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Scientific Reports volume 14 , Article number: 25253 ( 2024 ) Cite this article
Gestational Diabetes Mellitus (GDM) is associated with adverse maternal and perinatal outcomes and increased risk of developing diabetes in later life. Sri Lanka adopted universal GDM screening at two time points in pregnancy (before 12 weeks and between 24 and 28 weeks) in 2014 and its utilization has not been assessed. This study assessed the utilization of GDM screening services and associated factors among antenatal mothers in Southern Sri Lanka. A cross-sectional study was carried out in a consecutive sample of 420 postpartum mothers who delivered at three major hospitals in Sri Lanka. Data were collected on socio-demographics, pregnancy, availability and utilization of screening services and logistics using an interviewer-administered questionnaire and a data record sheet. Data was analysed using SPSS software. Chi-square test and binary logistic regression was used to assess the association between variables. The coverage of first and second screening tests were 91.4% and 94.5% and timeliness were 72.4% and 59.5%, respectively. The median period of amenorrhoea at the first and second screening were 10.0 (inter-quartile range: 2.5) weeks and 28.0 (inter-quartile range: 1.5) weeks. A higher utilization was associated with higher income (OR = 3.4, 95% CI: 1.1–10.5) and planned pregnancy (OR = 4.9, 95% CI: 2.2–10.7) for the first screening test. Primiparity (OR = 0.3, 95% CI: 0.1–0.9) and proximity of the nearest laboratory (OR = 3.5, 95% CI: 1.0–12.0) were positively associated with the second screening test. The timeliness of both screening tests was associated with planned pregnancy (OR = 2.1, 95% CI: 1.1-4.0 and OR = 2.3, 95% CI: 1.1–4.5) and being non-employed during the pregnancy (OR = 2.5, 95% CI: 1.4–4.3 and OR = 2.3, 95% CI: 1.3–4.1). A high utilization of GDM screening was observed. Timeliness should be ensured through improved availability and accessibility of screening facilities.
Gestational Diabetes Mellitus (GDM) is defined as ‘any degree of glucose intolerance with onset or first recognition during pregnancy’ 1 . It can lead to maternal hyperglycemia, which is associated with adverse maternal and perinatal outcomes and an increased risk of developing diabetes in the later life of the mother and child as well 2 . An increasing trend in the prevalence of GDM was observed in the global context 3 with an estimated global prevalence of 5–25% 4 , 5 . The highest prevalence is noted in the Southeast Asian Region (SEARO) and more than 90% of the estimated cases are found in low- and middle-income countries 5 . Sri Lanka, too shows an increasing trend in the prevalence of GDM, where a recent community-based study has shown a prevalence of 13.9% 6 .
The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study highlights the fact that maternal glucose intolerance has shown a linear relationship with adverse perinatal outcomes 2 . Thus, early detection and prompt control of maternal glucose levels is recommended. Screening is pivotal in the prevention of adverse perinatal and long-term outcomes by early detection of mothers with an increased risk of developing GDM. After reviewing published and unpublished data from the HAPO study and other related studies, the International Association of Diabetes and Pregnancy Study Group (IADPSG) proposed criteria for GDM screening in 2010 7 . Subsequently, many technical bodies including the American Diabetes Association (ADA) 8 , World Health Organization (WHO) 9 and The International Federation of Gynecology and Obstetrics (FIGO) 10 have recommended IADPSG criteria for GDM screening.
Though scientifically sound and valid screening and diagnostic tests and criteria were available, implementation of screening programmes is affected by client and service-related barriers in low-resource settings 11 . Lack of trained staff and equipment to perform screening tests and storage and transport issues for collected samples have been highlighted as healthcare system barriers and difficulty in attending clinics in fasting status, late contact with the healthcare system and higher distance to primary or specialized care facilities as client related barriers 11 . These barriers can reduce screening coverage in low- and middle-income countries leading to inadequate control of maternal hyperglycemia, thus increasing both maternal and child morbidity and mortality due to adverse outcomes of GDM 4 . Therefore, a simple and feasible screening test to be used in universal screening is highly needed at low-resource settings to overcome the barriers to screening 12 .
