Women’s perspectives on gestational diabetes mellitus screening services during antenatal care in Tanzania

Abstract

Background

Gestational diabetes mellitus (GDM) is the most common medical condition occurring during pregnancy. Screening for GDM during antenatal care (ANC) provides an opportunity to prevent its progress and complications. Women’s experiences should help shape how GDM screening guidelines are implemented, which will further influence uptake and adherence to screening services. We aimed to explore women’s experiences of receiving ANC at two hospitals in Tanzania where we introduced GDM screening services.

Methods

We employed an exploratory case study design in two district hospitals of Tanzania. We purposively recruited 22 women in 2024 who received ANC, which included GDM screening services. We conducted in-depth interviews using semi-structured interview guides, tape-recorded the interviews, transcribed verbatim, and analyzed the data using qualitative content analysis. Texts were condensed to meaningful units, abstracted to codes which were linked to the social-ecological model, developed sub-categories and categories.

Results

Participants described the suboptimal quality of health education and care provided during and after the GDM screening test. They expressed how the experience of receiving GDM screening services influenced their personal and community adaptations to a healthy lifestyle. Women suggested having GDM education in routine ANC health education sessions and to improve the timing and format of delivery of health education provided during ANC. Women expressed the need to simplify the logistics in doing the blood glucose tests, reduce user fees, and improve quality of care provided following the GDM screening test.

Conclusions

GDM screening services should be offered as part of routine ANC services. Receiving GDM care within routine ANC improved women’s perception of quality health care provided. Counselling and health education on GDM need to be strengthened to improve the quality of GDM care provided. Hospital health management teams should systematically engage the community and improve hospital logistics in offering quality GDM services during ANC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44263-026-00315-5.

Background

Antenatal care (ANC) offers a platform for the prevention of multiple conditions through detection and timely management during pregnancy [1, 2]. This occurs through screening of selected communicable and non-communicable diseases and conditions, which may be pre-existing, arise for the first time, or are exacerbated by pregnancy due to the physiological adaptations to the pregnancy state [3–5]. In addition to the screening, prophylactic medications are provided together with accompanying health education to foster a positive experience during pregnancy and childbirth [1, 2].

Gestational diabetes mellitus (GDM) is among the conditions for which screening is recommended during ANC [1, 6, 7]. This is due to the diabetogenic state of pregnancy, which puts women with pre-existing risks, including but not limited to age, high body mass index (BMI), and polycystic ovarian syndrome, at risk for GDM to become manifest for the first time during pregnancy [5]. Having more women with GDM has contributed to the ongoing obstetric transition, partly due to higher body mass index among women of reproductive age and those intending to conceive [8–10]. In Tanzania, similar to other African nations, the prevalence of GDM has increased from being undetected in the 1990s [11] to a level of 10%-30% in the 2020s [12–17]. When GDM is not diagnosed and managed promptly, adverse complications can occur during pregnancy, childbirth, and in the future of the woman and newborn. The complications may include pre-eclampsia, intrauterine fetal death, birth trauma, postpartum hemorrhage, difficulty in initiating breastfeeding, neonatal hypoglycaemia and early neonatal death, among others [7, 18, 19].

Screening for GDM is provided together with other services, and this requires having competent health care workers (HCWs) trained in providing comprehensive GDM care [18, 20]. These HCWs are responsible for delivering comprehensive education on GDM, including guidance on nutrition and lifestyle modifications, the importance and benefits of GDM screening, recommended timing for screening, and the type of care and follow-up provided based on screening results [1, 6, 18]. The health care system needs to be able to accommodate these competent HCWs and put in place a structure that allows the provision of all care needed for women with GDM [20, 21].

The World Health Organization (WHO) and professional associations agree that to prevent GDM-related complications during pregnancy and following childbirth, GDM screening should be included for all pregnant women at ANC [2, 18, 22–25]. Ministries of health in respective countries, including Tanzania, have adapted the recommendations to their national clinical guidelines [1, 6]. However, this evidence-based practice recommended by the guidelines does not always translate to improved user experience [26, 27]. Health care service user experience, satisfaction with services offered, adherence to care, and respectful maternity care improve when women’s perceptions of care are included in the implementation of the clinical guidelines [28]. To improve the quality of care, the health system needs to accommodate women’s care needs holistically from the point of the screening test through the postpartum period to enhance sustainability and acceptance of GDM care services [29].

