Diabetes in Pregnancy in Sub-Saharan Africa: An Overview

By Nr  Chinonso Cynthia Ukah. BNSc, RN, RM. Freelance Health Writer and DLHA Volunteer. Medically reviewed by the DLHA Team

A pregnant black woman holding her bulging abdomen in her hands.

 

Highlights

• Two different forms or clinical appearance of diabetes may be seen in pregnancy; pregestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM).
• PGDM refers to pre-existing Type 1 or Type 2 diabetes before pregnancy; whereas, GDM typically develops in the second half of pregnancy.
• GDM in sub-Saharan Africa occurs in nearly 1 in 7 (or 14% of) pregnancies.
• Researchers do not know why some women get GDM and other don't. 
• Risk factors include obesity, hypertension, family history, and ethnicity (race)
• Management involves lifestyle modifications, blood sugar monitoring, and sometimes medication
• Prevention strategies include maintaining a healthy weight, balanced diet, and regular exercise

 

Introduction 

Diabetes in pregnancy can develop when a woman is pregnant or before she gets pregnant. [1] Regardless of when it develops, it causes a higher than normal amount of blood sugar to be present in the blood. This is harmful to both mother and her unborn child.

The purpose of this article is to explain the different forms of diabetes in pregnancy to African women and men, so that they have information that would help in securing better pregnancy outcome for themselves and their baby. The information provided is not a substitute for the professional counsel and care that you will obtain from your healthcare providers, but it will cover the types, causes, risk factors, and ways of prevention and management of diabetes in pregnancy. 

If you have any concerns or questions, always feel free to speak with your doctor or midwife.

 

What are the forms of diabetes in pregnancy?

There are two forms of diabetes that women globally and in Africa can experience while pregnant:

• Pregestational diabetes mellitus (PGDM), and 
• Gestational diabetes mellitus (GDM).

Pregestational diabetes mellitus (PGDM)

PGDM refers to diabetes that exists before pregnancy, including both Type 1 and Type 2 diabetes. Studies show that among diabetic women under 49 years old, about 1% who become pregnant face complications related to their pre-existing diabetes. [1]

If you are diabetic and intend to get pregnant, keeping your blood sugar levels at a normal range before you conceive and during the first trimester is very important. These periods are critical points where uncontrolled type 1 or 2 DM can cause spontaneous abortions, stillbirths, and newborn deaths. 

These are saddening experiences for women and their partners considering how long a woman carries a baby in her womb and losing it in the end.

 

 

Related: Type 1 Diabetes Mellitus: An Explainer for Africans and Type 2 Diabetes: What Africans Need to Know 

 

Gestational diabetes (GDM)

This is first detected when a woman is pregnant and usually develops in the second half of pregnancy. It is a condition caused by a hormone(s) that is made during pregnancy, which lets sugar (glucose) to build up in the blood instead of being absorbed by the cells. The estimated global occurrence of GDM is said to be 1.7 to 15.7 percent depending on the woman's ethnic origin, her age, and the basis of diagnosis. [1]

GDM can cause several complications in the unborn baby, like:

• Higher odds of death before or after birth
• Big size baby with labour complications
• Delay in brain development, causing such disorders as a baby born with no brain, baby born with fluid filled brain (also known as hydrocephalus), etc.

Diabetic mothers generally, usually give birth to very large babies which is termed macrosomia. Good control of blood sugar levels during pregancy can reduce the possibility of these complications arising.

Prevalence of gestational diabetes in Africa

Gestational diabetes is a common pregnancy complication affecting about 15% of pregnant women worldwide, or roughly 1 in 7 pregnancies. Its prevalence varies significantly by location. For instance, in sub-Saharan Africa, it affects around 14% of pregnant women, while in Ethiopia, there's a notable urban-rural divide with 13% prevalence in cities compared to 5% in rural areas. Importantly, the incidence of gestational diabetes is on the rise with more cases being reported from low- and middle-income countries such as those in sub-Saharan Africa. [2]

 

What causes diabetes in pregnancy?