The Diabetes In Pregnancy Study Group in India (DIPSI) introduced a simple method of screening for GDM in low-resource settings. They proposed administering 75 g of oral glucose challenge to pregnant women irrespective of fasting state and 2-hour capillary blood glucose value to be checked - a test nominated as the non-fasting Glucose Challenge Test (GCT) 13 . It is claimed that this simple test can overcome most of the barriers specific to low resource settings highlighted above 13 . Further, when compared to the Oral Glucose Tolerance test (OGTT), GCT showed no statistically significant difference in diagnosing GDM at a cut-off threshold of 140 mg/dl after 2 h of glucose intake 11 .
GDM screening has been incorporated into maternal care programmes in Sri Lanka since 2011. At the outset, pregnant mothers with risk factors for developing GDM were screened at booking visit and all pregnant mothers were screened between 24 and 28 weeks of gestation using post-prandial blood sugar test with a cutoff threshold of 120 mg/dl 12 . However, risk factor-based screening is reported to have low sensitivity, compared to universal screening in several studies conducted in both community and hospital settings 13 , 14 . Sri Lanka adopted non-fasting GCT recommended by the DIPSI study as the universal GDM screening tool at field antenatal clinics in 2014. Universal screening of pregnant mothers for GDM before 12 weeks and between 24 and 28 weeks of gestation was incorporated into the field maternal care package. All pregnant mothers screened positive with non-fasting GCT were referred for a confirmatory test 14 . Nevertheless, there has been no assessment of the utilization of GDM screening services in the field setting and the influencing factors after the adoption of the new screening test.
In developing countries that account for 90% of the estimated GDM cases, optimum GDM screening is essential for early detection and provision of early and quality care to reduce the burden of GDM and improve pregnancy outcomes. Applicability, utilization, and barriers to utilization are of major concern when it comes to GDM screening in developing countries with low resources 12 . Thus, such factors need to be explored and understood for the optimization of screening and treatment services.
Sri Lanka has a unique healthcare delivery system mainly focusing on maternal and child health and it has a track record of delivering high-output care at low cost with minimal resources. Therefore, exploring the universal GDM screening programme in Sri Lanka will provide information on applicability, utilization, and facilitators/ barriers for the utilization of screening services, which will be of pivotal importance for the improvement of screening programmes in low-resource settings with low-cost interventions.
The current study has focused on assessing the utilization of universal GDM screening services and its barriers and facilitators in Sri Lanka. Further, it describes the coverage and timeliness of GDM screening as outcome measures, which will provide information on the quality of the screening programme as well. Thus, this study provides vital insights into utilization of universal GDM screening in a low-resource setting. The findings will enrich the existing knowledge on GDM screening in developing countries that can be effectively used by policymakers and health planners to strengthen GDM screening in both the global level and low-resource settings.
A cross-sectional study with retrospective data collection was carried out among mothers delivered at three major hospitals in Matara district in the Southern province of Sri Lanka. These three hospitals account for more than 95% of the deliveries taking place in the district.
A convenient sample of mothers delivered at the three selected hospitals was the study sample. The three hospitals accounted for over 95% of deliveries in the Matara district in the previous year. Data was collected from all mothers delivered at those three hospitals for two consecutive months assuming no significant variation in factors of interest among mothers delivered in a given month of the year.
The list of mothers who delivered at selected hospitals was obtained from the birth registers, and the mothers were contacted at the post-natal wards. Those who had pre-existing diabetes and delivered at a period of amenorrhea (POA) less than 28 weeks, were excluded.
The sample size was calculated using the formula suggested by Lwanga & Lemeshow for estimating a population proportion 15 . In calculating the sample size, an estimated prevalence of 0.5 and a precision of 0.05 were used at a probability level of 0.05 and a 10% allowance was added to account for non-response.
