour [44.0% (36.2-52.2) versus 38.7% (29.3-49.1)] were widely prevalent in public and private hospitals. CONCLUSION: Present practices fall short of evidence-based guidelines, with relative overuse of interventions in private hospitals and deficiency of patient-centred practices such as labour support in public hospitals.

A double-blind, randomized, placebo-controlled trial of the short-term effect of vitamin D3 supplementation on insulin sensitivity in apparently healthy, middle-aged, centrally obese men.

AIM: To determine the short-term effect of vitamin D(3) supplementation on insulin sensitivity in apparently healthy, middle-aged, centrally obese men. SUBJECTS AND METHODS: A double-blind randomized controlled trial was conducted at a tertiary care facility in which 100 male volunteers aged > or = 35 years received three doses of vitamin D(3) (120,000 IU each; supplemented group) fortnightly or placebo (control group). Hepatic fasting insulin sensitivity [homeostasis model assessment (HOMA), quantitative insulin-sensitivity check index, HOMA-2], postprandial insulin sensitivity [oral glucose insulin sensitivity (OGIS)], insulin secretion (HOMA%B, HOMA2-%B), lipid profile and blood pressure were measured at baseline and at 6 weeks' follow-up. RESULTS: Seventy-one of the recruited subjects completed the study (35 in supplemented group, 36 in control group). There was an increase in OGIS with supplementation by per protocol analysis (P = 0.038; intention-to-treat analysis P = 0.055). The age- and baseline 25-hydroxyvitamin D level-adjusted difference in change in OGIS was highly significant (mean difference 41.1 +/- 15.5; P = 0.01). No changes in secondary outcome measures (insulin secretion, basal indices of insulin sensitivity, blood pressure or lipid profile) were found with supplementation. CONCLUSION: The trial indicates that vitamin D(3) supplementation improves postprandial insulin sensitivity (OGIS) in apparently healthy men likely to have insulin resistance (centrally obese but non-diabetic).

Direct cost of ambulatory care of type 2 diabetes in the middle and high income group populace of Delhi: the DEDICOM survey.

OBJECTIVE: To estimate the direct cost of ambulatory care in diabetes patients in the middle and high income group populace of Delhi. RESEARCH DESIGN AND METHODS: We analyzed the drugs, investigations, consultation and monitoring related data available from a survey of 35- 65-year-old known diabetes patients conducted using a probability-proportionate-to-size 2-stage cluster design to calculate the direct cost of ambulatory diabetes care. RESULTS: A total of 819 subjects were enrolled from 20,666 houses. The average estimate of direct annual expenditure on ambulatory care of diabetes was approximately Rs. 6000 (approximately US$ 150). Time elapsed since diagnosis (p<0.001), education (p=0.011), gross family income (p=0.002), presence of co-morbidities (p=0.009) and requirement for useof oral hypoglycemic agents (p<0.001) or insulin (p<0.001) were significant correlates. Direct ambulatory cost of care comprised 1-3% of the gross family income of the subjects. CONCLUSION: Despite the limitations of the present study it may be concluded that a majority of the diabetes patients spend a significant proportion of their family income on diabetes related expenditure. The cost is higher for subjects with longer duration since diagnosis, those with higher education or income, those with co-morbidities and those requiring oral hypoglycemic agents or insulin.

Cardiovascular risk profile of subjects with known diabetes from the middle- and high-income group population of Delhi: the DEDICOM survey.

AIMS: To determine the cardiovascular risk profile of known diabetic patients from the middle- and high-income group populace of Delhi. METHODS: A cross-sectional survey was conducted using a probability proportionate to size (systematic) two-stage cluster design. Thirty areas were selected for a house-to-house survey to recruit a minimum of 25 subjects (known diabetes > or = 1 year; 35-65 years of age) per area. Data were collected by interview, blood sampling and from medical records. Scores from the Framingham, Joint British Society, United Kingdom Prospective Diabetes Study, Systematic Coronary Risk Evaluation, and Diabetes Epidemiology: Collaborative Analysis Of Diagnostic Criteria in Europe studies were used to calculate summary estimates of risk for coronary heart disease (CHD) and stroke. RESULTS: Eight hundred and nineteen subjects (25-30 per cluster) were enrolled. The mean age of the subjects was 53.6 years, the mean duration since diagnosis was 8.1 years, the mean body mass index was 28.1 kg/m(2), with 50.7% women; 74.3% had hypertension, 75.1% dyslipidaemia and 41.8% had poor glycaemic control (HbA(1c) > 8.0%); 8.4% had already had a myocardial infarction, whereas 2.3% had suffered a stroke. Only 17.6% were taking aspirin, 3.4% were on lipid-lowering drugs and 11.6% were taking antihypertensive agents. The risk engines estimated a 10-year CHD risk of 12.6-13.9% and a stroke risk of 5.1-5.7%. CONCLUSION: The study documents that the cardiovascular profile of known diabetes patients from the middle and higher income groups of Delhi is poor, strengthening the case for targeting interventions at patients, providers and other stakeholders for improvement.