This study aimed to explore the factors that facilitated or hindered GDM self-management among a group of women attending for pregnancy care in a low socio-economic setting. Findings suggest that women encountered a number of barriers in their quest to self-manage their condition. This included difficulty comprehending the urgency of immediate diet control. Most women spoke of the challenge of implementing a complex regimen of blood testing and dietary manipulation, within a very short time frame, while they were still coming to terms with the shock of diagnosis. Many reported commencing on insulin within 1–2 weeks of GDM diagnosis, and some women felt they would have mastered the requisite GDM self-management behaviours in a more generous time frame. This urgency of immediate treatment of maternal hyperglycaemia is echoed in the literature, where an immediate reduction of maternal blood glucose is recommended in order to minimize adverse pregnancy outcomes [13, 49]. Moreover, recent studies also indicate that maternal hyperglycaemia, at lower levels that those previously recognised, has a detrimental effect on fetal welfare  and this finding has further increased pressure on health professionals to effect an immediate reduction in maternal blood glucose levels .
Participants in this study, found dietary self-management difficult, related to the time required to learn food values, and to cook healthy food. Social factors such as eating with family and friends also contributed to the dilemmas women faced, while a lack of clear guidelines was identified as hindering the process of diet control. Only two study participants succeeded in self-managing their GDM without insulin and both women, identified personal character strengths and determination as assisting them to master the necessary skills and behaviours. This very low rate of non-insulin use was a surprising finding, particularly as women were recruited on a first come basis rather than on the basis of management regimens. However, further explication of this finding is beyond the scope of this qualitative study of women’s experience and future quantitative evaluation is recommended. The finding may be incidental, however, it is consistent with generally higher use of insulin at the clinic where limited maternal education and understanding are thought to impact on poorer dietary adherence and higher rates of hyperglycaemia [19, 20]. Whatever the reasons, rates of dietary self-management alone were considerably lower, among study participants than the recommended 65–90% of women discussed in the literature [24–26]. This feature may also reflect limited appropriate, culturally based educational resources for women in this area.
In general, dietary self-management is recognised as challenging [50, 51] and as requiring motivation, understanding of food values and of the amount to eat . This knowledge and motivation may have been deficient in our population due to their social circumstances and may have also been affected by cultural beliefs about particular foods, such as rice. Many participants struggled to believe that traditional foods such as rice could be considered ‘bad’ food, in terms of excess calories, related to portion sizes. Parallel findings present in the literature and dietary change is recognized as difficult to achieve, particularly among low socio-economic and migrant groups [52, 53]. Such difficulties relate to cultural mores, views about traditional foods and a lack of appropriate food alternatives [50, 51, 53, 54]. Many participants in our study were hesitant to change their diet, while at the same time they were willing to eat less in order to avoid hyperglycaemia. Parallel findings present in the literature, and participants in Rhoads-Baeza and Reis’ study among low income Latino women with GDM, were also reluctant to change from their traditional consumption of fatty meats to healthier alternatives . On the other hand, Bandyopadhyay et al.  who studied South Asian women with GDM in Australia, found that participants predominantly changed to the recommended diet, but were nonetheless unhappy about the type and quantity of food allowed, and complained of always feeling hungry.
One surprising factor in this study, was the frequency with which women identified the use of insulin as an easier option, rather than dietary control alone. This finding is not evident in the literature and appears to relate to the women’s concerns about hyperglycaemia at the same time as encountering difficulties with dietary restrictions and behavioural change. Women who regarded insulin as easier than diet control alone, expressed limited concerns about insulin use and regarded it simply as a solution to their current dilemma of high blood glucose and difficulty in effecting diet control. None of these women displayed any knowledge of a possible link between insulin use in GDM and subsequent development of type 2 diabetes.
In terms of facilitators, women in this study were intensely interested in maximizing fetal health and this finding of concern for the fetus is echoed in other research on women’s experiences of GDM [53–55]. Concern for the fetus motivated participants to take on the tasks of GDM self-management and, although many women struggled to understand food values and to prepare healthy meals, they remained dedicated to the baby’s welfare. This manifested in the discomfort they endured by eating less than they desired, eating foods they did not enjoy, doing blood glucose levels and administering insulin, and trying to meet with exercise requirements. In the literature, a desire to protect the fetus, or evidence of maternal-fetal attachment, is similarly associated with greater pregnancy investment and adoption of health promoting behaviours, such as healthy diet [56, 57].
Successful GDM self-management in our study was mediated by support from family and health professionals. Women identified husbands and partners as the most important source of psychological support. A less important, but additional form of psychological support was offered by health professionals, including diabetes educators, midwives, doctors, and dieticians. Similar findings of psychological support as important in encouraging GDM self-management, are found in the literature [58, 59]. In particular, the partner’s support is seen as especially valuable in effecting behavioural change such as increasing exercise  while support from health professionals was recognised as encouraging women to view GDM as within their control .
Finally, this study has some limitations and the recruitment of women who could speak conversational English may have excluded many other migrant women in the area. For this reason, a number of interpreter mediated focus group discussions are planned for the future, which will include representation of the most populous ethnic groups in the area. Additionally, this small sample is from one geographical area, which means that the findings cannot be generalised to the Australian population as a whole . However, the intent of the study was not to provide generalisable information, but to explore the facilitators or impediments to GDM self-management, among women in our area. This aim has been achieved and, although findings are not generalisable, they may also be applicable to other similar populations .
Implications for practice
This study has important implications for practice, as rates of GDM continue to increase globally, particularly among women with risk factors such as obesity, lower socio-economic status and migration from world regions of high GDM risk. It is therefore important that strategies are adopted to encourage these groups of ‘at risk’ women to self-manage their GDM. Such self-management will reduce the incidence and severity of GDM related complications. The greatest challenge faced by health professionals, engaged in the care of women with GDM, is to provide sufficient and appropriate education and support at what is a stressful time in a woman’s pregnancy. Most women describe being shocked and upset at their diagnosis of GDM and take some time to adapt. At the same time, there is a relatively narrow window of opportunity for women to master the complex tasks of GDM self-management, and thus reduce their hyperglycaemia. Dwindling health resources add to this conundrum, as educational resources are already stretched, often where they are most needed.
There is a need for targeted educational resources for women with GDM, and earlier studies indicate that initiatives that address the cultural context of the group in question, may produce the best results [55, 61]. Additionally, there is strong evidence to suggest that emotional support from the woman’s partner/husband/family improves adherence to GDM self-management regimens and, with this in mind, a family approach to GDM education may produce better results. This careful targeted approach may effect more successful dietary management and may thus reduce the percentage of women requiring insulin to control their condition. Successful GDM self-management, in turn, is associated with lower rates of serious pregnancy complication and serious infant morbidity. It is also associated with a lower risk of later developing type 2 diabetes.