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REVIEW ARTICLE
International Health 2022; 14: 211–221
https://doi.org/10.1093/inthealth/ihab054 Advance Access publication 25 August 2021
Barriers to screening, diagnosis and management of hyperglycaemia in
pregnancy in Africa: a systematic review
Thomas Hinneh a,b,∗,AlbrechtJahn
band Faith Agbozob,c
aDormaa East District Hospital, Department of Nursing, P.O. Box 38, Wamfie, Ghana; bHeidelberg Institute of Global Health, Heidelberg
University, Heidelberg 69120, Germany; cUniversity of Health and Allied Sciences, Department of Family & Community Health, Private
Mail Bag 31, Ho, Ghana
∗Corresponding author: Tel: +233246981265; E-mail: hinneh90@gmail.com
Received 8 April 2021; revised 1 July 2021; editorial decision 2 August 2021; accepted 3 August 2021
Gestational diabetes mellitus (GDM) complicates pregnancies in Africa. Addressing the burden is contingent on
early detection and management practices. This review aimed at identifying the barriers to diagnosing and
managing GDM in Africa. We searched PUBMED, Web of Science, WHOLIS, Google Scholar, CINAHL and PsycINFO
databases in May 2020 for studies that reported barriers to diagnosis and management of hyperglycaemia in
pregnancy. We used a mixed method quality appraisal tool to assess the quality and risk of bias of the included
studies. We adopted an integrated and narrative synthesis approach in the analysis and reporting. Of 548 ar-
ticles identified, 14 met the eligibility criteria. Health system-related barriers to GDM management were the
shortage of healthcare providers, relevant logistics, inadequate knowledge and skills, as well as limited oppor-
tunities for in-service training. Patient-related barriers were insufficient knowledge about GDM, limited support
from families and health providers and acceptability of the diagnostic tests. Societal level barriers were con-
comitant use of consulting traditional healers, customs and taboos on food and body image perception. It was
concluded that constraints to GDM detection and management are multidimensional. Targeted interventions
must address these barriers from broader, systemic and social perspectives.
Keywords: Africa, diagnostic tests, gestational diabetes, maternal health services, pregnant women, treatment.
Introduction
Across the globe, diabetes contributes significantly to the burden
of non-communicable diseases (NCDs).1According to the 2015
International Diabetes Federation report, among the 15.2% of
pregnancies affected by hyperglycaemia in pregnancy (HIP) glob-
ally, gestational diabetes mellitus (GDM) constituted 85% of all
cases.2Even though the current GDM epidemic affects both high-
and low-income countries, it is estimated that nearly 90% of the
global cases occur in low-income countries.3Pathologically, over
50% of pregnant women who develop GDM progress to develop
type II diabetes within 2–10 y after the index diagnosis.4,5If left
unchecked, GDM might compound the already high burden of
NCDs in the African region, where about 80% of the cases of dia-
betes occur.1,6,7
In accordance with the WHO guideline, GDM is defined as
carbohydrate intolerance resulting in hyperglycaemia of variable
severity, with onset or first detection in pregnancy.8Even though
diabetes in pregnancy (known diabetes before pregnancy) is a
matter of concern, the most common type of HIP is GDM3and,
therefore, understanding the practices associated with screening,
diagnosis and management within the African context is essen-
tial.
There is ample evidence that GDM exposes pregnant women
to the risk of caesarean section, traumatic delivery, prolonged
delivery, pregnancy-induced hypertension, pre-eclampsia and
could also lead to maternal and foetal death.9,10 Evidence has
also shown that exposure of the foetus to a hyperglycaemic in-
trauterine environment increases the risk of macrosomia, anen-
cephaly, spinal bifida, cerebral palsy and large for gestational
age.9,11–14 Apart from these short-term complications, offspring
born to mothers with GDM are also at a higher risk of developing
diabetes and obesity in later life.1,15,16
Glycaemic control through lifestyle modification and medical
therapy during pregnancy are promising strategies to reduce the
risk of adverse foetal, perinatal and neonatal events.17–19 How-
ever, preventing complications and improving disease prognosis
hinge on early detection and effective management. Nonethe-
less, some studies have established the merits of universal
screening for GDM.20,21 However, practical implementation of
© The Author(s) 2021. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. This is an Open Access
article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which
permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
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detection and management approaches may not be feasible due
to multiple constraints. Therefore, identifying these factors would
be essential in informing policy decisions on addressing the bur-
den of GDM.