Very little is known about women’s perspectives on how these GDM guidelines should be implemented within the ANC setting. In this study, we explore women’s perspectives on the provision of GDM screening services within ANC clinics in Tanzania.

Methods

Study design

This study is part of a protocol employing the sequential explanatory mixed methods approach and which is described in detail elsewhere [30]. We established a GDM screening protocol [14] in the two study hospitals prior to this qualitative study. We employed an exploratory case study design using in-depth interviews to explore the perspectives of women receiving ANC which includes GDM screening services. This study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Supplementary material 1: COREQ Checklist).

Study context

We conducted this study in two district-level, public primary health care hospitals, one in Coast region (Hospital A) and the other in the Dar es Salaam region (Hospital B) of Tanzania [30].

The health care system in Tanzania has a pyramidal structure, with the primary health care at the base of the pyramid. The primary health care system is composed of community health services, dispensaries, health centers, and district hospitals at the top of the primary health care hierarchy. After the district hospitals, there are regional, zonal, national, and specialized hospitals [31]. ANC services are offered at facilities of all levels within the system.

In the two study hospitals, ANC is provided by nurse-midwives along with medical doctors attending to those needing further medical attention. ANC provision follows Tanzania’s ANC guideline and standard treatment guideline (STG) [1, 32]. Both guidelines recommend preventive services to be provided, including health education and screening services. For health education, the recommended topics to be covered include non-communicable diseases, nutrition, emergency, and birth preparedness. Screening services, tests, and prophylactic therapy should be provided for malaria, hookworm infestation, HIV, syphilis, and urinary tract infections, as well as for hypertension, GDM, and anaemia.

In both hospitals, outpatient ANC is part of the services offered by the Department of obstetrics and gynecology (OBGYN). Specialized clinic services are also offered, managed by specialist medical doctors. During ANC, the attending HCW would request a laboratory test through an electronic system and the test would then be done at the central laboratory of the hospital. In both hospitals, before the study, GDM screening was not routinely done as part of ANC [33].

For study purposes, we introduced a GDM screening protocol where all HCWs in the OBGYN departments of both hospitals were informed of the study and study procedures. AK and KR provided a one-day seminar to the HCWs on key counselling information and management principles related to GDM as per the Tanzanian STG and ANC guidelines [1, 6] that needed to be provided to women before and after screening for GDM. The study provided all the laboratory supplies to screen for GDM, trained HCWs and study research assistants (RAs) [30] on how to screen for GDM (described under population and sample sub-section). Every morning, AK and the RAs, provided information about GDM and the study to the women waiting for ANC services at the clinic. The study RAs also linked all women who screened positive for GDM to the specialized OBGYN clinic, from which all the care provided, including other ANC services, follow-up visit schedule, was according to the Tanzania STG [6], ANC guideline [1] and the respective hospital protocols.

Population and sample

A total of 970 women were screened for GDM using a two-hour, 75gm oral glucose tolerance test, and results from this test were used to qualify women as positive for GDM (8.5mmol/L-11.0mmol/L) or negative per 2013 WHO criteria [34]. Women did two additional screening tests, glycosuria and checklist screening test, to assess their screening performance with 75gm oral glucose tolerance test (OGTT) as a diagnostic test [14]. Eligible pregnant women were recruited at 24 to 28 weeks of gestational age between June 19 and October 31, 2024 [14]. From those who were screened, prospective interview participants for this qualitative study were identified, and recruited for an interview, which was conducted four weeks after the screening test [30]. We purposively selected 33 women to participate in in-depth interviews. The purposive selection was based on the GDM screening test result, gravidity status, and level of education. Six women were not reached via the contact numbers provided, three declined to participate, and two travelled outside of the regions of the study hospitals and were not available for a face-to-face interview. The final study sample consisted of 22 women, 11 from each hospital (Table S1).

Data collection

Three RAs with experience in qualitative methodology, one in Hospital A and two in Hospital B, recruited and conducted the interviews with the women. The three RAs also recruited study participants for the screening of GDM in the second part of the overall study [14, 30]. This allowed maintenance of rapport between the study participants and the RAs in the two phases of the study. These RAs were non-clinical personnel; their role was limited to recruitment of eligible women, obtaining informed consent, and interviewing women. All clinically related care was provided by hospital medical staff within the respective hospitals.

