Knowledge, Attitudes and Practices Regarding Gestational Diabetes Mellitus Among Pregnant Women - A Cross-Sectional Study

Introduction

Gestational diabetes mellitus (GDM) is defined as, ‘any degree of glucose intolerance with onset or first recognition during pregnancy’.¹ The worldwide prevalence of GDM is around 14%, while in India, it ranges between 6-10%, with an increasing incidence trend.^2,3

GDM is found to be associated with increasing maternal age, overweight or obesity, a family history of Type 2 diabetes mellitus and history of hypertensive disorder spectrum, high maternal BMI, history of large babies or perinatal loss in previous pregnancies. Pregnant women with GDM are at a higher risk of developing complications such as maternal pre-eclampsia or eclampsia, delivering large babies, preterm delivery, birth trauma, an increased likelihood of caesarean section, respiratory distress syndrome, neonatal hypoglycemia and increased incidence of NICU admissions, along with a risk of developing Type 2 diabetes mellitus and cardiovascular disease in children as a long term complication.⁴

A multidisciplinary strategy is necessary for the management of GDM, involving both pharmacologic and non-pharmacologic modalities. Non-pharmaco-logical modalities comprise lifestyle modifications such as physical activities including exercise, dietary adjustments with monitored nutritional intake, and regular monitoring and management of maternal weight gain.⁵ Nearly one third of women with GDM need inclusion of either insulin or oral hypoglycemic medications as part of their pharmacotherapy.⁶ Both the modalities require involvement of patient and the family, as it requires life style modifications, changes in the diet with strict dietary habits, home monitoring of blood glucose levels and knowledge and skill acquisition for subcutaneous insulin administration. Identifying obstacles which can impede the maintenance of healthy behaviors is crucial for developing and implementing treatments aimed at enhancing the self-management of gestational diabetes mellitus. This KAP (Knowledge, Attitude and Practice) study was conducted to assess the knowledge levels of these women about the disease, as well as their misconceptions and beliefs regarding the disease and its management.

This study was undertaken with the following objectives:

1. To assess the knowledge levels among pregnant women regarding GDM, its risk factors, symptoms, complications, and management.

2. Understanding the attitudes of pregnant women towards GDM screening, diagnosis, and treatment.

3. Evaluating the practices adopted by pregnant women to prevent, manage, or cope with GDM.

4. To understand their dietary habits, physical activity and adherence to medical recommendations.

Materials and Methods

This was a descriptive study conducted prospectively at a tertiary care center attached to a teaching institute in Bangalore, from July 2023 to June 2024 for a total duration of 12 months.

Women aged above 18 years, with an OGCT [Oral glucose challenge test] result >140 mg/dL conducted between 24-28 weeks of pregnancy, and those willing to provide informed consent, were included in the study, while the pregnant women with multifetal pregnancy, preexisting diabetes mellitus, or other comorbidities like hypertension, cardiac disease, neurological disorders, renal disorders were excluded.

Sample size

Based on the meta-analysis conducted in India by Neha Mantri et al., where GDM prevalence was found to be 13%, with 95% confidence interval (α=5%) and absolute precision (d) of 5%, the sample size was calculated as below.⁷

N = (Zα/2)2pq/ D2

where,

N = Sample size

Zα/2 = Critical value of the normal distribution. For type I error (α) of 0.05(95% CI), it is 1.96.

P = Prevalence/sample proportion=13

Q = 1-p = 87

D = Margin of error = 5

N = (1.96)2x16 .5x83.5

5*5

N = 174

A total of 174 pregnant women were included in the study to identify gaps in knowledge, attitudes and practices, with the aim of improving the management of GDM. These women were asked to fill a pre-validated questionnaire with good to excellent reliability, which was previously used in a study conducted by Hussain Z et al., and Tan J et al., to address KAP about the condition.^7,8 The questionnaire included socio-demographic factors like age, education level, occupation, and clinical characteristics like obstetric index, mode of conception, history of diabetes mellitus among family members, history of large babies in previous pregnancies, polycystic ovary disease and calculation of BMI.

The knowledge section included 18 questions (K1- K18), with a scoring system of 1 point for each correct response and 0 points for incorrect responses or selecting a response of ‘unclear’. For the questions with multiple correct responses, a score of 1 was awarded when all the responses were correctly marked. The total score in the knowledge section ranged between 0 to 18.

A total of eight questions (A1-A8) were included in the attitude section, which were assessed using a 5-point Likert scale. The responses were scored as follows: ‘strongly agree’ = 5 points and ‘strongly disagree’ = 1 point. ‘Strongly agree’ or ‘agree’ were considered positive responses, while ‘neutral’, ‘disagree’ and ‘strongly disagree’ were considered as negative responses. The total score ranged between 8 and 40.