In this systematic review, we performed a comprehensive lit-
erature search to summarise evidence regarding the barriers to
screening, diagnosing and managing GDM in Africa. We sought to
answer three research questions: (1) What impedes GDM screen-
ing and testing? (2) What are the barriers towards supporting and
managing pregnant women diagnosed with GDM? (3) How can
the experiences of pregnant women regarding GDM testing and
management help to improve care?
Methods
Study design
We conducted this systematic review by searching through
PUBMED, Web of Science, WHOLIS, Google Scholar, CINAHL and
PsycINFO databases, taking into consideration the guideline of
‘Preferred Reporting Items for Systematic Reviews and Meta-
analyses’ (PRISMA) statement.22 A protocol for the review was
developed a priori and registered with the PROSPERO interna-
tional register for systematic reviews (2020: CRD42020180335).23
Using the PICo framework recommended by the Joana Briggs
Institute (JBI) and Cochrane collaboration as the preferred ap-
proach for developing review questions, search terms for the
review were categorised into three components: P=Population,
I=Phenomenon of Interest and Co=Context. Where appropriate,
Medical Subject Heading (MeSH) terms were used. The search
terms used and the search strategy for each database are in-
cluded (Supplementary Data 1). The review started in February
2019, but the search was completed in May 2020. Eligible studies
included in this review were published from 2012 to 2019 in En-
glish, which captured recent challenges to GDM care in the Africa
region. Reference lists of included studies were also screened for
eligible studies.
Inclusion and exclusion criteria
Studies considered for inclusion were peer-reviewed, published,
quantitative, qualitative, mixed-methods and randomised re-
search papers conducted in any African country or subregion re-
lated to barriers to screening, diagnosis or management of GDM
and/or diabetes in pregnancy (DIP) that focused on the women
and their families, as well as health practitioners, policymakers
and stakeholders involved in the care process. Studies that fo-
cused exclusively on prevalence and risk estimation or involved
postpartum women were excluded.
Study selection and eligibility
We included qualitative, quantitative and mixed-method stud-
ies. Deduplication, title and abstract screening, and reviewing of
reference lists of potentially eligible studies for relevant litera-
ture and full-text screening, was performed by TH. FA also inde-
pendently screened the full-text articles to assess their eligibility.
In instances where a decision could not be reached, discussions
were held with AJ. All studies retrieved were imported to End-
note library where deduplication was performed using Barmer’s
method.23
Data handling and extraction
Data was extracted by TH using Microsoft Office Excel. In addi-
tion to the findings of the studies, other data extracted included
the names of authors, aim of the study, year of publication, geo-
graphic zone where the study was conducted, study design, sam-
pling methods, sample size, characteristics of participants, ges-
tational age of participants at the time of screening and level of
healthcare where the study was conducted. TH and FA indepen-
dently reviewed the data extracted for each study using the data
items listed in the review protocol to ensure that the data ex-
tracted were compliant with the review objectives.
Risk of bias and quality assessment
Quality assessment of studies included in this review were in-
dependently assessed by TH using a mixed-method quality ap-
praisal tool (MMAT).24 FA reassessed a subset of the studies (one
in each design category) to verify the appraisal outcomes. The
studies were initially subjected to two mandatory screening ques-
tions according to the MMAT tool. A ‘yes’ answer was obtained for
all of the studies, making it feasible to apply the subsequent ques-
tions based on the study’s design. Overall, the scores obtained as
per methodological criteria and quality assessment ranged from
2 to 5 out of a total possible score of 5. A mark of 5 (represented
by five asterisks [*****]) implied that the study met 100% of the
quality criteria, whereas marks of four (****), three (***), two (**)
and one (*) corresponded to 80%, 60%, 40% and 20% of the qual-
ity criteria, respectively (Table 1). Overall, the studies were of ap-
preciable quality with the final quality rating ranging from 60 to
100%. Qualitative studies incorporated in the review showed ad-
equate interpretation of results supported by specific quotations
from respective participants. There was adequate coherence be-
tween data collected and the interpretation of findings. Three
of the qualitative studies25–27 used data saturation as a sample
size determination approach. One common trend observed in the
mixed-method studies was the inadequate integration of quali-
tative and quantitative data sources.
Data synthesis
Given the heterogeneity of the design of articles included in
the review, we followed an integrated and narrative synthesis
approach described by the JBI mixed method systematic review
methodology.28 The integrated synthesis approach allowed com-
bining data extracted from quantitative and qualitative studies
for further analysis into themes. The quantitative studies29,30
were ‘qualitised’ using textual descriptions of the findings. TH
and FA read and re-read the full text of the studies to understand
how the barriers to GDM care were reported in the articles. Fol-
lowing the grouping of the articles according to the three specific
objectives, we performed a thematic analysis of the results.
