CHAPTER ONE
INTRODUCTION
Background of the study
Pregnancy, or gestation, is a period of approximately 9 months when a woman carries an embryo or fetus in her uterus. The first sign of pregnancy is normally missed menstruation, but there are other signs too. Pregnancy lasts for about 280 days, or 40 weeks. The three stages of pregnancy are known as trimesters. Each one lasts approximately 3 months.Symptoms and early signs of pregnancy include the absence of menstrual periods, breast changes, tiredness, nausea, mood swings, or other symptoms. A pregnancy test measures the level of hormone human chorionic gonadotropin (HCG) in the urine or blood. The test may be positive before the first signs of pregnancy develop in some women(.
Diabetes is generally seen as a chronic, often debilitating and sometimes fatal disease, in which the body either cannot produce insulin or cannot properly use the insulin it produces. Insulin is the hormone that controls the amount of glucose (sugar) in the blood. Diabetes mellitus generally known as diabetes is a group of metabolic disease in which there are high blood sugar levels over a prolonged period of time [World Health Organization (WHO), 2014]. Diabetes is a disease in which the blood glucose comes from the foods we eat. Insulin is a hormone that helps the glucose get into the cells to give them energywith type 1 diabetes, the body does not make insulin (National Institute of Diabetes, [NID], 2018). Insulin dependent mellitus abbreviated as IDDM result from the destruction of the pancreas occurring most commonly in childhood or adolescence. With type 2 diabetes mellitus, abbreviated NIDDM or maturity onset diabetes is due to an insufficiency of insulin and usually occurs after the age of 40years without enough insulin, the glucose stays in the blood. Individualcan also have prediabetes this means that the blood sugar is higher than normal but not high enough to be called diabetes. Having prediabetes puts people at a higher risk of getting type 2 diabetes (NID, 2018).
The public health burden of diabetes hasdramatically increased worldwide. Not only its prevalencerate at present, but the increase of its incidence in thenear future can create a global health problem. Thenumber of subjects with diabetes will increase from atpresent 415 million to 642 million by the year 2040 (International DiabetesFederation, (IDF), 2015).Diabetes is a metabolic disorder of multiple etiology characterized by chronic hyper glycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both (WHO, 2011). In chronic hyper glycaemia of diabetes in association with long term damage, dysfunction and failure of various organs, primarily the eyes, kidney, nerves, heart and blood vessels.
Gestational diabetes mellitus (GDM) resembles type 2 diabetes in several aspect, involving a combinational of relatively inadequate insulin secretion and responsiveness. It occurs in about 2-10% of all pregnancies and may improve or disappear after delivery. However, after the pregnancy approximately 5-10% of women with gestational diabetes are found to have diabetes mellitus. In pregnancy, diabetes can either predate the pregnancy (pre-gestational) or be discovered first during the pregnancy (gestational). Whichever the scenario, the risks are similar for the mother and the fetus. Slight difference is only related to what will happen in gestational diabetes after delivery thus: whether the disorder will persist or revert and if it reverts, there are lots of controversies surrounding the management of diabetes mellitus in pregnancy (Dim, Okafor, Ikeme& Anyahie, 2013). Likewise, worrisome low knowledge of diabetes in pregnancy and high level of patients' mismanagement have been observed among health practitioners involved in maternal health.
In2015, there were 199.5 million women with diabetes and60 million of them of reproductive age (18-44 years old) (IDF, 2015).It is estimated that about 5-20% of pregnancies in theworld complicated by diabetes. It varies betweendifferent racial and socioeconomic groups while most of thewomen in developing and underdeveloped countriesremain undetected and many are detected duringmedical checkup for pregnancy. Hyper glycaemiain pregnancy is classifiedinto three main types: diabetes detected prior topregnancy or preexisting diabetes (type 1 and type 2),diabetes first detected in pregnancy and gestationaldiabetes mellitus (GDM) which is defined as degree ofglucose intolerance with onset or first recognized duringpregnancy. One in seven births is affected by GDM.According to IDF (2015) report, 20.9 million (16.2%) live birthswere affected by hyper glycaemia in pregnancy and an estimated 85.1% of those cases were due to gestational diabetes, 7.4% due to other types of diabetes firstdetected in pregnancy and 7.5%due to diabetes detectedprior to pregnancy.
It is expected that gestational diabetes occurs in up to 10% of all pregnancies, reaching higher incidence in developed countries, especially in the United States (Desisto, Kim & Sharma, 2014). Epidemiological data also suggest an alarming increase in the number of cases over the last few years (Albrecht, Kuklina & Callaghan, 2010). Therefore, whereas extensive research has focused on unraveling the consequences of obesity and type 2 diabetes (T2D), the long-term effects of gestational diabetes have been poorly scrutinized and are possibly underestimated (Poston, 2011). It is now known that women who developed insulin resistance during pregnancy have a six-fold increase in the risk of developing type 2 diabetes later in life compared to women who remained euglycemic.However, more recent and concerning evidence point to detrimental effects of gestational diabetes on the development, metabolism and behaviour of the offspring (Daraki&Roumeliotaki, 2017).
Considering that the perinatal period is critical for determination of adult behavior, including levels of anxiety, impulsivity and stress responses (Bolton & Bilbo, 2014).It is expected that the intra-uterine exposure to hyperglycaemia, hyperinsulinemia and proinflammatory mediators, hallmark features of gestational diabetes, might have other consequences to both brain function and behaviour. Animal models have been extremely useful in providing insights into this question. However, since gestational diabetes is a transient and multifactorial condition, animal models that recapitulate all aspects of the disease remain challenging (Pasek & Gannon, 2013). Both pre-gestational type 1 and type 2 diabetes confer significantly greater maternal and fetal risk than gestational diabetes mellitus. In general, specific risks of uncontrolled diabetes in pregnancy include spontaneous abortion, fetal anomalies, preeclampsia, intrauterine fetal demise, macrosomia, neonatal hypo glycaemia, and neonatal hyperbilirubinemia, among others. In addition, diabetes in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later in life (Young & Patterson, 2011).
