Exploring the perceptions, practices and challenges of gestational diabetes detection and management among health care providers in a district of Bangladesh

Study design

A total of 47 face-to-face surveys and 10 in-depth interviews (IDIs) were conducted with health care providers (HCPs) and with health managers. Furthermore, 30 ANC consultations were observed at 30 primary facilities at the community, union health center and upazila health complex level. Finally, 41 facility inventories were carried out using a preformatted checklist. Table 1 provides a summary of the study methods.

Study sites

This was a mixed methods study applying both quantitative and qualitative methods. It was conducted from November 2017 to January 2018 in the Mirzapur sub-district of Tangail district, Bangladesh. The sub-district has a population of 274,088, with 65 facilities including 53 community clinics, 10 union health and family welfare centres, one upazila health complex and one medical college hospital (tertiary facility). Out of 63 primary health care facilities (community clinics and union health and family welfare centers), 30 community clinics and nine union health and family welfare centers were randomly selected by simple randomization, achieved via the random number generator in Microsoft Excel 2010. The study also included the upazila health complex and medical college hospital for data collection.

Provider survey

A structured questionnaire was developed by the research team of the study, available as Extended data²¹. This questionnaire was pretested outside the study area to finalize the questionnaire. Pretesting was carried out among HCPs at one community clinic and one union health and family welfare centre in a different upazila within the district of Tangail. No changes were made to the questionnaire after pre-testing and no validity testing was performed. Then, the structured questionnaire was used to collect quantitative data from selected HCPs, which include grassroots level health workers, such as health assistants (HAs), family welfare assistants (FWAs), health inspectors (HIs), family planning inspectors (FPIs), and community health care providers (CHCPs), and also health workers from the lowest level primary health care centers such as family welfare visitors (FWVs) and sub-assistant community medical officers (SACMOs) (Table 1). The questionnaire included general information, health workers’ perspectives on GDM and availability of equipment and logistics to provide services for GDM patients in the primary health care centers. An official letter from the Mirzapur Upazila Health Complex was circulated among the health workers (n=52) in the 41 facilities, which explained the objectives and invited them to participate in the study. A copy of this letter is available as Extended data²¹. Four trained field data collectors were responsible for collecting data. Health workers were invited and those who willingly wanted to participate in the study were enrolled purposively. Five of the invited participants were not willing to participate as they were busy at that time with their own work. Data collection was conducted at their place of work and it took approximately 20 minutes to complete each of the face to face interviews.

IDIs

Two research assistants (anthropologists) were assigned to collect qualitative data through IDIs with the HCPs working at the facility level. A pretested interview guide was used for the interviews, available as Extended data²¹. Pretesting was carried out among HCPs at one community clinic and one union health and family welfare centre in a different upazila within the district of Tangail. Minor changes were made to the interview guide after pre-testing. No validity testing was performed. HCPs were chosen purposively and written consent was sought before participation in the face-to-face interviews. Out of 13 respondents, three participants weren’t able to participate in the IDIs due to their other engagements. The research assistant described the objectives of the study before data collection. Each of the interviews took approximately 20–25 minutes and were conducted at the facilities. Interviews were audio recorded upon permission and the research assistant took some key notes.

Observation

A total 30 ANC checkups were observed at different facility levels. Of them, eight were at Kumudini hospital, two at the upazila health complex, eight from union health and family welfare centers and twelve from community clinics. Four trained field data collectors used a pretested checklist to do the observations, available as Extended data²¹. Pretesting was carried out among HCPs at one community clinic and one union health and family welfare centre in a different upazila within the district of Tangail. No changes were made to the checklist after pre-testing and no validity testing was performed.

Permission to collect the data was obtained from the health department, the patients and HCPs. The checklist contained some key areas including infrastructure, logistics, waste management and staff. The observation was made during routine antenatal check-ups at the ANC area of the facility by a doctor or nurse during the hospital working hours.

Facility inventory

Facility inventory was conducted for 31 purposively selected community clinics, eight union health and family planning centers, one upazila health complex and from the Kumudini hospital. The field level data collectors used a structured checklist to collect the inventory data, available as Extended data²¹. Key areas covered supplies included furniture and durable equipment, clinical supplies and other optional equipment. During this process, the data collectors used hospital records and sought support from the responsible persons to fill out the checklist.

Data analysis

Quantitative data were cleaned and missing data were checked by the data supervisors. If any data were missing, the data collector revisited the home using previously collected sociodemographic data to contact participants for this purpose and collected the missing data from that responder. SPSS statistical software (version 21.0 for windows) was used for descriptive analysis.

The qualitative data were transcribed from the local language (Bengali) from audio recordings and translated into English by the anthropologists. The principal researcher randomly selected transcripts (10%) by simple randomization to review the quality of transcripts. Peer debriefing was also performed to maintain the reliability of the data. Initial open coding was performed and themes were identified, followed by selective coding, done manually by repeated reading of the transcripts. Themes were identified from the data^22,23 and analyzed thematically.

