Gestational diabetes mellitus: Awareness, risk factors, perceived effects, and lifestyle intervention among pregnant women in a Nigerian tertiary health institution

INTRODUCTION

In the global arena, where the diabetes pandemic is quickly engulfing developing nations, there is yet another condition gestational diabetes mellitus (GDM) which is gradually increasing and poses a public health threat.^[1-3]

GDM is a form of diabetes mellitus that emerges during pregnancy as a result of glucose intolerance.^[4,5] It is a significant contributor to both maternal morbidity and perinatal morbidity and mortality.^[6,7] The prevalence has increased by 12% annually in high-risk populations over the past 8 years, with Nigeria being no exception.^[8,9] There are a number of known risk factors for GDM in women, including older age, a history of the condition in the previous pregnancies, a family history of type 2 diabetes, pregestational body weight, and obesity.^[3,10] Untreated GDM can increase the risk of perinatal deaths, large-gestationalage fetuses, shoulder dystocia, neonatal hypoglycemia, fetal organomegaly, fetal birth trauma, neonatal respiratory and metabolic complications.^[4,11] There is a higher risk of miscarriage and congenital malformations if maternal hyperglycemia continues during organogenesis, particularly in patients with pre-gestational diabetes.^[12]

To prevent GDM, it is crucial to identify potentially changeable risk factors and to estimate their potential impact on this widespread condition. A lower risk of gestational diabetes has been linked to a number of potentially changeable prenatal factors and modified lifestyle changes.^[13] Education has been proven to be a powerful tool for increasing women’s awareness and knowledge of specific health conditions related to pregnancies, particularly GDM.^[14,15] In addition, the use of preventive measures is inversely related to the knowledge of harmful effects of GDM, which can only be acquired through a strong educational foundation and exposure to GDM through awareness campaigns, conferences, and workshops.^[3] There has been a paucity of research on antenatal women’s awareness of GDM in general, with or without GDM.^[16,17] Therefore, this study was carried out to ascertain the awareness, risk factors, perceived effects, and lifestyle interventions towards the prevention of GDM as well as the correlation between educational background and the level of awareness of GDM among pregnant women.

MATERIALS AND METHODS

A cross-sectional descriptive survey methodology was used in the study. There were 780 study participants. Using the Taro Yamane formula, a sample size of 264 was determined.^[18] The study’s inclusion criteria included the subjects’ willingness to participate, their availability at the time of the study, and their attendance at University of Nigeria Teaching Hospital (UNTH) antenatal clinic while pregnant. Selecting mothers who met the inclusion criteria was done using a straightforward random sampling technique.

A questionnaire created by the researcher served as the data collection tool. The questionnaire had 16 items which were arranged in five sections. Section A contained six items on demographic data; Section B comprised four items on awareness of GDM; Section C comprised two items on the risk factors of GDM; Section D comprised two items on the perceived effects of GDM on pregnancy; and Section E comprised two items on the lifestyle interventions toward the prevention of GDM. Three experts from the Department of Nursing Sciences, University of Nigeria, Enugu Campus, established the face and content validity. Twenty-six women from medical facilities with similar characteristics to the study facility served as the instrument’s pilot test subjects. The data obtained from the pilot testing were analyzed using Cronbach’s alpha test which yielded a reliability coefficient of 0.7.

The Institutional Review Board of the University of Nigeria Teaching Hospital in Enugu, Nigeria granted ethical approval for this study (NHREC\05\01\2008BFWA0002458IRB00002323). Following a thorough explanation of the study’s goals and the participant’s responsibilities, written informed consent was obtained from the participants. The study was voluntary, and confidentiality and anonymity were maintained throughout. Data collection lasted for 4 weeks. The data analysis utilized descriptive statistics such as means, standard deviations, frequencies, and percentages and was carried out with the help of SPSS version 21. The relationship between educational background and knowledge of GDM was investigated using Chi-square.

RESULTS

The total number of questionnaires distributed was 264, but only 244 (92.4%) of them were returned. Eight were lost, and 12 were not fully filled. The mean age of the study participants was 27.8 ± 7.5 years. However, the majority of 193 (79.1%) of the participants were married. The majority of the participants 193 (79.1%) were married, 141 (57.8%) had tertiary education, 212 (86.9%) were Christians, 189 (77.4%) were gainfully employed as; civil servants 103 (42.2%), artisans 86 (35.2%), 126 (51.6%) have had 2–3 pregnancies [Table 1].

Majority of the participants, 212 (86.9%) were aware of GDM, and 201 (94.8%) of them agreed that it is a condition characterized by high blood sugar that affects pregnant women. The majority of them, 149 (70.3%), cited medical professionals as their informational source. Two hundred and nine (85.7%) of the respondents agreed that diabetes can manifest itself for the 1^st time while pregnant [Table 2].

The majority of the participants 212 (86.9%) affirmed that they were aware of the risk factors associated with GDM. Only 82 (33.6%) of 244 (100%) participants chose options 7–10 on the questionnaire, indicating that fewer participants were fully aware of the risk factors, while 122 (50%) chose options 4–6, indicating partial awareness [Table 3].

The majority of respondents 227 (93%) confirmed that they were aware of the alleged effects of diabetes on pregnancy. One hundred and eighteen (48.4%) indicated full awareness by choosing 7–10 options on the questionnaire, while 99 (40.6%) chose 4–6 options, indicating partial awareness [Table 4].