Hyperglycaemia is the most common metabolic disorder complicating pregnancies across the globewith rising maternal age, obesity, physical inactivity and increasingly stringent diagnostic criteria, about one in seven women now has a pregnancy complicated by hyperglycemia (Young & Patterson, 2011). Emerging evidence suggests that the intrauterine and early postnatal environment can influence cardiovascular and metabolic health in later life. Maternal hyperglycaemia in gestational diabetes mellitus (GDM) is thought to confer a greater risk of diabetes and obesity in exposed offspring via fetal programming. Most human studies in this area are observational and therefore cannot control for transmission of risk from parent to child by shared genetic and environmental susceptibility.
Statement of the problem
Gestational diabetes mellitus can have significant impact on pregnant woman and birth outcomes, especially babies having macrosomia. The prevalence of diabetes among pregnant women diagnosed with and without gestational diabetes mellitus is alarming. The researcher observed thatsome pregnant women are unaware of the effects of gestational diabetes mellitus. Also observed that knowledge of diabetes among mothers can help decrease birth complications and outcomes. Poth and Carolan (2013) reported that the lack of appropriate knowledge of lifestyle and diet to prevent gestational diabetes mellitus has significant impact on birth outcomes. The researcher observed that most children who are born from mothers with gestational diabetes mellitus are likely to have health-related complications later in life and be at risk of infant death. Findings from other researchersrevealed that most infants born to gestational diabetes mothers are at risk of developing macrosomia. The researcher observed that pre-eclampsia is common among pregnant women which when not well taken care of can lead to eclampsia. Based on the above statement the researcher intends to assess the knowledge of effects of diabetes on pregnant women in Ikere local government area of Ekiti State.
Purpose of the study
The main objectives of this study was to assess the knowledge of effects of diabetes on pregnant women in Ikere local government area of Ekiti State. Specifically, the study seeks to:
1. investigate if miscarriage is an effect of diabetes among pregnant women in Ikere local government area of Ekiti State.
2. ascertain if pre-eclampsia is an effect of diabetes among pregnant women in Ikere local government area of Ekiti State.
3. examine if neonatal mortality is an effect of diabetes among pregnant women in Ikere local government area of Ekiti State.
4. find out if premature birthis an effect of diabetes among pregnant women in Ikere local government area of Ekiti State.
5. determine if complicated labour is an effect of diabetes among pregnant women in Ikere local government area of Ekiti State.
6. Assess respondents attitude toward diabetes mellitus among pregnant women in Ikere local government area of Ekiti State.
Significance of the study
The findings of the study will help pregnant women to have deeper and adequate understanding on the effects of diabetes to their health and that of their babies. Also, it will provide information to them on the need for taking diabetes prevention steps very serious and enhance the chance of safe delivery.
The study will help the health practitioner to have more knowledge about the complications that may occur to pregnant women and their babies as a result of diabetes and this will help them to provide counter-attack measures that will safe pregnant women.It will also help to broaden the knowledge of midwifery in handling and managing pregnant women who may be suffering from diabetes effects and helps to give adequate medical attention.
The finding of the study will help the government to know the possible measures to be provided in reducing the rate of occurrence of diabetes among pregnant women.
The findings of the study will provide pool of information, knowledge and references for future researchers and general public on the possible effects of diabetes among pregnant women.
Scope of the study
The study was delimited to assessing the knowledge of effects of diabetes on pregnant women in Ikere local government area of Ekiti State. The research involved independent variables of effects of diabetes such as:miscarriage, pre-eclampsia, neonatal mortality, premature birth, complicated labour and respondents attitude while dependent variable waspregnant women. Two research assistants were trained by the researchers to assist in data collection of the study. The research instrument for the study was a self-design questionnaire and the statistical analysis of Chi-square (x2)was used. The SPSS (Statistical Package for Social Sciences) computerized software of version 20 was used to analyse the data collected.
Research questions
This study was guided by these research questions:
1. Willmiscarriage be an effect of diabetes among pregnant women in Ikere local government area of Ekiti State?
2. Will pre-eclampsiabe an effect of diabetes among pregnant women in Ikere local government area of Ekiti State?
3. Will neonatal mortality be an effect of diabetes among pregnant women in Ikere local government area of Ekiti State?
4. Willpremature birth be an effect of diabetes among pregnant women in Ikere local government area of Ekiti State?
5. Willcomplicated labour be an effect of diabetes among pregnant women in Ikere local government area of Ekiti State?
6. What is therespondents’ attitude toward diabetes mellitus among pregnant women in Ikere local government area of Ekiti State?
Hypotheses
Based on the research questions of the study, these hypotheses were formulated for testing:
1. There is no significant miscarriage as an effect of diabetes among pregnant women in Ikere local government area of Ekiti State.
2. There is no significant pre-eclampsiaas an effect of diabetes among pregnant women in Ikere local government area of Ekiti State.
3. There is no significant neonatal mortalityas an effectof diabetes among pregnant women in Ikere local government area of Ekiti State.
4. There is no significant premature birth as an effect of diabetes among pregnant women in Ikere local government area of Ekiti State.
5. There is no significant complicated labour as an effect of diabetes among pregnant women in Ikere local government area of Ekiti State.
6. There is no significant respondents’ attitude toward diabetes mellitus among pregnant women in Ikere local government area of Ekiti State.
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