|Year : 2021 | Volume
| Issue : 5 | Page : 104-109
Practice patterns among healthcare professionals for screening, diagnosis, and management of gestational diabetes mellitus (GDM) in selected countries of Asia, Africa, and Middle East
Shabeen Naz Masood1, Balaji Bhavadharini2, Viswanathan Mohan3
1 Department of Obstetrics and Gynaecology, Isra University, Karachi-Campus, Pakistan
2 Women’s College Hospital, Toronto, Canada
3 Department of Diabetology, Madras Diabetes Research Foundation, ICMR Centre for Advanced Research on Diabetes and Dr. Mohan’s Diabetes Specialities Centre, IDF Centre of Excellence in Diabetes Care, Chennai, Tamil Nadu, India
|Date of Submission||20-May-2021|
|Date of Decision||01-Jun-2021|
|Date of Acceptance||02-Jun-2021|
|Date of Web Publication||20-Jul-2021|
Dr. Shabeen Naz Masood
Department of Obstetrics and Gynaecology, Isra University, Karachi-Campus.
Source of Support: None, Conflict of Interest: None
Background: Healthcare professionals (HCPs) face several challenges while treating women with gestational diabetes mellitus (GDM) and often get confused by the different diagnostic criteria recommended by different scientific organizations. A survey was carried out to understand the practices of physicians and obstetricians in South Asia, Africa, and the Middle East, to identify the screening methods and diagnostic criteria used by them for managing women with GDM in the respective countries. Materials and Methods: HCPs across three different regions including South Asia, Middle East, and Africa were contacted through professional diabetes organizations. An online survey designed with Google Forms was created. The link to the survey was shared with HCPs, and the responses were collected and stored in the Google Sheets which was later downloaded for analysis. Results: A total of 356 doctors participated in the survey. The survey covered a total of 18 countries: 3 in South Asia, 5 in Africa, and 10 in the Middle East. The vast majority of the HCPs (64.6%) screened all pregnant women for GDM. About 42.4% of them screened for GDM between 24 and 28 weeks, 21.1% screened before 12 weeks, and the rest carried out screening at different time points. With regard to the screening method, 58.5% of the HCPs responded that they followed the two-step process. However, when asked about the criteria used, the responses were inconsistent. The criteria of the International Association of Diabetes in Pregnancy Study Group (IADPSG) were used by 36.5% doctors and the 1999 criteria by the old World Health Organization (WHO) were used by 27.2%, and only 23.9% reported following the American Diabetes Association (ADA) criteria. Conclusion: This large international survey shows that there are still considerable inaccuracies in doctors following the recommended guidelines for GDM diagnosis. This reiterates the fact that more education and training will help HCPs to manage GDM better.
Keywords: DASG, diagnosis and management, gestational diabetes mellitus (GDM), HIP guidelines, hyperglycemia in pregnancy (HIP), IADPSG criteria
|How to cite this article:|
Masood SN, Bhavadharini B, Mohan V. Practice patterns among healthcare professionals for screening, diagnosis, and management of gestational diabetes mellitus (GDM) in selected countries of Asia, Africa, and Middle East. J Diabetol 2021;12, Suppl S1:104-9
|How to cite this URL:|
Masood SN, Bhavadharini B, Mohan V. Practice patterns among healthcare professionals for screening, diagnosis, and management of gestational diabetes mellitus (GDM) in selected countries of Asia, Africa, and Middle East. J Diabetol [serial online] 2021 [cited 2021 Jul 30];12, Suppl S1:104-9. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/5/104/321824
| Introduction|| |
Gestational diabetes mellitus (GDM) affects more than 15% of pregnancies worldwide. A recent systematic review reported that the prevalence of GDM in Eastern and Southeast Asia is found to be 10% but the prevalence ranges from 10% to 30% depending on the screening strategy used, population characteristics, and ethnicity. In Middle eastern countries, the prevalence ranges from 5.1% in Yemen to 24.9% in the United Arab Emirates. Women with GDM are at a higher risk of developing maternal and neonatal complications during delivery and postpartum., Women with GDM are also at a significantly higher risk of developing type 2 diabetes in the future., Hence, it is essential to accurately diagnose and optimally treat GDM not only to reduce the morbidity to mother and fetus but also to prevent future type 2 diabetes mellitus and cardiovascular disease (CVD).