For pregestational diabetes, the causes are the same as those responsible for type 1 and type 2 diabetes.

The cause of GDM is not known, but there are strong scientific speculations (theories) as to why the condition occurs. A placental hormone known as lactogen has been identified as a major cause of diabetes in pregnancy. [3] In nondiabetic pregnant women, its function is to reduce the blood sugar levels to normal levels thus avoiding any form of diabetes.

This hormone acts in reverse in diabetic pregnant women. Here, it increases insulin resistance, thus preventing the high sugar in the blood from going into the woman's body cells. This accumulates and causes diabetes in pregnancy. [3]

 

What are the risk factors for diabetes in pregnancy?

These risk factors include:

• Being overweight or obese
• Being hypertensive
• Having had a large baby (over 3.5 kg) in a previous pregnancy
• Having had gestational diabetes before
• Having a family history of diabetes
• Black race [3]

 

How can you know if you have diabetes during your pregnancy?

The truth is, you may may have diabetes in pregnancy and don't know that you do, because you have no identifiable health issues (symptoms). When you have symptoms, they may include the following:

• An increased need to drink water
• An increased need to pee more often than usual
• Always getting tired
• A dry mouth
• Blurred eyesight
• Itching around the genital area or thrush (a yeast infection caused by a fungus or mold)

 

How is diabetes in pregnancy diagnosed in African women?

The diagnosis of gestational diabetes involves your doctor taking a history and performing a physical examination. At the end of the examination, your doctor may ask you to take some tests to confirm if you have diabetes in pregnancy or not.

At what time during pregnancy is diabetes testing done?

Doctors usually test for gestational diabetes between 24-28 weeks of pregnancy. [4] This timing is chosen because:

1. Your body naturally becomes more resistant to insulin as pregnancy progresses.

2. Testing too early might miss some cases.

3. Testing too late doesn't leave enough time for its proper management before delivery occurs. [4]

How does diabetes testing work?

There are two ways that you may be tested for diabetes during pregnancy.

1. One-step method

You'll drink a measured quantity of glucose solution and have your blood sugar tested after 2 hours. This is called an oral glucose tolerance test (OGTT). [4]

2. Two-step method

• First, you'll drink a glucose solution and have your blood sugar tested after 1 hour.

• If your blood sugar is high in this first test, you'll do a second, longer test on another day to confirm. [4]

Who should be tested?

All pregnant women should get tested for diabetes in pregnancy. However, due to screening limitations, healthcare providers in some countries in Africa only test those women who present with some of the risk factors discussed earlier.

Should you get tested for diabetes after your pregnancy?

If you're diagnosed with gestational diabetes (GDM), you'll need another test about 6 weeks after giving birth to make sure your blood sugar has returned to normal. [4]

Many women who develop gestational diabetes have healthy pregnancies and babies with proper management. That is why early detection and proper management comes first. If you have any concerns or questions, always feel free to ask your doctor or midwife.

 

How is diabetes in pregnancy managed?

Your doctor or midwife may recommend one or all of the 3 steps of treatment for you to follow depending on the level of sugar in your blood and your risk level. These are:

• Lifestyle modifications
• Blood sugar monitoring
• Medication

Lifestyle modification 

This involves: 

• Exercise: Your healthcare providers might ask you to get about 30 minutes of moderate exercise, like brisk walking for 5 days every week. Even a short walk after meals can help control your blood sugar.

• Diet: You may be asked to work with a dietitian to create a meal plan that's right for you. Generally, it's good to eat smaller, more frequent meals throughout the day. Your focus should be on whole grains, lean proteins, healthy fats and eating fewer carbs at breakfast.

• Weight management: You may also be advised on ways to maintain a healthy weight gain during your pregnancy based on your starting weight.

Blood sugar monitoring

This is very important for women getting insulin injection to treat their diabetes in pregnancy. Regular blood sugar monitoring helps you know the right dose to inject each day.

• You'll need to check your blood sugar 4 times a day - once when you wake up (fasting) and after each meal.

• You will be taught how to use a glucose meter and keep a written record (log or diary) of your readings.