All interviews were conducted face to face in a private space – an unused consultation room, seminar room, or office within the hospital premises. The interviews aimed at learning experiences of women after receiving the results, including personal and household lifestyle adaptations that took place. We contacted every woman who was initially recruited a few days before the date of the interview to remind her and confirm her planned visit at the hospital’s ANC clinic. Interviews were conducted after the woman had completed her ANC visit.

Following written informed consent, interviews were conducted in Swahili and audio recorded using a Philips voice tracer, DVT2050 audio recorder device [35]. Topics included in the interviews were women’s perception of GDM screening services provided, what happened during and after the screening, and how they would have liked the screening process to be conducted in the respective hospitals. A semi-structured interview guide with questions and probes was used (Supplementary Material 2: Interview guide and participant information sheet). Interview duration ranged from 30 min to 90 min. Data collection spanned from 3rd August 2024 to 29th October 2024.

AK conducted debrief meetings with the RAs on each day when an in-depth interview was conducted. This allowed iterative identification of patterns from the interviews with reference to the study objectives. We further adapted the interview guide to the new information we extracted from the interviews to the point of data saturation. We reached data saturation when successive interviews produced repetitive patterns of data without generating new thematic insights [36]. Saturation was assessed across the combined dataset, rather than separately by hospital. Notes were taken following each debrief meeting to keep track of changes and ideas developed from the interview, but also reasons for the adaptations made. These notes supplemented the development of codes when formal review of the transcripts began.

Data analysis

All audio interview recordings were transcribed verbatim. AK sampled five audio interview recordings for quality check with the corresponding transcripts by reviewing them at random time points.

AK familiarized himself with the transcripts through repeated readings to develop a comprehensive understanding of the data. He then selected three transcripts and shared them with HO for independent inductive open coding. AK and HO then further extracted texts on interviewees’ perspectives about the provision of GDM screening services, which formed the unit of analysis. The texts were then divided into meaningful units, before being abstracted into codes, sub-categories and categories using qualitative content analysis, as inspired by Graneheim and Lundman [37] using NVivo 1.7.1 (version 1534) software. This followed reflections and discussion meetings with HO to share, triangulate codes, and reach a consensus on an agreed coding tree. We considered the context of ANC service provision in primary health care in Tanzania during the development of the codes. We linked the codes with the levels at which women’s perspectives on how GDM care should be structured within the ANC service provision, using the social ecological model [38, 39]. The linkage of the meaningful units to three levels, namely individual, family and community, and the hospital levels of the adapted social ecological model is provided through the codes (Fig. 1, Table 1 and Supplementary Material 3).

Fig. 1.

Organization and linkage of the codes with categories based on the socio-ecological model [39]. ANC Antenatal care, FBG Fasting blood glucose, GDM Gestational diabetes mellitus

Table 1.

Description of the development of the categories from the code level

Codes	Sub-categories	Categories
Partial nutritional counselling	i.  Quality of health education provided during ANC	1. The experience of receiving GDM services during ANC
Group health education provision
Partial nutritional counselling
First time GDM testing	ii. GDM screening test during ANC clinic
Pre-test counselling
Perception of test and test results
Access to a specialist	iii. Care provided after receiving GDM screening test results
Consultation fee
Perception of the test and test results
Family reaction to test results
Lifestyle adaptation	iv. Influence on women’s daily life
Dietary change benefits
GDM care for all
↓ GDM sensitization
Service satisfaction
↑ Male engagement
↑ Time for counselling	i. Quality of health education	2. Women suggestions for improving the provision of GDM services within ANC
Group health education provision
Provide leaflets
GDM should be part of health education
Willingness to FBG (Test willingness)	ii. Test   used for GDM screening
Adaptations for FBG
Willingness to OGTT (Test willingness)
Provide pre- and post-test counselling	iii. Care provided after the test results
↓ Consultation fee	iv. Fee for GDM care services
Waive test fee
Waive consultation fee

The social ecological model positions an individual at the center and is surrounded by multiple system layers. The proximity of the layers to the individual depends on the degree of influence and interaction the individual and the layer have to affect the intended outcome. These interactions can be between individuals, or individuals with the community or the environment that governs the community [39]. For this work, a pregnant woman receiving GDM care is influenced by her own perception of care, interactions at family, community and hospital levels.

