Gestational diabetes mellitus (GDM) is defined as ‘any degree of glucose intolerance with onset or first recognition during pregnancy’ (1). It can lead to maternal hyperglycaemia, which is associated with adverse maternal and perinatal outcomes and increased risk of developing diabetes in later life of the child and mother as well (2). An increasing trend in prevalence of GDM was observed in global context (3) with an estimated global prevalence of 5–25% (4, 5). Highest prevalence is noted in South East Asian Region (SEARO) and more than 90% of the estimated cases are found in low and middle income countries (5) Sri Lanka also shows an increasing trend in prevalence of GDM, where a recent community based study has shown a prevalence of 13.9% (6).
The Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) study highlighted the fact that maternal glucose intolerance has shown a liner relationship with adverse perinatal outcomes (2). Thus, early detection and prompt control of maternal glucose level is recommended. Screening is pivotal in prevention of adverse perinatal and long-term outcomes by early detection of mothers with increased risk of developing GDM. International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria has been proposed after reviewing published and unpublished data of HAPO study and other related studies in 2010 (7). Following that most of the technical bodies including American Diabetes Association (ADA) (8), World Health Organization (WHO)(9) and The International Federation of Gynaecology and Obstetrics (FIGO)(10) have recommended IADPSG criteria for GDM screening.
Though scientifically sound and valid screening and diagnostic tests and criteria were available, implementation of screening programmes is affected by client and service-related barriers in low resource settings (11). Lack of trained staff and equipment to perform screening tests and storage and transport issues for collected samples have been highlighted as healthcare system barriers and difficulty in attending clinics in fasting status, late contact with healthcare system and higher distance to primary or specialized care facilities as client related barriers (11). These barriers can reduce screening coverage in such settings leading to inadequate control of maternal hyperglycaemia, thus increasing both maternal and child mortality and morbidity due to adverse outcome of GDM in low- and middle-income countries (4). Therefore, a simple and feasible screening test to be used in universal screening at low resource settings is highly needed to overcome the barriers of screening (12). Diabetes In Pregnancy Study Group in India (DIPSI) introduced a simple method of screening for GDM for low resource settings. They proposed administering 75g of oral glucose challenge to pregnant woman irrespective of fasting state and 2-hour capillary blood glucose value to be checked - a test nominated as non-fasting Glucose Challenge Test (GCT) (13). And it claimed that such simple test can overcome most of the barriers specific to low resource settings highlighted above (13). Further when compared to Oral Glucose Tolerance test (OGTT), GCT showed no statistically significant difference in diagnosing GDM using a cut off at 140mg/dl after 2 hours of glucose intake. (11)
GDM screening had been incorporated to maternal care programme in Sri Lanka since ..... Pregnant mothers with risk factors for developing GDM had been screened at booking visit and all pregnant mothers had been screened between 24–28 weeks of gestation using post-prandial blood sugar test with a cut off threshold of 120mg/dl. (12) However, risk factor-based screening is reported to have low sensitivity, compared to universal screening in several studies conducted in both community and hospital settings. (13) (14) Sri Lanka adopted non-fasting GCT as recommended by DIPSI study as the universal GDM screening tool at field antenatal clinics since 2014. Universal screening of pregnant mothers for GDM before 12 weeks and between 24 to 28 weeks of gestation was incorporated to field maternal care package. All pregnant mothers screened positive with non-fasting GCT were referred for confirmatory test. (14). Nevertheless, there has been no assessment on utilization and factors associated with utilization of screening services at field carried out after the adoption of the new screening test.
Applicability, utilization, and barriers in utilization is of major concern when it comes to GDM screening in developing countries with low resources (12). Sri Lanka has a unique healthcare delivery system with high output with low resources. Therefore, the current study provides an insight on utilization of screening recommendation in a low resource setting and factors associated with it as facilitating factors and barriers. And thus, gives directions, that can be used to strengthen GDM screening in low resource settings, for policy makers and health planners in both global level and low resource settings.