Study Shows Gestational Diabetes a Hidden Threat to Maternal and Neonatal Health in sub-Saharan Africa

High rates of gestational diabetes may be a hidden factor in the continuing high ratios of maternal and neonatal mortality in sub-Saharan Africa, yet relatively easy and low-cost interventions could reverse the trend, according to a recent study conducted in Ethiopia by MSH.

“Diabetes is a massive problem and completely overlooked for women in Ethiopia and other poor countries and could explain why maternal mortality rates are stagnating while other basic health indicators continue to improve,” said Dr. Elke Konings, MSH senior principal technical adviser and one of the lead authors of the study. “Screening for and managing gestational diabetes may be the key to lowering maternal and neonatal mortality rates in developing countries.”

Without proper care, diabetes, whether pre-existing or gestational, increases the risk of eclampsia, miscarriage, obstructed labor, hemorrhage, and intrauterine fetal death, yet pregnant women in developing countries are rarely screened for the condition. Gestational diabetes is also a leading risk factor for preterm birth.

In marking International Women’s Day on March 8, Management Sciences for Health, the International Diabetes Federation (IDF), and the NCD Alliance are calling for recognition of gestational diabetes as a priority maternal and newborn health issue, especially in sub-Saharan Africa where a woman’s lifetime risk of dying during pregnancy or childbirth is 1 in 38, compared to 1 in 3,700 in the developed world according to the World Health Organization. 

The Ethiopia study was conducted at one rural and two urban public health centers in the northern Tigray region. It found that 11 percent of 1,242 pregnant women screened positive for gestational diabetes, which is higher than the US Centers for Disease Control and Prevention estimate of 9 percent in the United States, where risk factors such as obesity and urban residence are more common. Seventy-nine percent of the women diagnosed with diabetes in the study responded well to simple behavioral interventions, including dietary changes and increased physical activity.

“The Ethiopia study underlines the high prevalence of diabetes during pregnancy, which is a seldom studied but important cause of maternal and neonatal morbidity in low- and lower-middle income countries,” said Dr. Luis Tam, MSH global technical lead for maternal, newborn, and child health. “On the contrary, diabetes during pregnancy is well-researched and acted upon in higher-income countries. If we want to make further progress in reducing the high ratio of maternal mortality in developing countries, diabetes must be addressed.”

Under Millennium Development Goal (MDG) 5, countries around the world committed to reducing maternal mortality by three-quarters between 1990 and 2015. In those 25 years, maternal deaths have dropped 45 percent globally, but few African countries have made that achievement.

 “International Women’s Day is an opportunity to reflect on progress made on gender equality, and redouble efforts on new challenges facing girls and women in the 21^st century. Gestational diabetes for too long has been an overlooked maternal and newborn health issue,” said Katie Dain, executive director, NCD Alliance. “Concerted action on gestational diabetes has the potential to accelerate progress toward the MDGs, and simultaneously curb the growing burden of noncommunicable diseases (NCDs). It is a win-win situation.” 

 As in many developing nations, in Ethiopia diabetes screening is not a routine part of antenatal care in public health facilities and an estimated 80 percent of cases are undiagnosed. The disease is rarely registered as the underlying cause of maternal death, yet is likely a contributing factor in many cases.

 “Our Diabetes Atlas estimates that 13 percent of all births, or 3.7 million, in sub-Saharan Africa are affected by gestational diabetes,” said Dr. David Cavan, IDF director of policy and programs. “Diagnosing and managing gestational diabetes in a timely and appropriate way is pivotal for the future good health of mother and child.”

Globally, diabetes is much more common than HIV and TB combined. In Ethiopia, IDF estimates that 1.4 million people are living with the disease – twice the number living with HIV. Yet over half of all US government foreign assistance funding for health is allocated to HIV and TB and a tiny fraction goes toward diabetes.

“Because we have done a good job with public health efforts in general, people are now living longer,” said Dr. Gloria Sangiwa, MSH global technical lead, chronic diseases. “Diabetes is a pressing health challenge that demands that people, organizations, communities, and nations work together and make it a political priority to create a better future for those affected by the disease.”

Sangiwa said the response to HIV/AIDS has shown that Africa and its partners can effectively address these complex health challenges.

“In Ethiopia, diabetes is at least twice as prevalent as HIV, yet it’s easier to manage and has much less stigma. Unlike HIV infection, diabetes is reversible if diagnosed early on, and it is relatively affordable to manage,” Konings said. “We have every reason to pay attention to it and provide diabetes services to all pregnant women in the world, not only those living in rich countries.”

Although the MSH Ethiopia study is small, it is consistent with other similar studies in Africa, and the results make the case for prioritizing both research and interventions for gestational diabetes in Ethiopia and the rest of the developing world. MSH is conducting gestational diabetes research in Nigeria, sub-Saharan Africa’s most populous nation, which has among the highest number of maternal deaths in the world each year.

The Nigerian project empowers women to manage their blood glucose levels at home by using the low-cost GDm-Health glucometer, a smartphone-based system that records blood glucose levels and transmits data directly to health care professionals who interpret the results for the patient and advise next steps.

“We are able to reach women in remote areas through mobile phones,” said Dr. Zipporah Kpamor, MSH Nigeria country representative. “The woman does a pinprick, puts the blood on a sensitized strip, the glucometer reads the results, and the results go through a Bluetooth device to a phone, and then to a tablet accessed by a health worker.”

Kpamor emphasized the importance of addressing diabetes early to prevent a cycle of disease. Gestational diabetes is associated with an increased risk for Type 2 diabetes and other NCDs, such as obesity and hypertension, for the woman, child, and potentially future generations. Four out of five adults with diabetes live in low- and middle-income countries, according to IDF.