Can gestational diabetes explain Cameroon's maternal deaths? 

Measuring. A diabetes nurse checks the blood pressure of a pregnant woman
as part of screening for gestational diabetes.

For every 100 live births in Cameroon, one woman dies. The known causes are infections,  haemorrhage, eclampsia and pre-eclampsia. But many of the deaths remain unexplained. A team of diabetologists headed by Dr. Eugene Sobngwi has initiated a project focusing on gestational diabetes in Cameroon. They hope to find the cause behind some of the currently unexplained fetal and maternal deaths.

Cameroon today has a national diabetes programme, which developed as a result of funding from the World Diabetes Foundation dating back to 2003. However, this programme has very little information about gestational diabetes, and furthermore, the African guidelines for diabetes hardly say anything about gestational diabetes or how to screen for it. The lack of mentioning of gestational diabetes was one of the main driving forces for Dr. Sobngwi and his team to embark on this project which aims at raising awareness, build capacity, and provide key data on the magnitude and outcome of gestational diabetes in urban and rural Cameroon.

“In our observations, we realised that there was no uniform practical approach towards gestational diabetes. And people, including health authorities, basically ignored the problem, “ says Dr. Sobngwi who received his basic medical training in Cameroon and later has studied both in France and the UK as an endocrinologist and diabetologist. He currently works at the Yaoundé Central Hospital, the University of Yaoundé 1 and the University of Newcastle upon Tyne. “Upon receiving training in gestational diabetes, I felt a responsibility to clarify the situation and provide training and information – as well as capacity to the Ministry of Health in Cameroon,” he comments.

Good access to care

The access to ante-natal care in Cameroon is good and almost free of charge. This has a positive impact on the antenatal attendance which is as high as 82%. However, the knowledge of diabetes and its risk factors is almost non-existent among pregnant women, the health care personnel rarely know about gestational diabetes, and they surely do not know how to screen. “In other words, there is no set procedure, and we hope to change that,” says Dr. Sobngwi. 

While there are valid lessons to be learned from the gestational diabetes project in India for example, there is still a need to adjust the protocol to an African setting. “Among a pilot study of 200 women, we found that not all the methods used in India were applicable. The sensitivity of methods was low and as a consequence, we could miss several cases. So, we decided to validate the screening procedure to an African context. We use the same random blood glucose measuring, but the threshold for identifying women at risk is different,” Dr. Sobngwi explains. “I guess what we are doing is finding an African solution to the African problem, as many so poignantly put it.”

Inclusion in the national health budget

The project targets the country’s six southernmost regions: North-West, South-West, West, Littoral, South and Centre. To date 1,078 women have been screened in Bamenda, Yaoundé and Ayos representing urban, semi-urban and rural areas. The overall prevalence of gestational diabetes is 5%, and according to Dr. Sobngwi this rate merely confirms what they expected to find based on the global diabetes prevalence of 6% in Cameroon stated by the Ministry of Health.

“In the ongoing screenings, we expect to find a considerable rate of gestational diabetes because of the many unexplained fetal and maternal deaths. We believe gestational diabetes could be part of that problem,” Dr. Sobngwi says. While the analyses of the women screened is currently ongoing, it is too early to say whether gestational diabetes provides some of the explanation to the many unknown causes of fetal and maternal deaths. But one tangible advance made is that gestational diabetes has been found to exist and is now being recognised. The project is being coordinated with the National Diabetes Coordinator to ensure integration into the National Diabetes programme. Furthermore, gestational diabetes is expected to be included in the country’s national health care budget for 2010.

Expecting. Pregnant women wait outside the diabetes clinic at the
University Hospital in Yaoundé to be screened for gestational diabetes.

In search of a cost effective method

Apart from establishing recognition of gestational diabetes in Cameroon, an important objective of the pilot study is to find a cost effective screening method for women in developing countries, in this case Africa. This will enable early and appropriate diagnosis and treatment which will greatly reduce the incidence of complications. According to the project team, the current diagnostic procedure for gestational diabetes recommended by the World Health Organization is cumbersome and unaffordable to a majority of women and health systems in developing countries when the entire pregnant population has to be tested. As a consequence, most of them do not take the test and only a few centres in these countries carry out this type of tests.

Several screening tests exist but the performances and cut-off values may vary from one ethnic group to another. It is therefore important to validate these screening tests in different ethnic groups before recommending them to the general population. Therefore, validation of screening tests and may be cut-off values should be established in various ethnic groups.

Lifestyle education

Experience from a project on gestational diabetes funded by the World Diabetes Foundation in the Indian state of Tamil Nadu has shown that 90% of the women who were found to have gestational diabetes could control their glucose level by modifying their diet.

Patient education is essential for maternal health and it has proven to have many positive effects for mother and outcome. The first part of patient education in this project is about the condition and its implications; the second part about diet and lifestyle. Women are given basic information about gestational diabetes, and are told about the potential risks to them and their baby. Finally, the implications of gestational diabetes during and after pregnancy are explained to them, including the need for more frequent ante-natal visits and follow-up. Luckily, access to ante-natal care in Cameroon is good and is almost free of charge, which is an important base for recommending more anta-natal visits.

“As part of the patient education, we tell them to modify their diet, i.e. reduce fats and rapidly absorbed sugars and increase the consumption of vegetables. With regards to physical activity, we generally tell the women to use walking as the main means of commuting,” tells Dr. Sobngwi. Asked whether there is a cultural barrier to women doing sports, Dr. Sobngwi has no clear answer – yet! Instead he refers to a recent pilot study among 25 women with diabetes in Yaoundé. During 12 weeks a sports trainer made them engage in physical activity at a regular basis, and the changes in hip-to-waist circumference and Hba1c-levels were significant. “This means that now we have documentation that physical activity works and we will include physical activity into this project,” he says. 

Paving a way for the future

The World Diabetes Foundation’s reason for engaging in this project is obvious. “We have very good experience from this type of project in India and we hope to see the same model applied to an African context. A survey and a protocol for gestational diabetes has never been done in Cameroon before, and if the project team succeeds in developing a standard procedure for screening of gestational diabetes, they have achieved a very important objective,” says Programme Coordinator Ms. Astrid Hasselbalch. “Preventing and managing diabetes is important for mother as well as for child, especially because children comprise the future generation,” she comments.   

Although the project is in its very early phase, Dr. Sobngwi has a rather clear picture of the impact he wants to leave if we look five years down the road: “The main objective is that screening for gestational diabetes will be available and performed in all clinics in Cameroon and other African countries. The second is to reduce the adverse outcome of pregnancy with diabetes as a result of raised awareness and screening,” he says, clear and to the point. 

Read more about the project