The health management level should support the three levels to meet the needs of women in ensuring quality GDM care services. AK proceeded with coding the remaining transcripts using the agreed-upon coding tree, with the flexibility of iteratively adding new codes following a review of the rest of the transcripts.

Coding was done with transcripts in Swahili language to avoid loss of nuance and meaning in the process of translation. We grouped the agreed codes and reduced them further to develop tentative sub-categories and categories. These were discussed, revised, and agreed upon among all the authors. AK and HO are native Swahili speakers. Translation was done on the developed codes and on the selected quotes used in the manuscript. The final synthesis of the analysis was reviewed among all the authors. To safeguard the anonymity and confidentiality of participants and hospitals, all transcripts were anonymized before analysis and hospital names were de-linked from the narration of the results.

Results

A total of 22 eligible study participants were interviewed. Table 2 shows their distribution and characteristics.

Table 2.

Characteristics of women interviewed during the study (n=22)

Characteristic	Number of participants n (%)
Age
19-30	9 (40.9)
31-40	13 (59.1)
Gravidity
1	4 (18.2)
2-4	14 (63.6)
≥ 5	4 (18.2)
GDM results based on OGTT
Positive	8 (36.4)
Negative	14 (63.6)
Level of education
Primary school	16 (72.7)
Secondary school	6 (27.3)

*OGTT – Oral glucose tolerance test

We present women’s perspectives on the provision of GDM services within an ANC clinic setup. We begin by narrating the women’s experiences of receiving GDM screening services, highlighting both areas of strength and those requiring improvement. To interpret these findings, we use the social ecological model (Fig. 1) to demonstrate how the categories are situated across different levels of the model: individual, family and community, hospital, and health management team levels. This framework helps to contextualize women’s perspectives within the broader social and structural environment that shapes women’s experiences of GDM care. We further describe women’s suggestions about specific areas of improvement in the provision of GDM screening services in ANC clinics.

Experience of receiving GDM services during ANC

The GDM screening services in the study hospitals comprised multiple elements, which shaped women’s experiences during and after care. We group and narrate the experiences into four sub-categories with relevance to the elements of care provided.

Quality of health education provided during ANC

In the two hospitals, health education, if provided, was done in a group format at the ANC clinic. The provision of health education differed between the two study hospitals. In one, it was offered routinely daily, while in the other hospital, “group health education is only provided on the days when the majority of the attendees are women coming for their first ANC visit…” (P21). In both hospitals, it was only provided in early morning hours, meaning that women who arrived later in the day missed out “I am always late for the morning group health education sessions for pregnant women…” (P9). Women who were present during the group health education shared that it covered various topics, including birth preparedness, emergency symptoms identification, nutrition counselling, and anemia in pregnancy, among others. However, the topic of GDM was discussed for the first time on the day they were screened for GDM “This was the first time, because I don’t know much about diabetes or how it presents…” (P8). While women who received information on GDM appreciated it and acknowledged its importance to them, the inconsistent access to health education contributed to gaps in knowledge among others. “…If I got this information earlier, I would have changed how I eat. Because now I know its my eating habits that got me to this point, I ate and drank a lot of sugary things. In a day I would take three to four bottles of soda, sugarcane juice, and a malt drink. For breakfast, I would put a lot of sugar in my tea taking it with “chapati”, this is how I used to eat…” (P13)

GDM screening during ANC clinic

In both hospitals, women appreciated being screened for GDM. This was shared among those with a first-time pregnancy and those who had received ANC in previous pregnancies. None of the women with previous pregnancies and use of ANC reported having been screened for GDM before. However, at the laboratory, where the blood glucose test was conducted, minimal information on GDM was provided. This lack of information generated a sense of fear and anxiety during the test, and while waiting for the test results, “ Then I started wondering…what if I test positive, will I be like other diabetic patients? food restrictions? No more tasty food… ” (P5). These concerns stemmed from the societal perception of how a person living with diabetes looks; often seen as underweight, with open wounds, or with amputated limbs. “All that was going through my mind was those massive ulcers and restrictions on diet…like other people with diabetes we see in the community…” (P5).

Even with these fears, women appreciated the experience of being screened for GDM as it reassured them about their and their baby’s well-being during pregnancy, regardless of the test results.

