Barriers and facilitators for universal gestational diabetes Mellitus screening in a low resource setting: a cross-sectional study in Sri Lanka
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 hyperglycemia, which is associated with adverse maternal and perinatal outcomes and an increased risk of developing diabetes in the later life of the mother and child as well2. An increasing trend in the prevalence of GDM was observed in the global context3 with an estimated global prevalence of 5–25%4,5. The highest prevalence is noted in the Southeast Asian Region (SEARO) and more than 90% of the estimated cases are found in low- and middle-income countries5. Sri Lanka, too shows an increasing trend in the prevalence of GDM, where a recent community-based study has shown a prevalence of 13.9%6.
The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study highlights the fact that maternal glucose intolerance has shown a linear relationship with adverse perinatal outcomes2. Thus, early detection and prompt control of maternal glucose levels is recommended. Screening is pivotal in the prevention of adverse perinatal and long-term outcomes by early detection of mothers with an increased risk of developing GDM. After reviewing published and unpublished data from the HAPO study and other related studies, the International Association of Diabetes and Pregnancy Study Group (IADPSG) proposed criteria for GDM screening in 20107. Subsequently, many technical bodies including the American Diabetes Association (ADA)8, World Health Organization (WHO)9 and The International Federation of Gynecology 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 settings11. 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 the healthcare system and higher distance to primary or specialized care facilities as client related barriers11. These barriers can reduce screening coverage in low- and middle-income countries leading to inadequate control of maternal hyperglycemia, thus increasing both maternal and child morbidity and mortality due to adverse outcomes of GDM4. Therefore, a simple and feasible screening test to be used in universal screening is highly needed at low-resource settings to overcome the barriers to screening12.
The Diabetes In Pregnancy Study Group in India (DIPSI) introduced a simple method of screening for GDM in low-resource settings. They proposed administering 75 g of oral glucose challenge to pregnant women irrespective of fasting state and 2-hour capillary blood glucose value to be checked – a test nominated as the non-fasting Glucose Challenge Test (GCT)13. It is claimed that this simple test can overcome most of the barriers specific to low resource settings highlighted above13. Further, when compared to the Oral Glucose Tolerance test (OGTT), GCT showed no statistically significant difference in diagnosing GDM at a cut-off threshold of 140 mg/dl after 2 h of glucose intake11.
GDM screening has been incorporated into maternal care programmes in Sri Lanka since 2011. At the outset, pregnant mothers with risk factors for developing GDM were screened at booking visit and all pregnant mothers were screened between 24 and 28 weeks of gestation using post-prandial blood sugar test with a cutoff threshold of 120 mg/dl12. However, risk factor-based screening is reported to have low sensitivity, compared to universal screening in several studies conducted in both community and hospital settings13,14. Sri Lanka adopted non-fasting GCT recommended by the DIPSI study as the universal GDM screening tool at field antenatal clinics in 2014. Universal screening of pregnant mothers for GDM before 12 weeks and between 24 and 28 weeks of gestation was incorporated into the field maternal care package. All pregnant mothers screened positive with non-fasting GCT were referred for a confirmatory test14. Nevertheless, there has been no assessment of the utilization of GDM screening services in the field setting and the influencing factors after the adoption of the new screening test.
In developing countries that account for 90% of the estimated GDM cases, optimum GDM screening is essential for early detection and provision of early and quality care to reduce the burden of GDM and improve pregnancy outcomes. Applicability, utilization, and barriers to utilization are of major concern when it comes to GDM screening in developing countries with low resources12. Thus, such factors need to be explored and understood for the optimization of screening and treatment services.
Sri Lanka has a unique healthcare delivery system mainly focusing on maternal and child health and it has a track record of delivering high-output care at low cost with minimal resources. Therefore, exploring the universal GDM screening programme in Sri Lanka will provide information on applicability, utilization, and facilitators/ barriers for the utilization of screening services, which will be of pivotal importance for the improvement of screening programmes in low-resource settings with low-cost interventions.
The current study has focused on assessing the utilization of universal GDM screening services and its barriers and facilitators in Sri Lanka. Further, it describes the coverage and timeliness of GDM screening as outcome measures, which will provide information on the quality of the screening programme as well. Thus, this study provides vital insights into utilization of universal GDM screening in a low-resource setting. The findings will enrich the existing knowledge on GDM screening in developing countries that can be effectively used by policymakers and health planners to strengthen GDM screening in both the global level and low-resource settings.
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