AN ASSESMENT OF THE PREVALENCE OF GESTATIONAL DIABETES IN NIGERIA: A STUDY OF PREGNANT WOMEN IN ENUGU METROPOLIS

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AN ASSESMENT OF THE PREVALENCE OF GESTATIONAL DIABETES IN NIGERIA: A STUDY OF PREGNANT WOMEN IN ENUGU METROPOLIS

TABLE OF CONTENTS

Title page

Approval page

Dedication

Acknowledgement

Abstract

Table of contents

List of tables and figures

CHAPTER ONE: BACKGROUND OF THE STUDY

Introduction

1.1 Statement of the problem

1.2 Research objectives

1.3 Research questionnaire

1.4 Research hypothesis

1.5 Significance of the study

1.6 Delimitation of the study

1.7 Operational Definition of Terms

1.8 Limitation of study

CHAPTER TWO: LITERATURE REVIEW

Literature Review

2.1 Patholophysiology of GDM

2.2 Prevalence of GDM

2.3 Classification

2.4 Risk factors associated with GDM

2.5 Courses of GDM

2.6 Diagnosis of GDM

2.7 Complication associated with GDM

2.8 Management of Gestational Diabetes

CHAPTER THREE: RESEAHCH METHODOLOGY

Introduction

3.1 Research Design

3.2 population and sample

3.3 Sampling Technique

3.4 Data collection instrument

3.5 Data collection procedure

3.6 Data Analysis procedures

CHAPTER FOUR: RESULT AND DISCUSSION

Introduction

4.1 Result

4.2 Discussion

CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATION

Summary

5.1 Conclusion

5.2 Recommendation

REFERENCE

APPENDICIES

Appendix 1: sample questionnaire

ABSTRACT

Diabetes mellitus is a common complication in pregnancy. Its classification has been reviewed to reflect the various aetiological factors. Pre conception care, early antenatal bookings dedicated multidisciplinary ante natal care, and delivery in a centre with neonatal facility would reduce morbidty and mortality associated with the condition.

The study is aimed at accessing the prevalence of gestational diabetes among pregnant women in Enugu Metropolis. 250 pregnant women were recruited for the study, all in their second and third trimesters attending University of Enugu Teaching Hospital, State Specialist Hospital, Borno Medical Clinic and Nakowa specialist hospital antenatal clinics. Questionnaires were administered on each woman and data was collected. Results showed presence of risk factors among respondents. These includes having miscarriages, stillbirths, glucosuria, having GDM in previous pregnancies, history of diabetes in first degree relative, being obese, being delivered of large and small babies in previous pregnancies etc. 11.2% of the respondents were diagnosed with gestational diabetes mellitus in this pregnancy. This could be attributed to lack of adequate exercise and feeding among respondents. Recommendations in this study include prenatal counseling, antenatal care, exercises, eating balanced diet etc. by pregnant women to improve maternal and child health and reduce morbidity and mortality of both mother and child.

CHAPTER ONE

BACKGROUND OF THE STUDY

INTRODUCTION

Diabetes is a disease in which the blood glucose of the body or the blood sugar level is too high. When you are pregnant, high blood sugar is not good for the body.

According to Wikipedia, free encyclopedia, Gestational diabetes (or Gestational diabetes mellitus GDM) is a condition in which women without previously diagnosed diabetes exhibit high blood glucose (sugar) levels during pregnancy (especially during their third trimester). Gestational diabetes is caused when insulin receptors do not function properly. This is likely due to pregnancy related factors such as presence of human placental lactogen that interferes with susceptible insulin receptors. This in turn causes inappropriately elevated sugar levels.

Gestational Diabetes Mellitus (GDM) is carbohydrate intolerance of varying seventy with onset or first recognition during pregnancy (custom 1999). It does not exclude the possibility that the glucose intolerance may antedate pregnancy but has been previously unrecognized. The definition applies irrespective of whether or not insulin is used for treatment or th condition persist after pregnancy (WHO, 1999).

Resistance to insulin develops in all mothers during pregnancy. In about two to four percent pregnant women, result in temporary diabetes. It happens because pregnant women have less ability to produce extra insulin to overcome insulin resistance (Tahseen, 2015).

Gestational diabetes affect 3 – 10% of pregnancies, depending on the population studied, gestational diabetes generally has few symptoms and it is commonly diagnosed by screening during pregnancy. Diagnostic tests detect inappropriately high levels of glucose in blood samples (Thomas et al; 2005).

About 7 out of every 100 pregnant women in the united State gets gestational diabetes. Gestational diabetes is diabetes is diabetes that happens for the first time when a woman is pregnant. Most of the time, it goes away after you have your baby. But it does increase your risk of obesity and type 2 diabetes.