Care provided after receiving GDM screening test results

Responses to the test results varied, with majority of the women receiving the GDM test results positively. Those who were negative for GDM expressed relief and happiness, while those who were positive for GDM appreciated knowing their GDM status at that time “… I was glad to know my status timely because diabetes is affecting a lot of people in the community…” (P3). Others expressed being stressed after receiving positive test results, due to the fear of the disease and possible outcomes.

“….she (nurse) calmed me down, and because I was with my aunty, when I told her that I am positive for diabetes, she got confused…with diabetes and you are pregnant, she started sweating and trying to fit her ‘khanga’ well. I told her that I already went to see the doctor, but truthfully, I was also not okay probably because of our understanding of the disease. Even back home when I told my husband, he was shocked…” (P21).

Women who were diagnosed with GDM appreciated having a consultation with the specialist doctor in the hospital. This consultation eased the anxiety and clarified most questions and possible misconceptions they had after receiving positive GDM test results. This extended to the care they received for a follow-up glucose control test that the doctors scheduled, particularly after knowing the glucose control test became normal on a follow-up test “I was not expecting my blood sugar to be normal in my follow-up appointment, I realized following instructions helped me…my test results are good…its back to normal…its 4.6 “ (P4). Women also expressed concerns regarding the service fee for a specialist consultation and follow-up glucose tests that were needed after screening positive. They believed the service fees were unaffordable and would limit most women from accessing care.

We are asking that once someone is known to have diabetes, especially we pregnant women … If someone has to pay to see the doctor the first time, let it only be that first time, and then the following visits should just be for check-ups to monitor their condition….Sometimes we come from far with just enough money for transport and maybe for medication, but when it comes to other pregnancy-related tests that are required, you find yourself without any money and decide to just go to a local dispensary for next visit…”(P6)

Influence on women’s daily life

Women shared a general sense of satisfaction with the overall quality of ANC, which included GDM care. They suggested that GDM screening services should be provided as part of ANC in every health facility and should engage male partners and the whole community in GDM care. “In my opinion, I was suggesting even for those pregnant women in the rural areas should have access to this service on diabetes …” (P12). Among women who screened positive for GDM, the services offered triggered a realization of the need for diet modification and engaging in physical exercise. Which, after taking part in, they noticed the health benefits within a short time “I feel much better now, I don’t tire easily as I used to …” (P7). The diet modifications included removing sweetened carbonated drinks, and fries, together with developing a sense of self-awareness and control over the frequent cravings for sugary or carbohydrate-rich foods. Even though this transition was reportedly not easy, women expressed a willingness to modify their diets for their well-being and that of their baby “I have stopped taking soda and carbohydrates…and this was a difficult thing to do… “ (P4). However, some women struggled to adhere to the dietary modifications that were suggested due to financial limitations and societal expectations of what a pregnant woman should eat. As a result, they often ended up eating what was available rather than what was recommended.

“…not only for pregnant women, but everyone needs to know about diabetes. Because diabetes affects everyone, not only pregnant women. Back in the days, we used to know that diabetes is only for the old and rich people and knew very little about it. Now we hear about it everywhere, even young kids are getting diabetes…” (P19).

Women’s suggestions for improving the provision of GDM services within ANC

Quality of health education

Women preferred the existing format of health education sessions in a group and recommended that it be maintained. This is because of the question-and-answer sessions and group discussions that were held benefited even those who were shy to speak or ask questions. Women insisted that group health education sessions, with a topic on GDM, should be provided daily “…in every group health education session there should be contents of diabetes, every visit…” (P21). They also suggested that health education sessions should be at multiple time slots during the day to accommodate those who cannot reach the hospital early in the morning. The topic on GDM should be provided from the time a woman starts ANC, this will help the needed preparations for the test when the time comes to do it in the third trimester. This information will also allow them to make necessary dietary and lifestyle adjustments from the beginning of pregnancy. To supplement the verbal group sessions, women recommended the development and distribution of printed informational materials on diabetes and the use of the pre-recorded educational materials that can be played using the available TV screens at the clinic or other service-waiting areas within the hospital. “If we were also given leaflets, it will be great, we can even take them home and share with our family members…” (P3).