The practice dimension included 10 questions (P1-P10). P1-P5 and P7 (six questions), were analyzed as follows: response of ‘often’ was awarded 2 points, ‘occasionally’ 1 point and ‘never’ 0 points, while for the remaining four questions (P6, P8-P10), a response of ‘yes’ was awarded 1 point and a response of ‘No’ was given 0 points. The overall score ranged between 0-16 points in this section.

Individual responses from the KAP questionnaire were scored and a total score of greater than 75% was considered ‘good’ practice, 50-75% as ‘moderate’ and <50% as ‘poor’ practice.

The data collected were processed using SPSS 26.0 software. Continuous variables were expressed as mean±standard deviation (SD), after testing for its normal distribution. Continuous variables if not normally distributed, were expressed as median. Percentages were used to represent variables that were categorical. Chi- Square test was used to calculate P-value with 95% confidence interval and P value <0.05 was taken as significant while comparing the variables.

Results

In our study, a total of 174 responses were analyzed. The socio-demographic factors and clinical charac-teristics are depicted in Table 1. The mean age of the participants was 28±3.4 years, with 48.3% belonging to the age group of 26-30 years, while only 18% belonged to age group of >35 years. About 36.7% belonged to upper lower socioeconomic status. In our study, mean BMI recorded was 26+/- 2.4, with 49.4% belonging to pre obese group with a BMI ranging between 25-29.⁹

Around 47.1% of the patients were gravida 2, while 39.1% were primigravidas. 93% of the study population had natural conception and 31.6% gave a history of polycystic ovary syndrome (PCOS). About 29.3% had family members diagnosed with diabetes. Only 12% of the study population gave a history of macrosomia in previous pregnancies.

Table 2 lists the knowledge scores with the details of all 18 components and the percentage of correct responses. The total score for knowledge dimension was 18 points. The mean score in the knowledge section recorded in our study was 5±3.04 points, which indicates poor knowledge levels. The percentage of correct responses in the knowledge section for each question was between 13.5% to 46.5%. Only 13.5% of the study participants were aware of the correct definition of GDM [K1] which was the first component of the questionnaire and least positive response. Around 26% of the respondents knew about the effects of hyperglycemia on the mother, fetus and newborn. Only 40% had knowledge regarding the importance of dietary control in the management of diabetes.

The scores were further compared between the groups, based on baseline characteristics as depicted in Table 3. The P value of knowledge scores was not statistically significant in terms of different age groups, BMI and gravidity. However, the P value was significant for socio-economic status [P value-0.04], the method of conception [P value- 0.041], history of PCOS [P value- 0.021] and family history of type 2 diabetes [P value- 0.043].

Table 4 depicts the attitude component with percentages of correct responses. The total possible score in attitude dimension was 40 points. The mean attitude score recorded was 18+/-5.3. The percentage of positive responses for each question ranged between 31% to 52.2%.

About 43% agreed on the importance of regular glucose monitoring throughout pregnancy, while about 50% strongly agreed on the need for individualized guidance from medical personnel and nutritional clinics. About 31% of the participants acknowledged the difficulty in accepting insulin and oral hypoglycaemic agents, while 31% understood the need for repeat OGTT after 6-12 weeks post-delivery. About 45.4% of patients agreed on the need for good glucose control for risk reduction.

The scores were further compared between the groups, based on baseline characteristics and are depicted in Table 3. P value of the attitude scores was not statistically significant when compared between different age groups, BMI and gravidity. However, the P value was significant for socio-economic status [P value- 0.03], the method of conception [P value- 0.03], history of PCOS [P value- 0.04] and family history of diabetes [P value-0.02].

Table 5 shows the practice scores with details of all the components and responses. The correct responses ranged between 31% - 74.9% in this section. The average score of practice questionnaire was 8+/- 2. Only 31% of patients practiced self-monitoring of glucose, 41% regularly exercised, and 58.6% adhered to dietary advice provided by their treating doctor. Only 28% patients kept a track of their diet and weight. All the patients received routine antenatal care, while 65% sought medical attention when blood sugars were not under control.

The data indicates that women with GDM realized the importance of regular antenatal visits, with 75.9% women attending regular follow-ups. About 112 (65.4%) women sought medical attention when their sugars were not under control and 108 (62%) women followed the dietary instructions regarding calorie intake. But only 50 (28.7%) women regularly charted their diet and weight despite being explained of its importance and 54 (31%) monitored their blood sugars on a regular basis.

