A Report

Iodine Supplementation and Pregnancy Outcomes amongPregnant Women in Chautara Hospital

Principal Investigator

Dr. Anand Ballabh Joshi
Institute of Medicine
Maharajgunj, Kathmandu
December, 2007

Study Team
Study team members from Institute of Medicine
Dr. Anand Ballabh Joshi, PhD- Principal Investigator
Dr. Tara Pokhrel, MD, MPH- Clinician
Mr. Megha Raj Banjara- Research Officer
Mr. Bijaya Malla- Research Officer
Mr. Krishna Pant- Account and Administrative Officer
Mr. Prakash Joshi- Administrative Assistant
Study team members from Chautara Hospital
Dr. Nanda Lal Sikarmi, MD- Clinician
Mrs. Maya Shrestha- Staff Nurse
Mr. Prabhakar Sunuwar- Laboratory Technician
Mrs. Sita Shrestha- Auxiliary Nurse Midwife (ANM)
Mr. Dambar Gurung- Laboratory Assistant
Mrs Ambika K C- Maternal and Child Health Worker (MCHW)
Advisors
Professor Chikayoshi Atsuta, Japan
Professor Ramesh Kant Adhikari, Dean, Institute of Medicine

IISummary

Iodine Deficiency Disorder (IDD) is the world’s most significant cause of preventablebrain damage and mental retardation. Twenty nine percent of the world’s population
is at risk of iodine deficiency. IDD is also an important major micronutrient
deficiency problem in Nepal. Ministry of Health and Population (MoHP) has
prioritized IDD as a high level activity in its National Policy and Strategy 2004.
MoHP has set an objective to virtually eliminate IDD by the year 2017 and sustain theelimination. This quasi-experimental study entitled was carried out from June 2007.
The objective of the study is to find out maternal and newborn health status in relation
to the regular daily iodine supplementation in addition to appropriate maternal andneonatal health care intervention during pregnancy among pregnant women in
Chautara Hospital.

Sixty intervention and 60 control subjects were included in the study to compare
between pre and post intervention and also between control and intervention group.
Intervention was done with regular iodine supplementation in oral form at least forthree months during second and early third trimesters of pregnancy. The difference
between pre and post intervention and also between intervention and control groups
were analyzed using statistical software SPSS version 13.

Study findings revealed that number of adolescent pregnancy was still high with mean
age of pregnancy 22.1 year. More than 98 percent of respondents had heard about
iodine and more than 80 percent used iodized salt. Among them two third were using
it for more than 3 years. About two third of pregnant women were primigravida andmore than 97 percent of all pregnancies had attended antenatal clinic. More than 90
percent had taken the first dose of TT injection. Ninety five percent of deliveries were
uncomplicated and 93 percent of deliveries were full term with significant difference
between intervention and control group. Mean weight and length of newborns werestatistically significant between intervention and control group. In the biochemicalIIIindicators, level of thyroxin (T4) in the serum was significantly different between preand post intervention study.

The study concludes with regular daily supplementation of iodine in oral form morethan three months to the pregnant women of second and third trimesters withintegrated standard maternal and neonatal health care will bring significant positivechanges in perinatal outcomes. Intervention should be done in early stage ofpregnancy to get desired outcomes. Regular oral iodine along with iron and folic acidtablets and standard maternal and neonatal health (MNH) care package has been
recommended to implement during early stage of pregnancy. Further research iniodine supplementation during early pregnancy and perinatal outcomes should be
conducted in large scale to find out the effect in mental development of children.

IVAcknowledgement

We would like to express our sincere thanks to Professor Chikayoshi Atsuta forproviding fund and opportunity to carry out this research study.
We would like to acknowledge Dr. Nanda Lal Sikarmi, District Health OfficeSindhupalchok, staff of DHO, DHO/ANC Clinic, Chautara Hospital and Hospitallaboratory especially those who were directly involved in this study. Our sincere
thanks are due to the clients who attended antenatal clinic and maternity ward ofChautara Hospital with out whose co-operation this research would not have beenpossible.

VTable of Contents
Particulars

Page No.

Chapter I: Introduction
1.1 Background1

1.2 Problem statement2

1.3 Rational for the study3

1.4 Hypothesis

5

1.5 Research questions

5

1.6 Objectives

5

1.7 Limitations of the study

6

Chapter II: Review of Literature
2.1 Iodine deficiency disorders

7

2.2 Prevalence of the study

9

2.3 Indicators of IDD

10

2.4 Thyroid functions during pregnancy

10

2.5 Iodine supplementation and thyroid function in late pregnancy

11

2.6 Long term consequences13

2.7 Hypothyroidism during pregnancy

14

2.8 Diagnosis of hypothyroidism

14

Chapter III: Research methodology
3.1 Research design17

3.2 Study site17

3.3 Sample size and sampling17

3.4 Selection of the study pregnant women18

VI

3.5 Follow up

19

3.6 Midterm evaluation

19

3.7 Outcomes (finsl)evaluation including study of newborn

19

3.8 Outcome evaluation of control subject

19

3.9 Intervention

20

3.10 Monitoring and follow up

20

3.11 Validity and reliability

20

3.12 Schematic presentation of study design21

3.13 Exclusion criteria

23

3.14 Conceptual frame work24

3.15 Operational definitions25

3.16 Data collection

26

3.17 Data management and analysis

26

3.18 Ethical approval and informed consent

27

Chapter IV: Results
4.1 Demographic profile of respondents

28

4.2 Literacy and educational status of pregnant women30

4.3 Knowledge about iodized salt its use31

4.4 Pregnancy related characteristics of subjects

34

4.5 Maternal outcomes among intervention and control group37

4.6 Perinatal outcomes39

4.7 Laboratory characteristics of study subjects

42

Chapter V: Discussion

43

Chapter VI: Conclusion and Recommendations
6.1 Conclusion

47

6.2 Recommendations

48

VII

References

49

Annexes50

VIIIList of Tables

Table No.

Page No.

1. Age distribution of pregnant women28

2. Ethnic distribution of pregnant women educational status
and sex of the respondents29

3. Religion distribution of pregnant women29

4. Occupation distribution of pregnant women30

5. Literacy and educational status of pregnant women30

6. Knowledge about iodized salt and its use

32

7. Duration of use of iodized salt by subjects

33

8. Person who advised to use iodized salt to the subjects

33

9. Parity of subjects

34

10. Status of antenatal checkup of subjects

35

11. Status of antenatal visits

35

12. Status of tetanus toxoid injection and use of iron tablets

36

13. Mean weight and height of subjects

37

14. Type of delivery of intervention and control subjects

37

15. Duration of third stage and amount of blood loss38

16. Period of gestation at delivery and mean weight of subjects

39

17. Mean weight and length of newborn

39

18. General condition and cry of newborn

40

19. Color and sucking of newborn

41

20. Initiation of breast feeding of newborn

42

21. Laboratory characteristics of study subjects

42

IX

Abbreviations

ANC

Ante Natal Check up

DHO

District Health Office

FCHV

Female Community Health Volunteer

IQ

Intelligent quotient

IDD

Iodine Deficiency Disorders

MND

Micronutrient deficiency disorders

MCHW

Maternal and Child Health Worker

SAC

School Age Children

TFT

Thyroid Function TestTG

Thyroglobulin

TSHThyroid Stimulating Hormone

T3

Tri-iodothyronine Hormone

T4

Thyroxin Hormone

TT

Tetanus Toxoid

UIE

Urinary Iodine Excretion

X