Analysis of the interviews with HCPs revealed their perceptions regarding GDM screening; their understanding of current GDM screening guidelines and to what extent these were being followed; their knowledge of GDM and the source of this knowledge, and their recommendations on how GDM screening practices can be improved.
Perceived importance of screening for GDM
All HCPs interviewed emphasized the importance of screening pregnant women for GDM. They laid stress on early detection of GDM, commenting that prompt detection could minimize possible complications during delivery. One of the obstetricians mentioned that GDM screening was introduced a few years ago in the hospital and had noticeably reduced the risks associated with delivery.
“It is very good that we are diagnosing it (GDM) very early, the risk has been reduced so, it is very important; most of the maternal risk have been reduced. Since we diagnose early, we advise her (pregnant woman) diet and exercise early, and even we start metformin in an early stage" (IDI#3, Obstetrician)
A nurse participant elaborated on the potential advantages of knowing GDM status through screening as follows:
“It is easy if known (GDM status), it is easy to manage such cases. We can give more preference to such cases. If she is in line with many other women who are due for delivery, we can give preference to the one with GDM and prepare for the labour, and take necessary precautions. Like we can give her the needed medicines, inform paediatricians to attend to the baby soon after the delivery” (IDI#4, Nurse).
Current practices aligned with national guidelines
The obstetricians strongly supported the national recommendation of staged screening, in which women in the first trimester go through Glucose Challenge Test (GCT), and those testing negative are screened again using a Glucose Tolerance Test (GTT) between 24th and 28th week. Furthermore, women who test negative using GTT are additionally asked to undergo Fasting Blood Sugar (FBS) and Post Prandial Blood Sugar (PPBS) tests at 32 weeks. The women who come late to the hospital during pregnancy (in the second trimester) are recommended for GTT.
"We have our setup- free of cost. For GCT, before it was done in a fasting state, but now they (women) can come at any time. Even she can take a test irrespective of fasting status"[sic] (IDI#3, Obstetrician)
Obstetricians did not refute the World Health Organisation (WHO) guidelines that recommend women undergo OGTT on an empty stomach (fasting state)(19); however, they felt that GCT is better suited for pregnant Indian women in the first trimester. According to them, the test is ‘simple' and ‘practical', as it does not require pregnant women to visit the hospital to take the test on an empty stomach. The participating obstetricians recommend the OGTT (available under the MAASTHI project) for pregnant women who visit the hospital in and after the second trimester.
The nurses’ knowledge on GDM guidelines were limited. Their role in GDM screening or management is not well defined, and they have clear compartmentalization of tasks where the obstetrician prescribes and they follow instructions. This was expressed by a nurse as follows:
“After the test, women go to obstetricians. The obstetricians provide prescriptions and dietary advice. They provide treatment and tell them to come for follow-ups. We do not advise women, as this is more the role of the obstetrician. Nor does the patient ask us (nurse). If one patient is diagnosed of GDM, we register and send them to madam (Obstetrician). They advise. If patients do not understand what is written, only then do we read prescriptions and tell them what to do, such as how to take medicine.” (IDI#2, Nurse).
Nature of GDM knowledge
The obstetricians were well-informed regarding the causes, consequences, and management of GDM. Additionally, they were also aware of national guidelines and the protocols for screening and GDM management.
“There are two type of women, suppose if they (women) come in the first trimester we follow the Government of India guidelines, we give them 75 grams of oral glucose and check for glucose after two hours. This test is very suitable for the Indian population. If they miss and come in the second trimester, then we follow WHO guidelines, then we refer to MAASTHI cohort to do the test. They are doing research and they will counsel and then they will tell them to come on a particular day on empty stomach” (IDI#3, Obstetrician).
The obstetricians reported that they keep themselves abreast of the latest developments; specifically national guidelines are regularly updated through Continued Medical Education programs. They did not feel that any further training on GDM screening and management was required. However, the nurses reported that relevant training was lacking, and they expressed interest in receiving formal training on GDM specifically designed for the nurse role.
Barriers to the timely screening of GDM
The barriers to timely screening were unmet training needs of nurses in GDM health promotion, delays in screening for GDM, pregnant women accessing ANC at private clinics initially and then subsequently reporting at public hospital in late gestation, migration of pregnant women due to cultural practice where women deliver their first born at natal home, no system of follow up of deferred cases for GDM screening, resource deficit, and long waiting hours (Fig. 1).