The majority of the 191 participants (78.3%) were aware of lifestyle interventions for the prevention of GDM and that their options were not mutually exclusive. A regular visit to a health/medical professional 121 (63.4%), regular blood sugar testing 105 (55.0%), a good diet plan 101 (52.9%), regular exercise/regular physical activity 81 (42.4%), and education 11 (5.8%) were all listed as lifestyle interventions, respectively [Table 5].

Out of 212 pregnant women who indicated awareness of GDM, half 133 (62.7%) had tertiary education, and out of 32 (13.1%) who indicated not aware, less than a third 8 (25.0%) had tertiary education. The Chi-square test of the association was 50.7 with P = 0.0001 (<0.05) which indicated that there was a significant association between educational background and the level of awareness [Table 6].

DISCUSSION

GDM awareness, risk factors, perceived effects, and lifestyle interventions were measured from a group of pregnant women attending antenatal care in a Nigeria Tertiary Health Institution.

The result showed that most respondents were aware of GDM. A study in Samoa found that pregnant women had varying levels of knowledge about GDM, with a very small percentage having good knowledge based on the number of risk factors identified.^[19] Similarly, 92 (46%) of 200 study participants in a study by Shriraam et al. in a primary health center in South India were aware that diabetes can manifest for the 1^st-time during pregnancy.^[20] These results are at variance with a report of a study at a medical college hospital in Jaipur which showed majority of the study participants knew that pregnancy can cause diabetes.^[21] This variation in awareness might be related to the settings of different health-care facilities. It is possible that the respondents’ level of awareness was influenced by the fact that this study was conducted in a tertiary care facility and that the experts were able to provide them with accurate information about GDM. It is suggestive that more studies are needed to confirm this theory, but it is possible to explain the level of awareness found in this study by the fact that it was conducted there.

Although most respondents claimed awareness of the risk factors for GDM, not up to half were fully aware of alleged risk factors meaning more had partial knowledge. This result, therefore, became evident that in so far as pregnant women were reported aware of risk factors associated with GDM, the majority were not very clear of the associated risk factors of which the higher value recorded on partial awareness. The interpretation of the result is the fact that though a great number had got the information from health professionals; an outstanding number must have obtained the information through friends/relatives. It is suggestive that the information from friends and relatives may not be detailed when compared with that obtained from health professionals. The results were in line with other studies.^[20,22]

The majority of participants were aware of and identified the effects of diabetes on pregnancy. The result is not surprising because most of the participants said that they obtained their information directly from health-care professionals. This is probably why they were at home with the correct feedback. The findings agreed with the study on awareness of GDM among antenatal women attending tertiary care hospital in Sri Ramachandran Medical College, Chennai, Tamil Nadu,^[21] which revealed that respondents were fully aware of the effects of GDM on pregnancy outcome as they affirmed positively to the identified effects, lead to pregnancy complications and bad obstetric history. This finding is also in concordance with similar works.^[23,24]

The majority of them were informed about the lifestyle interventions for GDM prevention. A regular visit to a health/medical professional, regular blood sugar testing, and a good diet plan had the highest ratings. Diabetes association estimates that if the previous pregnancy had resulted in GDM, there is a 60% chance of developing GDM.^[25] Hence, a healthy diet and consistent exercise are both very beneficial in preventing GDM. Moreover, it has been established as a recommendation for all pregnant women to engage in 30 min of moderate-intensity physical activity most, if not every day of the week.^[25,26] Maternal glucose is used as a determinant of whether a dietary prescription is successful or unsuccessful when determining the best diet for pregnant diabetics.^[27] These findings were in concordance with a work carried out among antenatal women attending outpatient departments in a rural hospital in Bangalore in which most of the participants outlined helpful behaviors for curbing gestational diabetes.^[28] Furthermore, in urban areas in Mumbai, India, nulliparous literate women reported the usefulness of exercise and a good diet.^[23] Similar to this, Hewage et al., in a study in Singapore, identified desirable intervention characteristics, including information on GDM, diet and exercise options, reminders for blood glucose testing, a platform to record blood glucose readings and illustrate or understand trends, and a means of communicating with care providers.^[29]

In addition, there was a strong correlation between the educational level of pregnant women and their awareness of GDM (P < 0.05). Awareness about GDM increased as the education of participants increased regarding GDM level of awareness.^[30] The interpretation is that education is a strong determinant of GDM awareness. Parsons et al. emphasizes that education is a process that informs, inspires, and assists people in adopting and maintaining healthy practices and lifestyles.^[31] The significant relationship between knowledge of GDM and both levels of education in this study could be explained by the ease with which educated women can seek information from various sources and by the possibility that they may have learned about GDM at school, either through training or sharing of experiences. An equivalent study from Ghana found that pregnant women with higher levels of education were more knowledgeable about the risk factors associated with GDM and, possibly, its management and outcomes.^[32] On the other hand, this conclusion is inconsistent with a study from a rural hospital in Bengaluru which found no significant link between education and GDM knowledge.^[28]

CONCLUSION

Most of the respondents were familiar with GDM. More than half said that health-care professionals were their primary source of information. Even though the majority of respondents showed a high level of awareness, less than half had a complete understanding of the risks and the effects of GDM on pregnancy. Regular checkups with a health or medical professional, routine blood sugar testing, and a healthy diet plan were the most acceptable lifestyle interventions for the prevention of GDM. There was a significant association between educational background and level of awareness (P < 0.05).