This study sought to explore the experiences of HCPs in the screening and management of GDM. Two main themes and six subthemes were generated. The first theme was resource-centred experiences, which explored events at the ANC, and the challenges in GDM screening and management, with three subthemes namely: ANC setups, inadequate resources, and noncompliance. The second theme was care-centred experiences, which delved into patients’ emotions during GDM diagnosis, and the care they received post-GDM diagnosis, with three subthemes namely: raw emotions, non-pharmacological therapy, and pharmacotherapy.
On resource-centred experiences, this study noted that ANC is an important setup in screening for GDM; all pregnant women are screened, and positive cases are referred to laboratories for further testing. The free maternal health policy and national health insurance policies have been essential for accessing health care; however, these policies do not cover tests for GDM diagnosis, specifically the OGTT, which is recommended as a confirmatory test by many of the criteria used in the diagnosis of GDM [7, 8, 26]. This indicates the need for GDM diagnostic tests, particularly the OGTT, to be covered by the NHIS. Since, a delay in diagnosis could worsen the condition, and thus put both the mother and the baby at risk of complications. Some of the reasons for delayed diagnosis were lack of equipment to run tests and ignorance. Unsurprisingly, a review study in Africa also highlighted logistical challenges and ignorance among other factors as barriers when screening, diagnosing and managing hyperglycemia in pregnancy [5].
Inadequate resources, the second subtheme on resource-centred experiences, was documented as a challenge in GDM care in this study. One HCP recounted instances where OGTT were requested only for pregnant women to bring test results after two or three weeks, citing the cost involved as the reason for the delay. This has the potential to affect treatment, as HCPs are not able to adequately track or monitor blood glucose levels using internationally recommended standards. This further highlights the need to make the OGTT more accessible to pregnant women; this could be through the NHIS, the free maternal health policy or even subsidization of the cost for screening and diagnostic tests. Financial support and subsidization of care have been reported as facilitators of GDM care in Africa [27, 28].
As part of the subtheme on inadequate resources, inadequate staff and logistical challenges were recognized to affect GDM care. The current study noted that due to workload, follow-up is usually difficult. Relatedly, shortage of relevant staff and trained personnel in other African countries have been reported as barriers in GDM care [27, 29]. One HCP in the current study lamented over the absence of test kits to adequately screen and monitor blood sugar levels. Similarly, a study in Ethiopia reported on frequent shortages of logistics and supplies for GDM screening [14]. Also, on lessons learnt from the World Diabetes funded projects in some LMICs (Cameroun, China, Cuban, India, Jamaica, Kenya, and Sudan), poor follow-up systems and absence of test kits were reported as barriers to healthcare [29]. In India, lack of equipment and overcrowding at health facilities have been cited as challenges within the context of GDM screening and management [10]. Hence, there is a need for governments and other relevant stakeholders to regularly provide the resources needed to adequately screen and manage GDM.
The third subtheme on resource-centred experiences was non-compliance. Unavailability of foods for diet therapy, workload, and poverty were some of the reasons for non-compliance in the current study. Some of the foods prescribed by dieticians become scarce in the dry season, making them costly and inaccessible for some patients, thus threatening compliance to such dietary regimens. In line with the current study findings, environments dominated by unhealthy foods has been recognized as a barrier in GDM care [30]. Moreover, the synergy among the high cost of diagnostic tests for GDM, scarcity of certain foods in the dry season, and inadequate staff or HCPs creates the right atmosphere for non-compliance. This underscores the need for more HCPs to be recruited into healthcare delivery systems, especially dieticians/nutritionists, medical officers, midwives, nurses and laboratory scientists/technicians, to diligently monitor and follow-up on clients and possibly revise management regimen when compliance becomes an issue. For example, dieticians/nutritionists could revise diet plan of clients when prescribed foods become scarce. Similarly, Sinha and colleagues [9] noted that government programs and support groups facilitated the screening and management process after identifying access to healthy foods and insurance issues as a challenge in the screening and management of GDM.
With regard to care-centred experiences, one of the subthemes was raw emotions, HCPs observed that women and their families expressed mixed feelings after learning about GDM status. The HCPs noted that women were emotional about their diagnosis, as they expressed raw emotions, which included worry, shock, confusion, and indifference. Similarly, a couple of studies in Ghana reported on the emotional experiences of patients after being diagnosed with GDM, one of them reported mixed feelings from participants [31], while the other reported worry, confusion and fear [16]. Other studies in the past have also reported feelings of shock when women learnt about their diagnosis [32]. One of the HCPs further indicated that the emotions expressed were mostly dependent on the pregnant woman’s understanding of GDM; those who knew about GDM were worried about themselves and their foetus, and those with little or no knowledge were not bothered or even uncertain about how they felt. A study in China also reported that some women were bothered after being diagnosed with GDM, while others were not [33].
Support from family members and relatives was observed to be integral in modulating the emotional response of patients, particularly those that are hormonal in nature. Support, especially from close relatives, has been reported in previous studies to be essential for managing GDM [34, 35]. Hence, family members could be critical in helping pregnant women follow their dietary regimen despite hormonal changes. However, when family members do not provide the needed support, particularly financial and emotional support, it exacerbates the climate for non-compliance.
The second subtheme on care-centred experiences was non-pharmacological therapy and focused on counselling. Counselling was shown to be a major component of GDM screening and management. HCPs generally admonish pregnant women to engage in self-care behaviours, especially to patronize preconception care and to monitor blood glucose regularly; self-care behaviours have been reported to improve quality of life [36]. The current study revealed that the first line of action when treating or managing GDM is diet and exercise, and oral medications such as metformin and insulin are the last line of action to aid in blood sugar control. This is in line with the Norwegian guidelines for managing GDM [37]. Moholdt and colleagues [38] also recommended a combination of diet and exercise as the first line of action.
The third theme on patient-centred experiences was pharmacotherapy, and comprised medications used to lower blood sugar. Oral medications such as insulin and metformin were used to control blood sugar levels in the current study. HCPs resorted to oral medications when they were not able to control blood sugar with diet and exercise. The most common oral medication used was insulin, which is captured by Garrison’s [13] suggestion that pharmacologic therapy should be initiated with insulin, metformin or glyburide when blood sugar levels are still above target levels after glucose monitoring and lifestyle modifications. Another study showed that physicians initially tried to lower blood sugar levels by using diet and exercise and only used insulin when those methods failed [14]. In addition, the American Diabetes Association’s standards of medical care for diabetes patients recommend that when medical nutrition therapy, exercise, and glucose monitoring are not successful at controlling blood glucose levels, insulin may be given as a last resort [15].
This study is not without limitations; for instance, only five participants were interviewed, which could raise concerns about the generalisability of our findings. This notwithstanding, we believe that the key informants interviewed in this study adequately represent healthcare providers’ experiences because the ANC setups of secondary facilities are similar. In addition, the people interviewed were well versed about GDM screening and management in northern Ghana.
Additionally, HCPs provided their perspectives on patients’ feelings or emotions immediately after GDM diagnosis, which may not necessarily represent how patients felt after the diagnosis. However, we believe the healthcare providers’ perception of how patients felt after diagnosis could affect GDM care and patient compliance. For instance, pregnant women bemoaned the lack of attention and sympathy from HCPs in a study to describe their experiences on being diagnosed and living with GDM [31], while another study reported that HCPs did not have the time to explain diagnosis [30]. Hence, this study provides insights on healthcare providers’ experiences on screening and managing GDM, which could be relevant for advocacy, and social and behavioural change communication on GDM care. It could also be relevant for health planning and policies, because it provides insights into the resources needed to effectively screen and manage GDM.
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