In the case of one-to-one counselling, women suggested that more time should be allocated to allow them to ask questions for clarifications about GDM. To ensure a wider community is reached, women recommended using appropriate non-threatening communication materials on GDM using mainstream and social media platforms. The communication materials should show the success stories of management of GDM. This was compared to the existing available media content focusing on complications of unmanaged diabetes mellitus in the general public. Women recommended engaging the community in places with social gatherings like marketplaces, which would help to reach the majority of people with health educational materials on GDM.

“…a topic on diabetes should be provided like other topics, it should be on their agenda so that they don’t forget about it…. When you are in a group, when questions are asked, you benefit from the responses and resulting discussions…” (P17)

Test used for GDM screening

Women were comfortable with the OGTT for GDM screening, the solution used, and with the two-hour waiting time. Women also insisted on the importance of supervising women during intake of the 75gm solution to ensure they finish it as per instructions. However, some suggested that if there was a screening modality not requiring ingestion of any solution, it would be more appealing.

When asked about the possibility of using a fasting blood glucose test, there were mixed responses. Some women highlighted the difficulty of fasting for eight hours during pregnancy noting, “… remember, I now eat for two, I no longer eat for myself…the degree of hunger is different…” (P9). The difficulties in fasting were further compounded by the need to wake up early and the resulting transport difficulties they experienced before arrival at the hospital for ANC. Upon arrival at the hospital, the needs to queue for registration and wait for a time to have the glucose test after other routine ANC services.

Women suggested that sufficient information about the test should be provided in earlier ANC clinic visits. This would allow women to plan for that ANC visit with the test, know details of the fasting or other GDM test, and the time it will take for the test to be done. For the fasting test, they suggested that hospitals prioritize testing fasting women before other clinic activities begin on the day of the test. Women thought this would make the fasting glucose test for GDM more practical for them.

“…it should be in the clinic schedule so that one is aware in that visit I will be required to test for diabetes, that way women won’t be surprised when informed of the test….the way it is, you may have planned to come and finish early for the clinic and you find that you have to wait for two hours because of a diabetes test. But when someone knows beforehand, she can plan accordingly for that particular visit…” (P14)

Care provided after the test results

Women emphasized the importance of strengthening counselling after receiving the test results. This was more so for those who screened positive for GDM, who highlighted the need for individualized counselling following a positive test result“…the important thing is to get detailed explanations about the disease…” (P14). They preferred this information to be provided during the specialist consultation, because it allowed linking the counselling with the overall management of GDM. For the specialist consultation, women suggested having it immediately rather than a distant appointment and wanted clear information on follow-up care, like the schedule of the next visit and what needs to be done before the next follow-up visit. Women described how this would allow them and their families to have a better understanding of managing GDM. This also goes hand in hand with the process of disclosure of the test results, where women wanted privacy when receiving the results. This included not receiving test results in front of everyone in the laboratory waiting areas. “…there should be some privacy when receiving the test results…” (P20). For the disclosure of the test results, HCWs should take time to explain the results, particularly when the results are positive.

“…to get ample time to discuss, where I can clear my concerns…like when should I expect to deliver? I have a previous operation, when should I expect to deliver so that I can prepare myself? You find that I miss that opportunity, like the last time I was attended by those students, I couldn’t ask them…” (P14)

Fee for GDM care services

When women were asked about their willingness to pay the fee for GDM test and follow-up services, responses varied depending on the specific component of care. For the screening test, women were willing to contribute from 2,000 Tanzanian Shillings to 10,000 Tanzanian Shillings (equivalent to 1 USD to 4 USD). Interestingly, women preferred contributing to the overall fee with a sense that freely offered service may not be important “…the tests that are done for free, I never take them seriously….” (P19). For the care after the test results, women requested a waiver for the specialist consultation fee and for the follow-up glucose tests that will be required. However, where necessary, women suggested having a clear mechanism to support those who are unable to pay for these services. This will ensure women’s consistency in the follow-up plan of their GDM care.

“…I am only requesting improvements on diabetes services for pregnant women…if you are paying the consultation fee to see the specialist on the first day, you shouldn’t pay for the subsequent consultations. Otherwise, women will start missing out clinics and want to attend dispensaries to avoid this …” (P4).