Ethical statement

The study is under the project named ‘Evaluating community-based detection and surveillance of gestational diabetes’, which has been approved by the national ethical review committee of Centre for Injury Prevention and Research, Bangladesh (CIPRB) (Memo - CIPRB/ERC/2017/20). Informed written consent was received from each of the interviewees for participation before collecting their data for the study.

Knowledge and attitudes

Basic knowledge about GDM. The majority of the respondents who participated in the survey had never heard of diabetes that occurs during pregnancy or gestational diabetes (81%, n=38). Furthermore, 81.2% of respondents (n=38) were not aware of the risk factors for GDM and among them, 16.6% (n=8) stated that there are no risk factors (Figure 1). Data from the IDIs gave similar findings. HCPs had no clear perception of GDM and some considered GDM to be the same as diabetes.

Figure 1. Health care providers’ knowledge on risk factors for gestational diabetes mellitus.

“There is no difference between the diabetes and gestational diabetes. When diabetes occurs in pregnancy then it is called gestational diabetes and will not cure like diabetes. All the management and treatment of diabetes during pregnancy is similar to the diabetes.” (P2, Community Health Care Provider (CHCP))

Knowledge on the complications of GDM. Around 66.6% (n=31) of HCPs did not know about GDM related complications for mothers and their babies. Furthermore, 16.7% (N=8) thought that there are no GDM related complications and 16.7% (n=8) knew that there are some GDM related complications that could affect mothers and babies (Figure 2). Some respondents stated newborns could develop abnormally, pregnant mothers may have diabetes later in life and some might develop unspecific problems as a result of GDM complications.

Figure 2. Health care providers’ knowledge on complications of gestational diabetes mellitus (GDM).

“I don’t know clearly about the complications. But I perceive that a GDM mother has more chances for eclampsia, pre-eclampsia, intra-uterine death, stillbirth, pre-term delivery.” (P7, HI)

Knowledge on the GDM tests. Among the 47 respondents, 54.1% (n=25) said that a GDM screening test is essential for pregnant women, 29.1% (n=14) did not know and 16.6% (n=8) said a screening test is not necessary during pregnancy. Almost none (97.8%, n=46) could mention the exact timing for when a screening test should be performed during pregnancy (Figure 3). None of the participants (100%, n=47) had knowledge of the screening process.

Figure 3. Health care providers’ knowledge on gestational diabetes mellitus testing (GDM).

“We have no clear idea on gestational diabetes screening test of pregnant mothers. The test need to done during antenatal care; however, we do not practise. We need training on GDM and logistics for screening need to available during ANC.” (P4, CHCP)

Knowledge about GDM treatment. Regarding treatment, 95.8% (n=45) of the respondents did not know if there was any treatment for GDM available and 4.1% (n=2) said there is no treatment. Regarding delivery, 4.1% (n=2) mentioned that GDM patients should deliver by caesarian section and 95.8% (n=45) had no idea about the recommended mode of delivery for a woman with GDM. Regarding the necessity for follow-up after delivery, 70.8% (n=33) did not know whether follow-up was necessary and 22.9% (n=11) said postpartum follow-up is not needed for women with gestational diabetes.

“I think exercise and insulin are the only treatment for mothers who are suffering from diabetes during pregnancy” (P3, FPI)

GDM related practices

GDM screening. Regarding the screening practice, 79.1% (n=37) of HCPs never screened pregnant women for GDM and 18.7% (n=9) had no idea about screening. In addition, 68.7% (n=32) did not know what tests are available to screen for GDM in their health facility/department and 20.8% (n=10) said they have no screening equipment at their facility. One of the respondents described how to do a blood sugar test, but none of the other respondents knew the process (97.8%, n=46).

GDM management practices. Almost all (95.8%, n=45) of the providers did not know about a management protocol for GDM affected mothers. Regarding advice given to GDM positive mothers, 91.6% of providers (n=43) did not know what to advise, 6.2% (n=3) said they do not give any advice and only one HCP (2.1%, n=1) recommended exercise, diet and insulin for GDM mothers. Almost all (95.7%, n=45) did not know about drug therapy for GDM mothers. Some (4.3%, n=2) perceived that both oral medicine and insulin can be used for GDM management.

“We don’t have any management protocol for gestational diabetes. I perceive that after a woman is diagnosed, she is immediately referred to hospital for further treatment.” (P6, CHCP)

“Insulin is the only drug of choice for a GDM patient” (P8, FWV)

“In our hospital if a mother identified with diabetes during pregnancy, we refer to district hospital for management” (P-10, Nurse)

Follow-up of GDM patients. Around half (56.2%, n=26) of respondents did not know about follow-up for GDM patients. Additionally, 27.1% (n=13) providers said they did not advise GDM mothers to go for a blood glucose checkup at secondary or tertiary facilities and 62.5% (n=29) did not know what to advise a mother suffering from GDM. Nearly all of the providers (97.9%, n=46) did not know about follow-up for women who had GDM after delivery. None of the respondents knew about newborn blood glucose checkups after delivery.