One-time data collection on socio-demographic factors, access to health care and utilization of screening services was conducted using a pre-tested, interviewer-administered questionnaire (Supplementary file 1). A data record sheet was used to collect information on the availability of screening services and the logistics of providing services at the field clinics (Supplementary file 2). Face, content, and consensual validity of the instruments were ensured through several rounds of discussion with public health experts (Consultant Community physicians and experienced field health personnel). Interviews were conducted with mothers on post-partum day one at the hospital by the principal investigator. Details regarding the screening were traced from the pregnancy records. Data on the availability of logistics were obtained and recorded by inspecting stock ledgers at the field health facility [Medical Officer of Health (MOH) office] attended by the mothers.
Proportions of mothers who underwent the screening test at each time point were used to assess the screening coverage. The timeliness of screening was defined as conducting the screening test before 12 weeks for the first screening and between 24 and 28 weeks for the second screening. If one functioning glucometer and the monthly requirement of blood lancets, glucometer strips and 75 g glucose sachets were available as the stock ledger balance in the respective MOH office store, it was considered as the availability of logistics. The monthly requirement was calculated based on the average monthly use of each item during the previous year. Thus, it eliminated the error of calculating requirements for all mothers under care by calculating the requirement only for mothers who were likely to utilize the field antenatal care services for screening.
Data was analyzed using SPSS statistical software and the Chi-square test was used as the test of the significance in assessing the associations between variables, considering 0.05 as the cut-off probability level. Multivariate analysis was conducted using binary logistic regression and the enter method was used for model building. The logistic regression model included variables identified as barriers or facilitators of the utilization of screening services in the literature (age, income, education level, employment during pregnancy, planned pregnancy, parity and number of living children) and variables that showed significant associations in the univariate analysis (education level, family support during pregnancy, accessibility to services and place of screening). R square value and the Hosmer-Lemeshow test were used to check the goodness of fit of the logistic regression model (Supplementary file 3).
for the study was obtained from the Ethical Review Committee, Faculty of Medicine, University of Ruhuna, Sri Lanka. Administrative approval was obtained by all relevant authorities (Regional Director of Health Services - Matara, Director / Medical Superintendent of the hospitals). Written informed consent was obtained from all mothers who agreed to participate in the study. Mothers identified with problems were referred to the obstetrician through ward doctors.
Four hundred and twenty mothers who delivered during the study period participated in the study (response rate 92.8%), and their socio-demographic characteristics are summarized in Table 1 . The first screening was done in 384 mothers and the second screening in 393 mothers. There were 44 and 33 screening-positive mothers at the first and second screening, respectively. Among them, six mothers (three from each screening) were confirmed to have GDM after further investigations. However, further investigations were not carried out in all screening-positive mothers. Figure 1 shows the screening and further investigation process for the study sample.
Flow chart showing the screening and further investigation process in the study sample.
Coverage screening tests were considerably high for both screening tests as 91.4% (384/420) and 94.5% (393/416) for first and second screening, respectively. Among client-related and health service-related characteristics, a higher maternal education level was associated with higher coverage for both first and second screening tests ( p = 0.02 and p = 0.03, respectively). Primiparity ( p = 0.03), having no living children ( p = 0.03) and planned pregnancy ( p < 0.001) were associated with higher coverage of the first screening test only. Shorter distance to the nearest laboratory ( p = 0.02) and having family support during pregnancy ( p = 0.03) were associated with higher coverage in the second screening (Tables 2 and 3 ). However, only planned pregnancy (OR = 4.9, 95% CI: 2.2–10.7) and income equal to or higher than the median (OR = 3.4, 95% CI: 1.1–10.5) showed significant associations with better coverage of the first screening test in multivariate analysis (Supplementary Table 1a). Primiparity (OR = 0.3, 95% CI: 0.1–0.9) and less than 30 min distance to the nearest laboratory (OR = 3.5, 95% CI: 1.0–12.0) were associated with coverage in the second screening test (Supplementary Table 1b).