Gestational diabetes may damage the health of the fetus or mother and about 20 to 50% of women with gestational diabetes develop type 2 diabetes later in life. Gestational diabetes occurs in about 5.5 – 8.8% of all pregnancies (Kenneth, 2006). It is temporary and fully treatable, but if untreated, may cause problem with pregnancy such as macrosomia, (height birth weight), fetal malformations, increased caused respiratory syndrome. Hyperbilurubineamia may result from red blood cell destruction in this type of diabetes. In severe cases perinatal death may occur, most commonly as a result of poor placental perfusion due to vascular impairment (Kenneth, 2006).

Diabetes mellitus occurs throughout the world, but it is more common (especially type 2) in the more developed countries. The greatest increase in prevalence is however expected to occur in Asia and Africa, where most patients will probably be found in 2030. The increase in the incidence in developing countries follows the trend of urbanization and life style changes, perhaps most importantly a “western-style” diet. But there is little understanding of the mechanism(s) at present, though there is much speculation, some of it most compellingly present (Wild et al; 2004). Diabetes mellitus has no doubt been on the increase in prevalence for the past 10years in Nigeria. The National prevalence puts it at about 2.2% and this continues to increase (Nyenwa et al; 2003).

Globally, as of 2010, an estimated 285 million people had diabetes, with type 2 making up to about 90% of the cases. Its incidence is increasing rapidly, and by 2030, this number is estimated to almost double.

Gestational diabetes mellitus is associated with both morbidity and mortality in both mother and child. Since it is much in common condition and associated with significant morbidity and mortality, its early detection is very important as treatment greatly affects pregnancy outcome (O’sullivan, 1975).

Recent American Diabetes Association guidelines recommend selective screening for gestational diabetes mellitus (GDM) based on the presence of the risk factor. Because there is high incidence of GDM among certain ethnic groups, ethnicity is included as one of the risk factor during routine screening (American Diabetes Association, 2000).

Gestational diabetes is thought to arise because the many changes, hormonal and otherwise, that occur in the body during pregnancy lead some women to become resistant to insulin. Insulin is a hormone made by specialized cells in the pancreas that allows the body to effectively use glucose for fuel (energy). When levels of insulin are low or the body cannot effectively use insulin, blood glucose levels rise.

Some degree of insulin resistance and impaired glucose tolerance is normal in late pregnancy. However, in some women this risk factors that can increase your risk of getting gestational diabetes. Risk factors include: Being overweight or obese, Having a history of gestational diabetes in a previous pregnancy, having had a baby with high birth weight (over 9 pounds), having parent or sibling with type 2 diabetes, having polycystic ovary syndrome (PCOS), being of African American, African Indian, Asian American, Hispanic or pacific Islander American ethnicity, If you are an older mom, age 35 or over etc (American Diabetes Association, 2000).

Good parental care is important for all pregnant mothers, but especially important for women who carry risk factors gestational diabetes. Diabetes during pregnancy needs to be properly controlled to ensure the well-being of both the mother and the baby (American Diabetes Association, 2000).

Usually, under your healthcare provider’s guidance, a healthy balanced diet and more exercise can go a long way towards controlling gestational diabetes. Occasionally, insulin will also be used to use to keep blood glucose levels as close to normal as possible. Good control will ensure a happy healthy outcome for all (American Diabetes Association, 2000).

Women with gestational diabetes who receive proper care typically go on to deliver healthy babies. However, if you have high blood glucose levels, the elevation in the blood glucose can cause the fetus to be larger than normal, possible making delivery more complicated. The baby is also at risk for having low blood glucose (hypoglycemia) immediately after birth. Other serious complication of poorly controlled diabetes in the new born can include an increased risk of jaundice, an increase risk for respiration distress syndrome and a higher chance of dying before or following birth. The baby is also at a greater risk of becoming overweight and developing type 2 diabetes later in life. Diabetes in early pregnancy, there is an increased risk of birth defects and miscarriage compared to those mothers without diabetes.

Women with gestational diabetes have a higher chance of needing a cesarean birth (C-section) due to the large sizes of their babies. Gestational diabetes may increase the risk of preclampsia in the mother, a condition characterized by high blood pressure and protein in urine. Women with gestational diabetes are also at increased risk of having type 2 diabetes after pregnancy (American Diabetes Association, 2000).

The poor performance of Nigeria’s health system can therefore also be primarily attributed to poor financial resourcing of health services. The bulk of the nation’s resources come from oil revenues, which are deposited into the federation account and shared among federal, state and local governments according to an allocation formula. The federal government is currently unable to monitor the expenditure of funds allocated for secondary and primary health services, while local governments allocate funds with little influence from state as observers (Olakunde, 2012).

In most settings of developing counties including Nigeria, there is limited access to medical care and the need to identify women whose pregnancy is at increased risk of complications is an important part of antenatal screening.

The situation is more critical in Nigeria, especially in Borno state and most of the north eastern states where the resource allocation to the health sector is increasingly being challenged by other competing requirement such as those associated with rising insecurity in Nigeria, rising cost of governance, poverty, ignorance or illiteracy, cultural and religious beliefs and the most of all, corruption.