“I advised the mothers having diabetes during pregnancy to do a blood glucose test on a weekly basis at the medical college hospital” (P2, CHCP)

Challenges of GDM management

Nearly none of the providers (97.9%, n=46) received any special training on diabetes mellitus and/or GDM during training or on the job. Many of the interviewed providers (97.9%, n=46) never got an opportunity to deal with GDM patients. Moreover, there are limited resources (equipment, material) for testing in their facilities. As the majority of providers are not very knowledgeable on GDM, they do not feel competent to discuss the topic with the women who come for ANC. In terms of equipment, 93.7% (n=44) of the providers said they have only blood pressure devices. Only two providers (4.2%) stated that glucometers are available in their facilities and one provider (2.1%) stated the availability of a blood pressure device, an ultrasound machine, urine dipstick and leaflets on nutrition at her facility.

“I only heard about the term gestational diabetes. But I never received any training on screening. I even have a limited idea on counseling pregnant women to prevent GDM” (P1, FPI in IDI )

“We don’t have any special facilities for GDM management at our union family welfare center.” (P10, FWV in IDI)

ANC observation

A total of 30 ANC sessions were observed in the facilities. In 31.3% of observed consultations (n=9), blood sugar test related information was collected. Of all the observations, a high blood sugar level was found in 12.5% (n=4). In only one (4.2%) of the ANC observations did the patient receive GDM related information. None of the patients were asked about any previous history of GDM. In 45.8% (n=14) of the observations, the blood pressure of the pregnant woman was measured. In none of the ANC observations did providers counsel on GDM and provide information on the risk of developing diabetes later in life, the disappearance of GDM after pregnancy or when to diagnose. Furthermore, in none of the observed ANC consultations was a capillary sugar test or urine sugar test carried out, nor were any women referred to a laboratory for a sugar test (Table 2).

Facility inventory

The inventories of the facilities were assessed using a structured checklist. Among the 41 facilities assessed, 95.1% (n=39) provided outpatient services. All facilities provided ANC and postnatal care (PNC) but limited equipment for essential tests like glucose tests, urine tests and hemoglobin tests for ANC. Only two (4.8%) facilities had a separate breast-feeding corner, ANC corner and PNC corner and equipment for ultrasonography and hemoglobin testing. The referral facility (Kumudini Hospital) had a consultant trained on GDM. Nine (21.9%) of the facilities provided 24/7services.

Record keeping. During September to November 2017, a total of 6805 pregnant women received ANC from 41 selected facilities. Only six GDM women were detected in the referral hospital, whereas other facilities didn’t identify any women. Among the 41 facilities, 78% (n=32) did not perform any deliveries in last three months. A total of 31 preeclampsia/eclampsia cases, 125 premature babies, 215 cases of premature membrane rupture, 45 still births and four maternal deaths were reported in Kumudini hospital but such records about obstetric and newborn complications were not available in the other facilities (Table 3).

Human Resources. Only 29.2% (n=12) of the facilities have an obstetric consultant and 17% (n=7) have a SACMO, none of whom were trained on diabetes. Moreover, 26.8% (n=11) have a midwife/FWV, almost all (93.5%, n=29) community clinics have CHCPs and 41.4% (n=17) facilities have community skilled birth attendants (CSBAs). GDM-trained medical officers and nurses are only available in Kumudini hospital.

Equipment and resources. Weighing machines were present in all facilities, 26.8% (n=11) had glucometers but only 4.8% (n=2) had glucose test strips. In terms of other equipment, 95.1% (n=39) had blood pressure devices, 7.3 % (n=3) had a fetoscope, 12.1% (n=5) had an equipped labor room (with remaining facilities having an unequipped labor room), 87.8% (n=36) had a patient examination table and 95.1% (n=39) had a baby weighing machine (scale). Laboratory testing and the availability of ultrasound scanning existed only at Kumudini Hospital and Mirzapur Upazila Health Complex. Supplies of glucose to do oral glucose tolerance tests were available only at the Mirzapur Upazila Health Complex. Metformin tablets and insulin injections were not available at any of the facilities (Table 4).

Underlying data

Data is stored at the Centre for Injury Prevention and Research, Bangladesh (CIPRB). Due to sensitivity of the data (contains identifying information), permission is required from the Ethical Review Committee (ERC) of CIPRB, Dhaka, Bangladesh for sharing data with a third party. Data can be requested from the CIPRB, who will contact the ERC to gain approval to share the data. The conditions for gaining data access are a formal request with a clear objective and formal permission from the ERC. Please contact the corresponding author in order to request the data through email at info@ciprb.org.

Extended data

Figshare: Qualitative tools for GDM study in Bangladesh. https://doi.org/10.6084/m9.figshare.11925318.v1²¹

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).