Despite several guidelines laid down by various scientific societies, controversy still exists on best screening and diagnostic criteria for GDM. Different countries follow different diagnostic criteria, with varying glucose cut points making it difficult to compare prevalence of GDM across countries. Healthcare professionals (HCPs) face several challenges while treating women with GDM and often get confused by the different diagnostic criteria recommended by different scientific organizations. A survey conducted by the Women in India with GDM Strategy (WINGS) project showed that more than half of the physicians and OB/GYNs in India do not follow any of the recommended guidelines for GDM diagnosis. This underscores the need to increase awareness about GDM management among HCPs. This study attempted to carry out a similar survey to understand the practices of physicians and obstetricians in South Asia, Africa, and the Middle East, to identify the screening methods and diagnostic criteria used by them for managing women with GDM in the respective countries.
| Materials and Methods|| |
An online survey was designed with Google Forms. The link to the survey was shared with physicians and OB/GYNs across three different regions including South Asia, Middle East, and Africa, who were contacted through professional diabetes organizations. Data collected through the online survey were stored in the backend Google Sheets which was then downloaded for analysis. The questionnaire included questions about screening techniques, diagnostic criteria used, type of oral glucose tolerance test (OGTT) carried out, and management and follow-up of women with GDM.
| Results|| |
A total of 356 doctors participated in the survey. The survey covered a total of 18 countries: 3 in South Asia, 5 in Africa, and 10 in the Middle East.
Primary institution of practice
Twenty-three percentage of the doctors who participated in the survey practiced in a government general hospital, whereas another 23% worked in private multispecialty hospitals. The rest worked in maternity hospitals and clinics, military hospitals, private clinics, and university hospitals [Table 1].
Number of pregnant women and women with GDM seen in a year
The majority of the doctors (58.9%) stated that they saw more than 500 pregnant women a year. A significantly higher number of doctors in South Asia (63.7%) reported seeing more than 500 pregnant women a year, compared with doctors in Africa and the Middle East (50.8%).
With respect to the number of women with GDM, overall, the majority of the doctors (39.6%) reported seeing less than five women with GDM in a month. Nearly 47% of the doctors in Africa and Middle East reported seeing less than five women with GDM per month [Table 2].
Universal screening vs. risk factor-based screening
The vast majority of the doctors (64.6%) screened all pregnant women for GDM, with similar percentages being reported in each individual region: South Asia, Africa, and the Middle East. The remaining 33.9% preferred to do risk factor-based screening. A small percentage of the doctors (1.4%) did not respond to this question; hence, information is unavailable in this group [Table 3].
|Table 3: BG screening: universal vs. selective and gestational age at screening|
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Gestational week of screening
About 42.4% of the doctors performed screening for GDM between 24 and 28 weeks, whereas 21.1% of them screened for GDM before 12 weeks. The rest of them carried out screening at different time points: 5.1% of the doctors performed screening between 12 and 16 weeks, 10.9% between 16 and 20 weeks, 19.1% between 20 and 24 weeks, and 1.4% after 28 weeks. In South Asia, a significantly higher percentage of doctors (14.1%) screened for GDM between 16 and 20 weeks when compared with Africa and Middle East (4.6%).
Screening process followed
The majority of the doctors (58.5%) followed the two-step process for blood glucose (BG) screening in pregnancy to diagnose GDM, whereas 41.5% of the doctors followed the single-step process. There was no difference in the screening process followed by doctors in South Asia, Africa, and Middle East.
As per the International Association of Diabetes in Pregnancy Study Group (IADPSG) criteria, OGTT is usually performed in the fasting state using 75-g glucose load. Our survey showed that 82.5% of the doctors carried out OGTTs in the fasting state, of which 77.2% of them used 75-g glucose load, whereas 12% used 100-g glucose load and the rest (10.7%) used 50-g glucose load. A significantly higher percentage of doctors in South Asia (89.8%) carried out BG test in the fasting state, the majority (83.2%) of whom used 75-g glucose load. Comparative figures for Africa and Middle East are as follows: 70% carried out BG test in the fasting state and 66.9% used a 75-g glucose load [Table 4].