Unmet training need of nurses in GDM health promotion
A nurse participant at the tertiary care felt confident that she had all the necessary practical information regarding the appropriate management of GDM and how to prepare to care for a woman with GDM during delivery and post-delivery:
I tell women to get the blood test after one week of taking medicine/ insulin, so that they know if sugar levels decreased/ increased,(…………………)we tell them to control sugar levels through diet control and by taking medicine correctly.
“And then, for those women who come for delivery, we check if they have taken insulin and how much had they taken”.
“After delivery, we recommend women to take General Random Blood Sugar (GRBS) test 2 times. Suppose a woman’s sugar level is not under control, we put them on insulin. Those women, who deliver through C-section, usually stay for 5 days in the hospital, so we check and monitor their sugar level every day. And then after 40 days we ask them to come to hospital for check-up.” (IDI#5, Nurse).
However, all the nurses stressed the importance of obtaining formal training on how to educate and support pregnant women, emphasising that such training would ensure they share the correct information.
“It would be very helpful if we get some training on GDM treatment, we (nurse) will be in OPD (Out Patient Department), and there we see many pregnant women. And, that is where they approach us and ask us for information. So, it would be useful to know how to and, what information should be given to them. Now when they ask, we are providing some information, but we need training to provide correct information, and we also need training on how to give correct information. If you organise any class (trainings) we will attend that”.(IDI#5, Nurse).
“We haven’t had any training but we definitely need it. We have more GDM cases, but have very little information. It will be useful. We can also provide information in our neighbourhood. People will be interested to know, and GDM will gain importance that way. We can reduce death, improve mother and child health and conduct the delivery nicely”. (IDI#1, Nurse).
Delayed screening of GDM
A health care provider stated that the initial screening of pregnant women for GDM is a challenge. According to a nurse, pregnant women who are not from urban areas have limited avenues for meeting the obstetrician and they end up consulting the wrong HCP:
“Women do not visit the hospital at the right time and they do not visit the right doctor. For example, in villages there will not be an obstetrician, so they would not have consulted any obstetrician. But they come here (city) for delivery. When you open their records, you find that they were consulting some Ayurvedic (Indian system of Medicine) obstetrician, sometimes paediatricians and those with small shops. These women would not have received proper care and treatment or information. So, they will not be identified (screened) early. Educated women go for check-up, but sometimes they might not receive proper guidance. Women in working class (labourers) often go to those obstetricians who may not be obstetrician. So, I think people need correct information.” (IDI#4, Nurse).
Availing ANC at the private clinic in the first trimester
HCPs described how women visiting the public hospital in their second trimester or later have usually availed ANC at private clinics in the first trimester and such private facilities have not guided them to undergo GDM screening. A nurse throwed some light on this as follows:
"When people go to small clinics where there are no obstetricians, obstetricians in such clinics usually do not write (prescribe) for blood tests, rather think that scanning is important. They (women) would have undergone 7 to 8 scans. I can give you proof of this. Sometimes I scold them and ask why you have done so many (scans)? And why have you not done single blood tests, for that they say that the doctor had not told them" (IDI #1, Nurse)
As a result, many of these women miss out on GDM screening at the early stages of pregnancy. If the screening is not done on time, this will be the most significant impediment for effective management of GDM, as these women are not aware of their condition.
Public hospitals seen as a delivery destination only
According to a nurse, women are only getting screened for GDM between 6–8 months of pregnancy. Some pregnant women who have already had experience of childbirth through their earlier pregnancies visit the public hospitals considering it as a delivery destination only; therefore have delayed seeking services from the tertiary and community health facilities and thus miss out on timely GDM screening.
“Women do not go to mother’s place for the second or third delivery, (stay with husband’s family, where they have many responsibilities to fulfil). So, in that situation, women usually go to the clinic nearby (to husband’s place) for routine check-up (up to 9th month) and later (four to five days before the due date) for the delivery they come to the government hospital. For such cases I pay more attention to see if they have even undergone any blood tests or sugar test (because chances them not having blood test reports are higher.” (IDI#4, Nurse).
Antenatal mothers visit private clinics for initial ANC (after six to seven months), and when they are near the date of delivery, they visit the public hospital with plans to deliver. At this advanced stage of pregnancy detection of GDM is delayed.