The timeliness of the first and second screening were 72.4% (278/384) and 59.5% (234/393), respectively. The median POA at the screening was 10.0 weeks (inter-quartile range: 7.5–12.5) for the first screening and 28.0 weeks (inter-quartile range: 6.5–29.5) for the second screening.
The performance of screening tests at the field clinics was low for both screening tests. Only 38.3% (147/384) and 30.3% (119/393) of the mothers have been screened at field clinics for first and second screening, respectively. Private laboratories were the commonest place for screening while 44.5% of the first and 59.8% of the second screening were done at private laboratories. Availability of logistics to perform non-fasting GCT at the field antenatal clinics (glucometer and strips, lancets and 75 g glucose sachet) was 22.7% and 11.5% at the time of the first and second screening tests, respectively.
Timeliness of the first and second screening tests was positively associated with performing the screening at field clinics ( p < 0.001 and p = 0.007, respectively). Further, being unemployed during pregnancy ( p = 0.005) and planned pregnancy ( p = 0.023) were positively associated with timeliness in the first screening and availability of logistics at field clinics ( p = 0.007) was associated with timeliness of the second screening (Tables 4 and 5 ). The multivariate analysis revealed that planned pregnancy (OR = 2.3, 95% CI: 1.1–4.5), being not employed during pregnancy (OR = 2.3, 95% CI: 1.3–4.1) and being screened at field clinics (OR = 3.2, 95% CI: 1.8–5.5) were associated with better timeliness for the first screening tests (Supplementary Table 2a). However, only being screened at the field clinics (OR = 2.0, 95% CI: 1.2–3.2) was associated with better timeliness for the second screening test (Supplementary Table 2b).
This study assessed the coverage, timeliness and associated factors of antenatal screening for gestational diabetes mellitus (GDM) among Sri Lankan pregnant mothers. The participants were recruited from post-partum mothers to ensure the inclusion of mothers who received the entire antenatal care experience at the field level. A hospital-based approach was used to recruit an adequate sample within a short period. As more than 99% of the deliveries in the Matara district were institutional deliveries 16 , the study sample could be assumed as representative for all the pregnant mothers in the area. Further, the characteristics of the study sample corresponded with national and provincial figures in ethnic distribution and education level favouring the generalizability of results 17 .
Despite the higher coverage for both screening tests, a significant percentage of screening tests had been performed at private sector laboratories (44.8% and 59.8%), which exceeds the national average of out-of-pocket expenditure (44%) 18 . Though the timeliness of the first screening was reasonably good with the median POA at the time of testing being 10 weeks, the second screening test showed poor timeliness, where the median POA at the time of test exceeded the recommended period for the second screening.
A positive association has been evident between a higher income and education level and better health-seeking and screening participation in many studies in developing countries around the globe 19 reinforcing current study findings. Mothers with a higher education level are more aware of the services and have a higher autonomy in households and this can lead to higher utilization of services 20 , 21 . This fact has been highlighted in both quantitative and qualitative studies in developing countries 19 . While showing no association with coverage in univariate analysis, the higher income category showed a positive association with the first screening coverage in the multivariate analysis. The association between higher education and screening coverage was not significant in multivariate analysis. Moreover, it was well established that those who had planned pregnancies showed higher utilization and timely attendance for antenatal care 22 , 23 , as confirmed in the present study. Parity or birth order has been an important determinant of the utilization of antenatal care services, and it was highlighted in a systematic review of studies in developing countries 19 and a separate study in South India 24 . The current study also showed an inverse association of coverage with parity.
