Table 2.

Key informant views on policies and clinical practice guidelines for the management of GDM

Available guidelines	Key Informant comments
A: International guidelines
➢ National Institute for Health and Clinical Excellence (2015) [33]. Diabetes in Pregnancy: Management of Diabetes and its Complications from Preconception to the Postnatal Period. NICE Guideline NG3.	“We follow international guidelines, I suppose more the NICE Guidelines from the UK but we adapt them for local context. The therapies we use are used internationally and then we try and adapt everything. You can’t use a London diet for our patients from Soweto” – Professor, Obstetrician 1
➢ World Health Organization. (2013) [37]. Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy. Geneva, World Health Org. (WHO/NMH/MND/13.2).	“From the beginning of 2014 we’ve been using the WHO criteria. We used to use the 100 g test, which was the United States test, but we changed in January last year, to 75 g” - Professor, Obstetrician 1 “The new definition has made it easier. It said any altered carbohydrate metabolism, which included Impaired Glucose Tolerance; and then we used the WHO criteria from 1990” - Professor, Obstetrician 4 “Everybody knows what to do with GDM - we all follow international standards and we all follow international protocol and recommendations within the resource constraints” – Obstetrician 5
B. National guidelines
➢ Guidelines for Maternity Care in South Africa. A manual for clinics, community health centres and district hospitals. 4th Ed. Pretoria: NDoH 2015: 172.	“There would be something on diabetes and there is a national maternity care guideline” - Professor, Obstetrician 2
C. Provincial guidelines
Western Cape Department of Health policy guidelines
➢ Diabetes in Pregnancy, Provincial guideline of the Western Cape, for the management of diabetes and its complications from pre-conception to the postnatal period (2010).	“We have very little to do with implementation of services, but at our level, we do policies; we’ve got to write policies. We assist with guidelines and protocols, and what we do, is we monitor and evaluate the implantation of these guidelines and policies” – Health service manager, Policy maker 2 “We do have a provincial policy - Circular 124 of 2010 which is due for review” – Health services manager, policy maker 2 “Yes, there is a Western Cape province policy for diabetes in pregnancy which we put together. It’s about 5 years old so I think it needs revision but there haven’t been major changes so it will be minor revisions” – Obstetrician 6, Policy maker 1 “So this would then be management of Diabetes during pregnancy. The policy speaks a little bit about what happens postnatally but not much,. We know that is where the gap is. We are currently busy doing a postnatal policy for the province” - Health services manager, Policy maker 2
➢ Metro West Protocols for Basic Antenatal Care	“So you will find in the City BANC Clinics, that they use our BANC protocols as well” – Health services manager, Policy maker 2
➢ Midwife Obstetric Units (MOU) Protocols for clinical practice at level 1 maternity care facilities in the Metro West (PMNS)	“There are the provincial guidelines and the protocol for each of the facilities is based on the overarching guideline” – Health services manager, Policy maker 2
D. Hospital – clinical practice guidelines
(i) Selective screening criteria for Gestational Diabetes  (ii) Postpartum management of diabetic patients  (iii) Information sheet and Meal plan	“..there is a guideline for the tertiary hospital and that’s the one we follow in terms of management” - Professor, Obstetrician 2 “…we just go with the guidelines that were produced by our department by our Professor, which I think he bases on some international opinion” – Obstetrician 5
E. Evidence from empirical studies
➢ ACHOIS study (Crowther et al.; 2005) [38]	“We follow international guidelines on the management of Gestational Diabetes. It’s been proven in many studies, the HAPO and the ACHOIS studies, that you have to actually follow up people with just gestational or milder form of Gestational Diabetes as well, as this has an impact on the outcome of the baby” – Obstetrician 3
➢ HAPO study (HAPO Study Cooperative Research Group, 2002) [39]	“We are influenced quite a lot by recent research – such as the ACHOIS study, which was looking at GDM. For quite a long time, people didn’t think that impaired glucose tolerance was going to have a negative impact on the pregnancy” – Professor, Obstetrician 2