Criteria used for GDM diagnosis
There are several different criteria that are currently in use for screening and diagnosis of GDM. The IADPSG criteria were used by 36.5% of the doctors, and 27.2% used the WHO 1999 criteria, whereas 23.9% used the old ADA criteria and 6.5% used the Diabetes in Pregnancy Study Group of India (DIPSI) criteria.
In South Asia, 39.4% of the doctors reported that they follow the IADPSG criteria, followed by WHO 1999 criteria (31.4%) and old ADA criteria (18.6%) while 7.1% followed the DIPSI criteria. In Africa and Middle East, the criteria that were most widely used by doctors were the old ADA criteria (33.1%), followed by IADPSG (31.5%) and WHO 1999 (20%). Around 10% of the health practitioners in Africa and Middle East and 3.5% in South Asia reported being unaware of what criteria was being used [Table 5].
Timing of postpartum appointment
With regard to timing of postpartum appointment, 47.2% of the doctors said that they advised women with GDM to return for postpartum appointment 1 week after delivery, followed by 39% of the doctors who advised women to return at 6 weeks postpartum [Table 6].
Advice for postpartum OGTT and postpartum follow-up rates
Overall, 69% (n = 246) of the HCPs advised their patients to return for postpartum OGTT, of which 42.7% of the HCPs reported the postpartum testing rates to be less than 10%, followed by 25.6% who reported the rate of follow-up to be between 10% and 20%. This result was consistent across regions [Table 7].
|Table 7: Advice for postpartum OGTT and actual postpartum follow-up rates|
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| Discussion|| |
The topic of screening for GDM has long been debated. There is still lack of consensus on the screening methods and practices employed for screening for GDM. Results from this study show several inaccuracies with regard to diagnosis of GDM that is being followed by HCPs across three different regions. There are several methods for screening and diagnosing GDM. One of them is the two-step method that is most often recommended by the ADA criteria. In our survey, 58.5% of the doctors reported that they followed the two-step procedure to screen and diagnose GDM. However, when asked about the criteria used, the responses were inconsistent as 36.5% and 27.2% of the HCPs reported using the IADPSG and WHO 1999 criteria, respectively. Both of the above-mentioned criteria are single-step criteria and 23.9% of them reported to follow the ADA criteria, which is much lower than the doctors who reported following the two-step process.
The topic of BG screening for GDM has long been debated. There is still lack of consensus on the screening methodology. Several international guidelines recommend BG screening in women of high-risk ethnic groups for GDM. The Middle Eastern countries such as Qatar have implemented universal screening approach due to high prevalence of diabetes and obesity. Among Indians, the prevalence of GDM is 11-fold higher than that in Caucasians, and therefore universal screening is recommended by the DIPSI guidelines. Data from our survey cover three ethnic populations, including South Asia, Africa, and Middle East. Overall, the survey results show that the majority of HCPs (64.6%) prefer universal screening method.
In an earlier survey conducted in India, 18.8% of the doctors reported screening during early pregnancy, whereas 40% reported screening between 20 and 28 weeks. Data from our survey show similar results, with 21% of the doctors practiced BG screening for GDM during early pregnancy, whereas 42.4% of them reported carrying out screening between 24 and 28 weeks. Delaying screening until second trimester could lead to missing diagnosis of pre-existing diabetes. However, screening earlier during pregnancy will also mean detecting hyperglycemia under the threshold for overt diabetes in pregnancy, and this would be classified as early onset GDM. Similar to controversy around diagnostic criteria used for conventional 20–24 weeks screening for GDM, there is no consensus on the screening criteria for GDM in early pregnancy as many believe that there are no data with regard to benefits and harms of diagnosing and treating GDM in early pregnancy.