The scores were further compared between the groups based on baseline characteristics, as depicted in Table 3. P value of the practice scores was not statistically significant when compared between different age groups in terms of BMI, gravidity and history of type 2 diabetes mellitus among family members. However, the P value was significant for socio-economic status [P value- 0.02], the method of conception [P value- 0.01] and history of PCOS [P value- 0.031].

Discussion

Our study on the KAP of pregnant women with gestational diabetes mellitus (GDM) revealed poor knowledge, but moderate attitudes and practices. These results contrast with studies conducted by Tan et al., (2023) in China, which found the knowledge regarding GDM to be moderate, attitude towards GDM management being good, while the practices being moderate among their GDM patients.8 Similar to our study, research conducted in Poland by Lis-Kuberka et al., (2021) and Hussain et al., (2015) in Malaysia found a lack of awareness about GDM risk factors.^9,10 These parallels suggest that inadequate knowledge can increase GDM-related risks, underscoring the importance of educational programs to improve the same.

Our study aligns with the findings of Tan et al., (2023), which indicate that factors such as history of PCOS, socioeconomic status, and history of type 2 diabetes in family members positively impacted patients' knowledge, attitudes and practices regarding GDM.⁸ These similarities likely reflect prior experiences with lifestyle modification and medical care, which enhance understanding and adherence to GDM management strategies. In contrast to Tan et al., our study found that age, parity, and BMI did not significantly impact the KAP scores.⁸

In addition to the studies previously mentioned, a broader review of literature reveals a consistent trend of inadequate knowledge about the condition across various global settings, with mixed results regarding attitudes and practices. A study conducted by Carolan-Olah and Vasilevski (2021) in Australia using a similar KAP framework reported that, while knowledge about GDM was moderate, there was a substantial gap in understanding the long-term implications of GDM for both maternal and neonatal health.¹¹ This finding aligns with ours, where only 13.5% of respondents correctly defined GDM, and around 26% were aware of the complications of high blood levels on the health of mother and baby. Similarly, only 40% of our participants understood the importance of dietary control, reflecting challenges in educating GDM patients.

Furthermore, Hussain et al., (2015) in Malaysia found that only 20% of their respondents had the knowledge of the proper criteria for blood glucose control during pregnancy.¹⁰ This mirrors our findings, where only 16.6% of patients knew the criteria for controlling 1-hour postprandial blood glucose. In both the studies, knowledge gaps regarding specific management strategies indicate a need for more focused educational interventions, tailored to blood glucose monitoring and dietary management in GDM patients.

A study by Offomiyor and Rehal (2023) in Nigeria observed limited awareness of GDM, especially among women from lower socioeconomic backgrounds.¹² This aligns with our observation of socioeconomic status being a significant factor influencing knowledge, attitude, and practices, with patients from higher socioeconomic backgrounds showing better under-standing and adherence to management strategies.

Comparative studies have also explored the impact of educational interventions. A systematic review by Mantri et al., (2024) noted that targeted educational programs in India have been effective in increasing awareness and improving practices related to GDM management.⁷ This suggests that similar interventions could be beneficial in our study setting, where financial constraints and limited access to education were barriers to effective GDM management. The inclusion of nutritional clinics, regular follow-ups, and individ-ualized patient counseling could improve outcomes, as indicated by the higher levels of engagement seen in studies where such interventions were implemented.

Although our participants demonstrated restricted knowledge, their moderate attitudes and practices suggest that imparting targeted education and coun-seling can improve patient engagement in GDM management. This highlights the need for structured educational interventions, especially in resource-limited settings where financial constraints and lack of awareness impede optimal home base monitoring of blood glucose and other preventive measures.

Conclusion

Our study provides valuable insights into the facts regarding poor knowledge, attitude and practices of patients visiting government tertiary care center in India. Despite the evolving disease burden and significant maternal and fetal complications, the educational programs to create awareness regarding GDM are scarce. The significance of self monitoring of blood glucose is not strictly adhered to, primarily due to lack of education and financial constraints.

This study reflects poor knowledge levels in women regarding the significance of control of blood sugar levels and the adverse effects on both the mother and fetus in case of poor control. This necessitates the importance of inclusion of health education in schools and colleges regarding diabetes and GDM, which has become a major public health burden. Knowledge about this can be improved by displaying videos or role plays about GDM in patient waiting areas of antenatal clinics and conducting special GDM clinics on designated days of the week, where detailed care is rendered to these women. Addressing these gaps can significantly improve the adherence to various interventions and improve outcomes.

Ethics approval

The study has been reviewed and approved by ethical committee of Bangalore Medical College and Research Institute. [No.:BMCRI/EC/25/2024]