Discussion

This study describes the perspectives of women who received ANC care in two district hospitals where we introduced GDM services within ANC. Women appreciated being screened for GDM and the care provided following the screening results. Women further expressed the desire for GDM services to be integrated into routine ANC at all health care facilities. The GDM services provided led to a positive change in diet and exercise among those screened. Women recommended improvements in the content, timing, and frequency of the health education provided during ANC, improvements in GDM counselling services, consultation with the specialist for those who screened positive, and revision to the fees for GDM services. The following paragraphs will unpack the discussion of the findings grouped according to the three levels of the social-ecological model used, starting with the individual level, to the community and health facility level. We further discuss how the interactions between the levels influence each other and the needed adaptations at the health management level to improve GDM care at individual, community and health facility level.

Human behavior is a function of multiple interacting elements that may influence or restrict occurrence of such behavior [40, 41]. At individual level, some women attributed their poor dietary practices, that was perceived to contribute to developing GDM, to simply lack of information on GDM. While the lack of information may contribute but developing diabetes mellitus is not because of having bad nutritional choices alone but is a result of underlying metabolic changes [5, 42], community level factors which include environmental constraints, and other socially biased circumstances that limit a healthy lifestyle [43, 44]. An individual woman’s dietary behavior is not simply a wrong choice but a result of community and health system level factors that need to be improved to support prevention and GDM care beyond having screening tests at the health care facilities.

A diet that supports a normal glucose level for a pregnant woman and normal well-being of the baby is the intention for diet modification in women with GDM. During pregnancy, physiological changes such as increased energy demands, endocrine and neuronal changes affect eating behavior and heighten appetite [45]. Women’s dietary choice in response to these physiological changes is partly affected by what is available and cultural expectations within the community about what pregnant women should eat [46, 47]. For dietary behavior change to be practical at the individual level, diet counselling needs to be provided by skilled personnel in the community or health facility level [48]. From our results, women preferred counselling to be provided by skilled HCWs who would spend time explaining and clarifying their concerns. Diet counselling relevant to GDM should not only focus on limiting carbohydrates, but also include modifying the type, proportion, and source of locally available carbohydrates [49]. Without this approach, it may lead to poor adherence or dietary choices which may worsen insulin resistance and compromise maternal and fetal well-being [50–52]. High-quality diet counselling from the health facility level can modify preconceived societal beliefs in the community on diet and nutrition by fostering positive attitudes, strengthening intentions, and building recommended skills to adapt to the required nutritional practices at the individual level [53, 54].

In this study, women appreciated the nutrition information provided and said it influenced their dietary practices. However, because GDM is diagnosed between 24 and 28 weeks of pregnancy, there is a limited period where all these dietary changes must be implemented. This may prove difficult for most women to accommodate without quality and consistent supportive counselling [55]. Efforts at the hospital level may be limited by individual-level factors, for example, counselling content may conflict with women’s personal food preferences and purchasing power, highlighting the need to tailor dietary information to each individual to promote adherence [56]. Aspects like managing food cravings, pressure over adapting to a new diet while accommodating the needs of a growing baby, and financing the recommended care should be addressed [57–59]. HCWs should understand that diet counselling is a process and should individualize it to enhance a positive experience in GDM care [60, 61]. The health system should be strengthened to support HCWs in the provision of GDM-tailored health education, have standardized counselling tools, engage with the community through existing networks, and provide quality individualized counselling to women with GDM.

Beyond the group counselling that needs to be provided for GDM at the hospital level, attention to cater for individual emotional stress during care needs to be prioritized. Women expressed feelings of fear and anxiety in the process of testing and waiting for test results. Similar observations of emotional reactions that included being shocked, worried or upset have been reported elsewhere [62–64]. These emotional reactions have been attributed to fear of their health having a potential to harm their un-born baby and additional responsibilities that come with monitoring GDM [65]. Supporting women with GDM starts from the partner and extends to society in ensuring access to quality services and communal lifestyle changes that support physical activeness are in place [66]. This communal support can extend to include the traditional and social media space by providing correct information, support on GDM care and management [67].

Traditionally, performance indicators for service delivery have focused on which services are delivered rather than examining how the services are delivered [68]. This, among other factors, has contributed to a compromise in the quality, user experience, and implementation of ANC services [69]. Using GDM screening as a case study, we highlight that effective care requires more than simply having GDM test kits available at the health facilities. It also demands having a structured system that accommodates women’s needs through the provision of health education and easily accessible GDM testing during ANC. Health education should be accessible to all ANC attendees and should be engaging to ensure a comprehensive understanding of GDM. In Tanzania, the quality of services within ANC that require more contact time with the HCWs, such as health education provision, remains low [70]. Our results show similar findings, and women receiving ANC preferred better health education services that included GDM content. Similar to other health services, a well-informed individual is likely to have a positive attitude about a service, which in turn could influence the uptake and adherence to the services provided and lifestyle adaptations recommended [53].