One of the earliest criteria established by O’Sullivan and Mahan in 1964 recommended a 3-h 100-g OGTT based on women’s risk of developing type 2 diabetes later in life. The Carpenter and Coustan criteria later came into existence and became widely accepted and were later endorsed by the ADA, which recommended either a one-step or a two-step approach using an initial 50-g glucose challenge test, followed by a 100-g diagnostic OGTT. These ADA criteria (referred to as old ADA criteria in this paper) have been widely used in several countries. However, following the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, the IADPSG criteria were developed, which recommended a single-step diagnostic OGTT. Since the publication of the IADSPG, several scientific guidelines have been updated. The ADA, in particular, initially endorsed the IADPSG in 2011, but then quickly amended their guidelines in 2014 and recommended the use of either strategy, the IADPSG (one-step approach) or the old ADA (two-step approach) for GDM diagnosis. Frequent changes in the recommendations for GDM diagnosis by international organizations can lead to confusion among HCPs across the world as to which criterion to use. As seen in our survey, although 58.5% of the doctors reported following two-step process, only 24% reported following the old ADA criteria and 36.5% reported following the IADPSG criteria, which are actually a one-step procedure. This mix-up of criteria and the type of OGTT (one-step vs. two-step), plus the confusion with regard to the amount of the glucose that needs to be administered, make it difficult for non-specialists to diagnose and treat GDM effectively.
Women with GDM are at a high risk of developing type 2 diabetes as well as CVD in the future. Reports from India also show that over 70% women with a history of GDM develop diabetes within 10 years after delivery. The American College of Obstetricians and Gynecologists (ACOG) recommends screening women who had GDM for 6–12 weeks after delivery, which coincides with the first postpartum visit. Our survey shows that 47.2% of the doctors advice women to return for postpartum visit 1 week after delivery, followed by 39% who recommend women to return at 6 weeks’ postpartum. It is worth noting that not many HCPs offer postpartum BG testing. Only 69.4% of the doctors advice postpartum OGTT, but in practice postpartum glucose testing rates are less than 10%. A recent study from India reported the rate of dysglycemia (pre-diabetes + diabetes) to be 15.5% at 12 weeks’ postpartum in women with GDM, and an additional 38% transitioned to dysglycemia before end of 1 year after delivery. Therefore, being unaware of their glycemic status postpartum will only increase their risk of developing diabetes in subsequent pregnancies. Using proactive reminder systems, providing dedicated professionals to provide postpartum counseling, introducing home-care services, or remote monitoring telehealth services are some ways to address the barriers to postpartum screening.
This survey can help countries to carefully assess the cost and health impact of disparities in GDM screening and diagnosis in order to identify the best practice options to reduce the existing diabetes-related burden of maternal and perinatal morbidity and mortality. Adoption of appropriate BG screening and diagnostic modalities can reduce future burden of diabetes in mothers and prevent intergenerational transmission of diabetes to newborns.
This survey has covered most important aspects right from screening to postpartum care, and the results reiterate the fact that frequent changes in recommendations and lack of consensus among various bodies only create more confusion among HCPs treating gestational diabetes. Frequent updates and training of HCPs would definitely help in bringing down these discrepancies.
This survey may assist in setting goals for Continuous Medical Education about hyperglycemia in pregnancy (HIP) to incorporate, address, and bring down the disparities and confusions. This will help provide an insight and set benchmark about screening and diagnostic modalities of HIP to HCPs.
This is a large international survey conducted in 18 countries across South Asia, Africa, and Middle East, where the prevalence of diabetes is huge. The survey accentuates the enormous discrepancies and large variations in estimated GDM prevalence, screening, diagnostic criteria, and postpartum care of GDM women.
Direct comparison between countries could be useful but it is understood that it is difficult due to different diagnostic strategies and subpopulations.
| Conclusion|| |
This large international survey conducted in several countries across South Asia, Africa, and Middle East shows that there are considerable inaccuracies among HCPs to follow recommended guidelines for the screening and diagnosis of GDM. More education and training will help doctors to stay up to date with recent advances in diagnosis and management of GDM. Women should also be made aware of the impact of dysglycemia on their health and motivate them to manage their condition and to follow recommendations to come for postpartum follow-up.
Financial support and sponsorship
This research did not receive any specific grant from funding agencies.
Conflicts of interest
The authors declare that they have no competing interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]