The variable African diabetic phenotype: tales from the north and the south

Although most African diabetic patients are clearly phenotypically type 1 or 2, some do not easily fit into these categories. Examples are malnutrition-related diabetes mellitus (MRDM) and atypical ketosis-prone type 2 diabetes. To explore this problem we have compared two cohorts of diabetic patients from very different parts of Africa ­ rural KwazuluNatal in South Africa, and Mekelle District in northern Ethiopia. Basic demographic data were collected as well as measurements of blood pressure (BP) and glycated haemoglobin (HbA1c). South African patients were older (56±11 vs 41±16 years, p<0.001) than Ethiopian patients, and more were female (70% vs 30%, p< 0.001). Body mass index (BMI) was higher in South African patients (31.5±6.3 v 20.6±5.4, p<0.001) and 56% were obese (BMI >30.0) compared with 4% in Ethiopia (p<0.001). Hypertension (BP >140/80) affected 80% of South African patients but only 4% of the Ethiopian cohort (p<0.001). Insulin treatment was more common in the Ethiopian patients compared with South Africans (66% vs 25%, p<0.001). Duration of diabetes and HbA1c were similar in both groups. Phenotypically, 96% of the South Africans had typical type 2 diabetes, whereas only 42% of the Ethiopians had such type 2 characteristics (p<0.001). The high occurrence of apparent type 1 diabetes (42%) in the Ethiopian patients, in conjunction with their very low BMI levels and local chronic food shortages, raises the possibility as to whether at least some of this group may have MRDM

Responding to the Maternal Health Care Challenge: the Ethiopian Health Extension Program

Background: Responding to challenges in achieving Millennium Development Goals (MDG); the Ethiopian government initiated the Health Extension Program in 2003 as part of the Health Sector Development Program (HSDP) to improve equitable access to preventive; promotive and select curative health interventions through paid community level health extension workers. Objective: To explore Ethiopia's progress toward achieving MDG 5 that focuses on improved maternal health through the Health Extension Program. Methods: This paper reviews available survey data and literature to determine the feasibility of reaching the targets specified for MDG 5 and for HSDP. Important findings: Achieving the set targets is a daunting task despite reaching the physical targets of two health extension workers per kebele. The 2015 MDG target for the Maternal Mortality Ratio (MMR) is 218 while the 2005 MMR estimate is 673. The HSDP target is 32skilled birth attendant use by 2010 but only about 12use was found in the four most populated regions of the country in 2009. Conclusions: Accelerating progress towards these targets is possible through the Health Extension Program at the worker level through improved promotion of family planning and specific maternal interventions; such as misoprostol for active management of third stage of labor; immediate postpartum visits; and improved coordination from community to referral level

Utilization of Post-Abortion Care Services in Three Regional States of Ethiopia

Background: In Ethiopia; utilization of post-abortion care service is minimal and it seems that the expanding services are underutilized. The purpose of this study was to assess factors which influence decisions for utilization of abortion related services at community level. Methodology: The study was carried out in six selected districts (woredas) within the three big regions of the country; namely Amhara; Oromiya and SNNPR. The study employed a descriptive cross-sectional design. Both quantitative and qualitative study techniques; including structured interview questionnaires; focus group discussions (FGDs); and in-depth interviews. The study population comprised randomly selected 1;492 women of reproductive age; service providers; and key informants of the sampled districts. Results: Majority of respondents said that they prefer public health facilities. According to the respondents; the reason why women do not visit health facility for PAC services include lack of community support; unavailability of services; services are expensive; facilities are distantly located and lack of means of transportation. From the multivariate analysis it appears that public health facilities are preferred by younger respondents; those with no education; those with no history of unwanted pregnancy and those with better income. The qualitative study indicated that women do not go to health facilities for PAC mainly because of inappropriate treatment by providers at the health facilities. Conclusion: Public health facilities especially health centers are the most preferred but there are barriers that should improve. Introduction of supportive supervision should be considered as a tool for improving quality of care. A mechanism should be in place to obtain community opinion regularly and use it to continuously improve services. To correct some misconceptions and improve community awareness on abortion related issues community providers; including reproductive health agents and health extension workers can teach about availability of services and about abortion related complications

Diabetic complications and glycaemic control in remote North Africa

Background: Delivery of diabetes services in resource-poor areas of Africa is difficult. Control is often poor and complications are common. However, adequate robust surveys are uncommon, particularly in remote rural areas. This makes needs assessment difficult and health-care planning impossible. Aim: To accurately assess the glycaemic control and burden of complications in a group of diabetic patients from a remote area of a resource-limited north African country. Design: Prospective cohort study. Methods: Over a 6-week period, all patients attending the diabetic clinic at Mekelle Hospital in northern Ethiopia were intensively assessed, using imported western technology as necessary. Glycated haemoglobin (HbA1c), lipid profile, serum creatinine and urinary albumin­creatinine ratio were measured. Complications were assessed as accurately as possible, including examination of fundi by an ophthalmic specialist, and biosthesiometry for neuropathy. Results: There were 105 patients, mean (± SD) age 41 ± 16 years and diabetes duration 7 ± 6 years. There were 74 (70%) males, and 69 (66%) on insulin. Median body mass index was low at 20.6 kg/m2, but mean HbA1c high at 11.3 ± 2.8% (68% had an HbA1c over 10.0%). Cataract (12%), retinopathy (21%), neuropathy (41%) and microalbuminuria (51%) were common; but nephropathy (2%) was rare, as was large vessel disease (6% had peripheral vascular disease, and none had coronary artery disease or cerebrovascular disease). Risk factors such as hypertension (5%) and smoking (2%) were uncommon, and lipid profiles were generally good. Discussion: We conclude that in this severely resource-limited area of North Africa, glycaemic control amongst diabetic patients is very poor. Neuropathy, retinopathy and microalbuminuria are common; but large vessel disease risk factors are beneficial, and macroangiopathy prevalence is low. Scattered populations, shortage of drugs and insulin and lack of diabetes team care are major factors behind these serious issues of diabetic control and complications