1.1 STATEMENT OF THE PROBLEM

GDM is estimated to occur in about 5.5-8.8% of all pregnancies, associated with both morbidity and mortality in both mother and child. It may also damage the health of the fetus or the mother. Another major concern is that about 20 to 50of women with GDM develop type 2 diabetes and obesity later in life.

1.2 RESEARCH OBJECTIVES

The main aim of the project therefore is to access critically the prevalence of gestational diabetes mellitus and its complications among pregnant women in Enugu metropolis and its burden on public health. Specifically, the objectives of the project are to:

Determine the effects of GDM on pre-natal complications.
Discuss the pattern, risk factors, morbidity/mortality, and complications of gestational diabetes.
To propose strategies for prevention of GDM among pregnant women.
The study will also facilitate further study from where this project paused for academic excellence.

1.3 RESEARCH QUESTIONS

1. Does GDM affect pre-natal complications?

2. Does GDM affect the morbidity and mortality rate of pregnant women and their babies?

3. Are there strategies for the prevention GDM among pregnant women?

1.4 RESEARCH HYPOTHESIS

The hypothesis of this study is that Gestational Diabetes Mellitus is given as:

NULL HYPOTHESIS (Ho):

GDM does not significantly impact on pre-natal complications

ALTERNATIVE HYPOTHESIS (H_i):

GDM significantly impact on pre-natal complications.

1.5 SIGNIFICANCE OF THE STUDY

The health system is faced with an increase in Gestational diabetes mellitus. Therefore, pregnancy complication will require increased resource to manage appropriate glycemic control during pregnancy and reduce adverse prenatal outcomes (Crowther et al; 2005). In addition ~50% of women with GDM are expected to develop type 2 diabetes within 5years of index pregnancy (Kim et al; 2002). Recent clinical trials have shown that health behaviours such as diet and physical activities prevent or delay onset of diabetes (Tuomilehto et al; 2001, knowler et al; 2002). Such behaviours interventions have been shown to be cost effective at a higher level than a pharmacological intervention (Hernan et al; 2003). Therefore, clinicians will increasingly have to primate plasma glucose testing and improved health behaviours at post-partum visits of women who had GDM to prevent development of diabetes and recurrent GDM. Also, some physicians may not recognize that women with GDM are at risk of diabetes.

1.6 DELIMITATION OF THE STUDY

The delimitations of this study significantly narrow the scope of the research. Some of these delimitations include:

Participation in this study is voluntary.
The population is restricted to pregnant women in Enugu.
The sample is limited to pregnant women with gestational diabetes mellitus.
Only few hospitals (antenatal clinics) are involved in the study out of many clinics in Enugu metropolis.
Religious and cultural belief affects women participation in the study.
Present insecurity challenges in the region limits access to relevant information especially at the University of Enugu Teaching Hospital (UMTH) and University of Enugu libraries.

1.7 OPERATIONAL DEFINATION OF TERMS

Gestational diabetes mellitus:

Gestational diabetes mellitus is defined by the world health organization as being “any degree of glucose intolerance with onset or first recognition during pregnancy” and should therefore include glucose readings that fall within diagnostic ranges for diabetes.

Prevalence:

Refers to the total number of cases of a disease in the given statistical population at a given time. According to Wikipedia free encyclopedia, in epidemiology, it is the proportion found to have a condition (typically a disease or risk factor). It arrived by comparing the number of people found to have a condition with the total number of people studied. Usually expressed as a fraction, percentage or as a number of cases per 100,000 people.

Risk factors:

This refers to something that increases a person’s chances of developing a disease eg. Cigarette smoking is a risk factor for lung cancer, and obesity is a risk factor for heart disease.

Glucose tolerance (impaired):

Is a situation whereby blood glucose is raised beyond normal range but not high to cause diabetes. It is a risk factor for diabetes.

Insulin resistance:

Is a condition in which the body produces insulin but does not use it effectively.

Morbidity:

The incidence of a disease and the rate of a population affected. Or the quality of being unhealthful, morbid.

Mortality:

This is the condition of being susceptible to death or the death rate of a population.

Prenatal care:

Refers to the care given to pregnant woman before birth. Also known as antenatal care.

Perinatal outcomes:

These are outcomes pertaining to the time around birth.

1.7 LIMITATIONS OF THE STUDY

The limitations of the study are real or perceived problems which have been identified in the course of the study. They are almost beyond our control and are associated with the design and methodology which will have impact or influence on the application or interpretation of the result of this study. Some of these limitations are:

Limited funds and resources: because of severe resource constraints, the study focuses on few antenatal clinics. This limits the extent to which other data sources are explored which may provide additional information for this study.
Small sample size: A sample size for the survey in this study was limited to only 250 participants.
Short period for the research: The period within which the study was conducted is restrictively short. More time is required to ensure wider coverage.
Language barrier:

Though the questionnaire was designed in English language, with little or no contributions from the research assistants that volunteered in administering it , the research assistants were given short training on how to administer it. Languages were still a challenge as most interactions were done in local languages ( kanuri and hausa). Few reported having difficulty with the participants understanding some of the questions.