The diagnostic accuracy of GDM tests is well established [71–74], with a consensus toward universal screening of GDM during pregnancy [18]. While the OGTT is currently the gold standard test for GDM, its high cost limits widespread use in low-income countries [18, 75]. Fasting blood glucose is one alternative to the OGTT [18], but its acceptance depends on the restructuring of the laboratory testing procedures [2]. In this study, women suggested logistical structural improvements, including prioritizing fasting blood glucose testing in the early morning. This further emphasizes the importance of aligning service delivery with women’s values to promote uptake of the services offered [76].

We acknowledge that some of the women’s experiences may have been influenced by components controlled by the research study. This includes orienting the HCWs and RAs on the screening and provision of health education related to GDM and providing the GDM screening laboratory supplies to the two hospitals. This was done to model an ANC clinic that provided GDM services without interfering with other routine procedures within the hospital in providing ANC. The staffing and laboratory capacity of the two study hospitals may limit the transferability of these experiences to facilities without in-hospital medical specialists or laboratory capacity to perform the glucose tests. However, lessons gained through womens’ experiences presented in this paper can be used in similar settings to improve GDM care within ANC. Throughout the study, there was continuous monitoring to ensure study procedures did not affect the flow of routine ANC services. Interviewees may have provided socially desirable responses because of associating the RAs with service provision. The RAs introduced their role to the interviewees as researchers and insisted on information provided would not influence the quality of ANC provided. Further, the experience of RAs in qualitative methodology and authors’ diverse training backgrounds allowed for an objective structuring of the interview guides, conductance of the interviews and synthesis of the results which limited potential interpretive bias. We believe the results presented reflect what needs to be improved in GDM care within ANC clinics with a similar context.

Conclusions

Routine ANC should incorporate comprehensive GDM services. Nutrition education and other counselling services should be strengthened alongside other ANC services. The health system, through the management, should accommodate women’s views of how these services can be delivered, recognizing that the uptake of GDM screening services requires coordinated interventions at multiple levels, including individual, family, and community, and hospital levels.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ANC

Antenatal Care

GDM

Gestational Diabetes Mellitus

HCW

Health Care Worker

HIV

Human Immunodeficiency Virus

OBGYN

Obstetrics and Gynecology

OGTT

Oral Glucose Tolerance Test

RA

Research Assistant

STG

Standard Treatment Guideline

WHO

World Health Organization

Author contributions

Designing, planning, data collection, and first draft of manuscript AK; Data analysis AK, HO; synthesis of results AK, HO, LB, ABP, NS, KR, and JLP; Supervision, review, and validation of manuscript KR, NS, ABP, JLP, and LB. All authors read and approved the final manuscript.

Funding

This work was supported by the Directorate-General Development Cooperation and Humanitarian Aid Belgium through the Institute of Tropical Medicine, Antwerp, Belgium (Institute of Tropical Medicine in Antwerp) as part of the Sandwich PhD scholarship for AK. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data availability

The datasets generated and/or analysed during the current study are not publicly available to maintain the confidentiality and identity of the study participants but are available from the corresponding author on individual reasonable request through the National Institute of Medical Research, Tanzania - National Health Research Ethics Review Sub-committee - ethics@nimr.or.tz; www.nimr.or.tz.

Declarations

Ethics approval and consent to participate

The study received ethical approval from the Institutional Ethics Committee at the Institute of Tropical Medicine Antwerp (1687/23), the Muhimbili University of Health and Allied Sciences Research and Ethics Committee (MUHAS-REC-07-2023-1834), and the Tanzanian National Health Research Ethics Review Committee (NIMR/HQ/R.8a/Vol.IX/4457). The study conformed to the principles of the Helsinki Declaration. Written informed consent was obtained from all interview participants. All transcripts were de-identified before analysis. We kept the hospital names anonymous to safeguard the identity of the hospital in the services provided.

Consent for publication

Not applicable.

Competing Interests

The authors declare no competing interests.