Better timeliness was associated with the performance of screening tests at field clinics. This might have been due to the strict adherence to the screening guidelines by the field healthcare workers and the strong performance monitoring system in line with the field health activities. Further, a qualitative study conducted among healthcare workers pointed out that visiting private clinics during the first trimester has contributed to delayed screening and not following recommended guidelines 25 . At the same time, planned pregnancies were also associated with timely screening as evident in previous studies 22 , 23 . Similarly, mothers who were not employed during the pregnancy showed good timeliness, in keeping with the findings from a similar study in South India on the utilization of maternal care services 24 . Most health services are only available during office hours. It creates barriers for working mothers to attend these services. Interestingly, only planned pregnancy and not being employed during pregnancy showed significant association with better timeliness in the multivariate analysis. Non-availability of logistics might have made it impossible to perform screening at the field clinic, making the screening delayed as highlighted in a study on antenatal care service utilization in Kenya 26 .
Over 99% of deliveries are institutional deliveries in the Sri Lankan context. Therefore, a sample of postpartum mothers recruited from hospitals that account for more than 95% of deliveries in the district has given an adequately representative sample and thus contributed to the generalizability of the study findings. The interviewer-administered questionnaire minimized missing data and the extraction of data from clinic and other records added more validity to data by eliminating recall bias. However, data on logistics and PHM availability were inconsistent due to a lack of uniform record-keeping at MOH offices. In addition, data on logistics and PHM availability for mothers who resided out of the Matara district were not included in the analysis. Therefore, the data quality of logistics and PHM availability might have been limited compared to the other aspects.
The study confirms a high uptake of the screening programme, which endorses the acceptability of the programme. The barriers and facilitators of service utilization that emerged from this study would guide the health care planners in designing and implementing future interventions, especially for pregnant mothers. The findings suggest areas for improvement in implementing screening services at the field level and further highlight the need for further studies with prospective data collection. Future studies using a qualitative approach would be beneficial to explore other factors determining the utilization of screening services such as socio-cultural factors and perceptions of key stakeholders.
This study shows that the universal GDM screening at field antenatal clinics shows higher coverage, however, its timeliness needs to be improved. Measures should be taken to improve the availability and accessibility of screening facilities. Further studies are recommended for assessing healthcare service providers’ perspectives on the utilization of screening services and measures to improve their availability and accessibility.
The datasets used and/or analyzed during the current study is available from the following link, https://drive.google.com/drive/folders/1-etsFgQ5hj6BpvveEbiao1YiDoABBvJO? usp=sharing.
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Authors acknowledge the Regional Director of Health Services -Matara district, the Director of District General Hospital, Matara, the Medical Superintendents of Base Hospital Kamburupitiya and Deniyaya, Consultant Obstetricians and Gynaecologists at all three hospitals and all Medical Officers of Health in Matara district for supporting the project.
The study has been self-funded by the corresponding author.
Department of Community Medicine, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
Janaka Godevithana & Champa Jayalakshmie Wijesinghe
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CW was involved in technical guidance and supervising the research project while JG did the planning of the research project, data collection, analysis and report writing. All authors read and approved the final manuscript.
Correspondence to Janaka Godevithana .
The authors declare that Ethical approval for the study was obtained from the Ethical Review Committee, Faculty of Medicine, University of Ruhuna (Registration no. 17.07.2017:3.1) and the administrative approval was obtained from the Regional Director of Health Services -Matara district, Director - District General Hospital, Matara, Medical Superintendent - Base Hospital Kamburupitiya and Deniyaya. Written informed consent was obtained from all mothers who agreed to participate in the study. Abnormalities detected were communicated to the doctor in charge of the ward for further management. The study was conducted while adhering to the World Medical Association Declaration of Helsinki on ethical principles for medical research involving human subjects.
In the current study consent for publication is not applicable because no individual-level data with identification are included in the manuscript.
The authors declare no competing interests.
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Godevithana, J., Wijesinghe, C.J. Barriers and facilitators for universal gestational diabetes Mellitus screening in a low resource setting: a cross-sectional study in Sri Lanka. Sci Rep 14 , 25253 (2024). https://doi.org/10.1038/s41598-024-76863-3
Version of record : 24 October 2024
DOI : https://doi.org/10.1038/s41598-024-76863-3
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