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Table 1 Reported challenges with GDM screening and management grouped by thematic area

From: “Why screen if we cannot follow-up and manage?” Challenges for gestational diabetes screening and management in low and lower-middle income countries: results of a cross-sectional survey

a. Guidelines b. Human resources c. Access & follow-up d. Costs e. Service availability f. Equipment & drugs g. Community & patients h. Collaboration & coordination
Lack of national guidelines/standard protocols Not enough awareness of problem as no prevalence studies/poor knowledge about GDM Access (travel)/access to care Patients have to pay, not affordable to screen and manage/socioeconomic status does not allow to test all women, even those with high risk No government facility for screening/screening not in all government facilities No screening reagents/limited resources to test/to have sufficient lab supplies for measurements of GDM Lack of knowledge in population/low community information/low patient awareness/lack of knowledge of women about diabetes risk and its frequency No multidisciplinary team with endocrinologist and nutritionist
Limited guidelines for screening/management Lack of provider sensitization 15 % women attend public facilities only Hard for poor to get repeated test done and hard to convince them GDM only screened and managed at tertiary and private level Stock-out of screening material and test strips/stock out lab equipment and reagents Ignorance and false belief about diabetes development/ignorance about diabetes and its consequences in pregnancy/ Multidisciplinary collaboration challenge because few endocrinologists and neonatologists
Guidelines not properly disseminated and used Lack of capacity/technical competency/no capacity building/training/few lab technicians know to do O’Sullivan test ANC coverage low Costs of lab tests and ultrasound/costs of treatment and tests/costs for travel, investigations, medication, hospitalization Laboratory not available 24/7 Unavailability of test strips and sometimes glucometers Get patient to understand complications of diabetes/spending a lot of time convincing them about long term problems and also have to ring and remind about follow-up visits Pregnancy not managed together by endocrinologist and obstetrician
Policy guidelines not well articulated Most providers screen in case of risk factors only/screening not even done when risk factors present or when previous obstetric history would indicate Late presentation for ANC/late booking/emergency deliveries, women were not follow-up before No insurance coverage for most, so cannot afford cost of follow-up Shortage of laboratories in the public sector/good labs only urban Sometimes glucose strips not available/screening not routinely as no dipsticks Low compliance to ANC and testing/in first trimester not able to do test in patient with vomiting/some patients easily nauseated and may throw up after anhydrous glucose/2nd and 3rd trimester: some patients are not willing to wait for two hours Laboratory service not fast and patient has to wait for result
Limited access to internet Inadequate counselling/If proper counselling mothers very cooperative/no educated midwives who can counsel women in community Patient without fridge needs to go to close center for treatment but with the problem of transport Long hospitalization to balance glucose levels/patients requested to get glucometer even while admitted No screening because of technical problems of lab Many difficulties in the lab to do correctly O’Sullivan test and HbA1C, primarily due to lack of reagents and organizational issues Frequent pricking and venous puncture/SMBG cumbersome/difficulty of self-monitoring blood glucose/many patients illiterate and cannot use rapid test/rare that women have a private glucometer Result seen after 1 week by doctor/late detection by gynecologists
No forum for updates Few specialists interested in GDM/not enough endocrinologists/nutritionist may not be around/no nutritionists Majority of pregnant women not followed-up correctly/poor monitoring of patients Patients have to pay for additional exams and drugs: therefore many women are not screened-treated/financial access limit the demand for specific tests Glycaemia not regularly checked at lower level of care Glucose availability/getting anhydrous glucose for tests Some patients do not undergo screening at recommended times/patient does not come at advised delivery date/patients only come when complication Patient has to consult several doctors for management
   Surveillance problem (glycaemia, lab, US, CTG) to best plan delivery OGTT requested at clinic and patients do it at lab when they have money for it/O’Sullivan test too expensive and often not done in public labs No routine blood tests Calibration of glucometers not checked against lab standards Patients don’t always follow management instructions/non-compliance with investigations, diet control/deficient compliance, needs husband cooperation, convince for prevention Crowding in maternity does not allow to screen routinely and follow-up
   Women lost to follow up/Mothers are not returning for postnatal follow-up Ultrasound often expensive and done in private facilities No general screening so most cases are picked up late Difficult to get charts for glucose surveillance GDM complex, needs close supervision while patient has domestic commitments/no gym, only brisk walking as exercise possible Two hours blood sample needs to be taken to lab in time otherwise result error/organization for OGTT is a challenge
   Glucose not well monitored after discharge Costs for medication affect patient compliance/difficulties to buy insulin/expensive glucose strips for home monitoring Non availability of O’ Sullivan test and OGTT/for OGTT patient sent to secondary level/O’Sullivan test often not done in public labs Shortage of drugs to treat GDM in the public sector Adherence to nutrition/adherence to diet/discontinuation of diet, exercise and drugs/Inadequate control of glucose by diet and exercise (lack of motivation)/getting patients to follow diet and to take insulin if required/difficulty for women to keep their sugar level balanced/very difficult to commence a diet, difficult to change dietary habits Patients don’t know where to go for screening and follow-up/complex care system for women
    Low income makes diet control difficult as proteins expensive, they eat much carbs/cannot adhere to diet because expensive Ultrasound often done in private facilities- in the public sector difficult to get appointment Use of oral agents not very popular with most health care providers Glucose not well monitored after discharge/getting them to continue physical exercise and diet even after delivery/screening after delivery is systematically prescribed but not always realized by the patient/mothers not returning for postnatal follow-up  
    No financial resources for training of providers HBA1C hardly performed/Cannot check surfactant levels Accessibility of insulin analogues/insulin during labor as no infusion pumps Some fear about insulin/side effects of insulin/women reluctant or irregular to take insulin/difficult to store insulin