First birth at natal home
It is a cultural practice in Karnataka that women are sent to their maternal home for delivery of their first-born child. Hence, women travel from their marital homes to deliver in Bengaluru, usually at six months of pregnancy or later. These pregnant women then report late in pregnancy at the government hospital near their maternal home. Since they have not undergone screening of GDM at the clinics near their marital home, they are late for the screening of GDM at these tertiary and Community Health Centres.
No system to follow-up deferred cases
In many instances, the OGTT is incomplete as the pregnant women experience vomiting and nausea. They are often asked to revisit the hospital to complete OGTT. However, according to HCPs, these women mostly do not revisit the hospital -either since they forget to turn up for screening or have other compelling reasons to miss screening.
An example of this challenge is demonstrated in the quote below:
"In the first trimester, if women are complaining about any health issues, like vomiting, that time we cannot tell them to undergo GDM test. If we tell them to come again for the test, often they are left out, and that is the biggest challenge. We do not have such a system to call them for the test, like recording their contact numbers and calling them (over the phone to follow-up) to visit for the test." (IDI#1, Obstetrician)
Further, government hospitals lack the system to remind women who are due for GDM test or to follow-up women where the screening is deferred.
Resource deficit
The interviews with HCPs revealed that both the included hospitals are differently equipped to manage GDM cases. The general hospital at the tertiary level is better equipped to manage high-risk pregnancies compared to the referral center, a Community Health Centre (CHC). A nurse explained the lack of obstetrician in the night and other facilities to handle complicated cases of GDM as follows:
“There was no such severe case. If we get any such case, we refer them to other hospital, because this is a small hospital, and we do not have obstetrician at night. We do not have facilities to manage complications, so we refer to other hospitals. If it is high (high sugar level), we refer to higher centres. We conduct only those deliveries which we can actually manage.” (IDI#2, Nurse)
The CHC is equipped only to manage borderline GDM cases and refer cases to tertiary care for management and delivery. The HCPs at the CHC reported only the lack of Information, Education and Communication (IEC) material related to GDM.
However, the providers at the tertiary hospital reported lack of glucose, only availability of damaged glucose monitoring machine, and lack of IEC materials (i.e., diet chart with necessary information) to hand out to women and their family members.
An obstetrician complained regarding the lack of infrastructure in hospitals essential to handle GDM cases and emphasized the need to inform policy makers regarding it as follows:
“See just think how many General Random Blood Sugar (GRBS) machines working now (implied that GRBS machines are not working) if you admit them (women) if it (GRBS) is not working, then you are not able to monitor. Such things should not happen. GRBS machine is there but strips are not there. These are some technical problems we usually face here. Policymakers should be aware of all these and make some strict policy.” (IDI# 3, Obstetrician)
The obstetrician further adds the lack of basic supplies such as glucose packets needed for GDM screening as follows:
“In spite of Government program, there is no supply of glucose packets; I think that should be made available. Then other things are not available here. I would like to have a counsellor, in antenatal clinics. They will educate them about medical problems…….” (IDI#3, Obstetrician)
Long waiting hours
Another important challenge for effective screening and management of GDM is the long waiting hours that pregnant women experience while availing service at public hospitals. For instance, a nurse elaborates how women forget to collect their blood test report and also recognised the long waiting hours being a reason for that as follows:
“We tell women to get blood tested, she says yes, but she goes home without being tested.
It is negligence, whether educated or not educated, they do not like to wait. They will not have time, they come to government hospital and they don’t have time! They cannot wait in line in front of laboratory. Laboratory people go for lunch at 1 pm, and they do not conduct any tests after they come back from lunch. So, when they (women) come for next ANC, when we ask for lab reports, they say “I have not undergone test yet and I will get it today. Then I send them back for blood test and only after that I send them for ANC check-up. This delays early detection sometimes.” (IDI#1, Nurse)
“One thing is that they (women) have to wait in long line. And they have to wait for 3 hours to get the report. So, they usually do not collect on the day they get tested, instead they go off thinking that they can always collect it next time. Then they forget and come directly for check-up, some they go to their mothers/ husband’s place, and the report will be lying here for months. Sometimes a woman would have gotten tested in another place and then she come here with other reports but not the diabetes report. These things happen we need to find solution to this.”(IDI#1, Nurse)
Barriers to effective management of GDM
The barriers to proper management of GDM were incomplete information on GDM management, lack of standard protocol and lack of system to follow-up management of GDM.
