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