Medication

Medications in common use in the treatment of diabetes in pregnancy may include:

• Insulin

This is often a first choice if medication is needed. It's safe for the baby because it doesn't cross the placenta. You'll be taught how to give yourself insulin injections and adjust the dose based on your blood sugar readings.

• Oral medications

Sometimes, pills like metformin are used but only after careful consideration. These can have some more severe side effects compared to insulin.

 

Related: Management of type two diabetes in Nigeria

 

How do I prevent diabetes in pregnancy?

There are proven ways to prevent diabetes in pregnancy if you have any of the risk factors that were previously discussed. These are:

• Maintain a healthy weight before and during pregnancy.

• Follow a balanced, nutritious diet. Work with a dietitian if you're overweight or obese to make appropriate dietary changes.

• Get regular exercise. Researchers suggest at least 30 minutes of strenuous activity 3-4 days per week, like swimming, cycling or brisk walking. Always check with your doctor about the exercises that are suitable for you.

• Monitor your blood sugar levels as recommended by your healthcare provider if you are already diabetic.

• Consider taking a special supplement (myo-inositol) as recommended by your healthcare provider, as this helps the insulin in your body to work better. [6]

• Attend all prenatal and antenatal appointments when they are due and follow your healthcare provider's advice.

• If you have risk factors like being overweight, having a family history of diabetes, or belonging to certain ethnic groups, be extra vigilant about these prevention strategies.

• Avoid excessive weight gain during pregnancy by following the recommended guidelines for weight gain in pregnancy. This usually depends on your weight before getting pregnant. [6]

 

Conclusion

Diabetes in pregnancy, whether pregestational or gestational, poses significant risks to both mother and baby. However, with early detection, proper management, and preventive measures, these risks can be substantially reduced or contained.

African women, particularly those with risk factors, should be vigilant about their health before and during pregnancy. Undertaking regular prenatal check-ups, maintaining a healthy lifestyle, and following medical advice are important steps to adopt in ensuring a healthy pregnancy and baby.

As the prevalence of diabetes in pregnancy continues to rise, especially in countries in sub-Sagaran Africa, raising awareness and improving access to screening and management resources becomes increasingly important.

Healthcare providers, public health managers, and community stakeholders in health like the media community associations, traditional and religious leaders, influencers should work together to raise more awareness in order to reduce the incidence of diabetes in pregnancy in the region..

 

References 

1. Ornoy A, Becker M, Weinstein-Fudim L, Ergaz Z. Diabetes during pregnancy: a maternal disease complicating the course of pregnancy with long-term deleterious effects on the offspring. a clinical review. Int J Mol Sci. 2021 Mar 15;22(6):2965. doi: 10.3390/ijms22062965. Available from here.

2. Tola A, Assefa N, Dessie Y, et al. Epidemiology of hyperglycemia during pregnancy in Ethiopia: prevalence, associated factors, and feto-maternal outcomes: systematic review and meta-analysis. Syst Rev. 2024;13:116. doi: 10.1186/s13643-024-02526-z. Available from here.

3. Quintanilla Rodriguez BS, Vadakekut ES, Mahdy H. Gestational Diabetes. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [updated 2024 Jul 14]. Available from here.

4. Moon JH, Jang HC. Gestational Diabetes Mellitus: Diagnostic Approaches and Maternal-Offspring Complications. Diabetes Metab J. 2022 Jan;46(1):3-14. doi: 10.4093/dmj.2021.0335. Available from here.

5. Rani PR, Begum J. Screening and Diagnosis of Gestational Diabetes Mellitus, Where Do We Stand. J Clin Diagn Res. 2016 Apr;10(4):QE01-QE04. doi: 10.7860/JCDR/2016/17588.7689. Available from here.

6. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Gestational diabetes: Learn More – What can help prevent gestational diabetes? [Updated 2024 Apr 17]. Available from here.

 

 

 

Related: Complications of Diabetes in Pregnancy: What African Women Need to Know

 

 

 

Published: October 11, 2024

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