Incomplete information on GDM being disseminated due to excessive workload
HCPs discussed the dissemination of GDM-related information based on the information that obstetrician and nurses provided to pregnant women with GDM. HCPs felt that information was often limited and only shared on a need-to-know basis. Women are advised by HCPs to undergo screening of GDM depending on the trimester of their visit to the hospital. However, they are not informed regarding the reason or relevance of the test.
Few HCPs said they would advise women with GDM to change their lifestyle, such as diet and exercise and they rarely explained the consequences of uncontrolled sugar levels for their unborn child. HCPs said that lack of time was the main reason for sharing limited information regarding GDM.
For instance, a nurse explains that women with GDM are often not informed of their condition by the obstetrician because they are overburdened with the workload, therefore in such situations the nurses take the initiative to give detailed explanation to such patients.
"Sometimes, we (nurses) talk about it. Obstetricians also explain, but they would not have time, so we do it many times. Some (women) do not understand, so, on their slip we write GDM, such that each time we see that we repeat (messages about diet control)" (IDI#2, Nurse)
The obstetricians elaborated that if they have time they provide detailed counselling for women and family members with high sugar levels. However, the borderline cases are not counselled for GDM screening as they do not have time:
"We cannot explain it to every individual patient. To women with high levels, we may explain, but those who are borderline sugar level also require some diet tips or lifestyle changes tips. It is good if it (such information) is displayed to family members and her" – (IDI#3, Obstetrician)
A nurse attributed their inability to give detailed information to the pregnant women due to excessive workload as follows:
“Obstetricians prescribe treatment. The same things we explain to the woman, that is all we can do when we sit in OPD. We cannot really explain or follow-up in detail. Because there will be too much work and we do not have any assistance, so we could only provide detailed information or follow-up closely to 50% of women. Many women come to this hospital. We will not have time but to record their BP, check their height and weight and document all this information into registers. It is a lot of work”. (IDI#4, Nurse)
Lack of standardized protocol for disseminating information on GDM management
The messages provided to women regarding GDM by the HCPs are less comprehensive. These messages are generic (do's and don'ts) or cautionary - generating fear (e.g., if you do not control your sugar, it will affect your baby) as expressed by the obstetrician below:
"She (woman with GDM) needs treatment, and she has to come for follow-up. If she does not come (for check-up), it may affect fetal health, if she knows this much it is enough. We have no time to explain all things" (IDI#1, Obstetrician)
A nurse also mentioned using fear as a strategy to ensure compliance on the part of women to take medication as follows:
“I ask which month (of pregnancy) are you in, then see what the obstetrician has prescribed. And I explain which medicine to take before food and which one to take after food. I also tell them that if medicine is not taken correctly, the baby would have some problem. If we tell them like this, she will definitely take the medicine, because women care for baby more than herself. So, if I tell her that medicine is good for her (health), she may even neglect, so we talk (emphasise) about baby.” (IDI #4, Nurse.)
In the absence of disseminating standardized information and protocol for screening and management of GDM, the reality is that the messages received by pregnant women are not educative, but mostly instructive pieces of advice.
No system to follow-up management of GDM
The HCPs explained that women who visited these public health facilities during the early stages of pregnancy were most likely to be advised by the Obstetrician and Gynaecologist (O&G) to undergo GDM screening. A nurse elaborated that only when these women are admitted, can they monitor GDM and its management. She lamented that the pregnant women tend to forget what is prescribed:
“I: How do you monitor sugar levels?
R: For those admitted in the hospital we monitor 3 times: morning, afternoon and in the evening, we have to do that. (…….) Post-delivery, women stay for a week in the hospital, in that case we monitor whether they take medicine or not. We can only do that. After they are discharged from hospital, we do not know whether they follow whatever has been prescribed or told”. (IDI #5, Nurse)
However, there is no mechanism to follow-up on further monitoring of the sugar levels. The same participant elaborates:
“I: Do you have a system to follow -up women with GDM?
R: No, we do not have any system. Only when they come to hospital, we ask them about their condition, that’s it. After delivery we give enough tablets, but we do not know whether they take it or not. Some women do not even come for blood test post-delivery.” (IDI# 5, Nurse)