We then discussed the themes generated until agreements on
the themes were reached. The major themes generated were
health system- and patient-related barriers under objectives
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Tab le 1 . Result of quality and risk assessment using the mixed method appraisal tool24
Studies Q 1.1 Q 1.2 Q 1.3 Q 1.4 Q 1.5 Q 2.1 Q 2.2 Q 2.3 Q 2.4 Q 2.5 Q 4.1 Q 4.2 Q 4.3 Q 4.4 Q 4.5 Q 5.1 Q 5.2 Q 5.3 Q 5.4 Q 5.5
Mensah et al., 201731 11111
Mensah et al., 201927 11111
Mukona et al., 2017a32 11111
Mukona et al., 2017b25 11111
Muhwava et al., 201933 11111
Muhwava et al., 201826 11111
Woticha et al., 201934 11111
Ugboma et al., 201235 11101
Nwose et al., 201929 10101
Njete et al., 201830 11111
Utz et al., 201639 11111 1011111111
Nielsen et al., 201237*11111 1011111111
Nielsen et al., 201238*10101 1111111111
Mukona et al., 201736*11100 1111101111
Questions for the quality rating
(Qualitative studies) (Quantitative descriptive studies)
Q 1.1. Is the qualitative approach appropriate to answer the research
question?
Q4.1. Is the sampling strategy relevant to address the research question?
Q 1.2. Are the qualitative data collection methods adequate to address
the research question?
Q 4.2. Is the sample representative of the target population?
Q 1.3. Are the findings adequately derived from the data? Q 4.3. Are the measurements appropriate?
Q 1.4. Is the interpretation of results sufficiently substantiated by data? Q 4.4. Is the risk of non-response bias low?
Q 1.5. Is there coherence between qualitative data sources, collection,
analysis and interpretation?
Q 4.5. Is the statistical analysis appropriate to answer the research question?
Q 5.1. Is there an adequate rationale for using a mixed methods design to address
the research question?
(Randomised control trial studies) (Mixed method studies)
Q 2.1. Is randomisation appropriately performed? Q 5.2. Are the different components of the study effectively integrated to answer
the research question?
Q 2.2. Are the groups comparable at baseline? Q 5.3. Are the outputs of the integration of qualitative and quantitative components
adequately interpreted?
Q 2.3. Are there complete outcome data? Q 5.4. Are divergences and inconsistencies between quantitative and qualitative
results adequately addressed?
Q 2.4. Are outcome assessors blinded to the intervention provided? Q 5.5. Do the different components of the study adhere to the quality criteria of
each tradition of the methods involved?
Q 2.5 Did the participants adhere to the assigned intervention?
Key: yes (1 point), no (0 points), cannot tell (0 points).
*Mixed method studies; NB: questions ranging from 3.1 to 3.4 are missing as none of the studies adopted a quantitative non-randomised approach. Studies are arranged in order
of the design; the first five studies are qualitative, the next one is a randomised controlled trial, the next two are quantitative and the last four are of mixed method design.
A quality rating of ***** means that 100% quality criteria were met, **** 80%, *** 60%, ** 40% and * 20%.
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Figure 1. Thematic synthesis of results showing a summary of the themes and subthemes. ANC, antenatal care.
one and two. An additional subtheme on sociocultural barriers
was generated specifically under objective two. The themes and
subthemes are summarised and shown in Figure 1.
Results
Search outcome
The search of the various electronic databases and other sources
yielded 548 articles. Sixty-five duplicates were found and re-
moved; 489 articles had their titles screened, of which 417 were
excluded. The remaining 72 had their abstracts screened, and 30
other studies conducted outside Africa were removed. Forty-two
full-text articles were assessed for eligibility, of which 28 were
excluded. Articles were eliminated on the basis of being non-
primary research (n=3) alongside not being relevant regarding
barriers to GDM care or reporting any experience on GDM screen-
ing, diagnosis or management (n=23). Two articles that pre-
sented findings from low- and middle-income countries (LMICs)
were excluded because findings specific to Africa could not be ex-
tracted separately. The study selection process is represented in
a PRISMA flow diagram in Figure 2.
Studies included in the review
A total of 14 primary studies were included in this review
comprising 7 solely qualitative articles, 2 solely quantitative
articles, 4 mixed-methods articles and 1 randomised control
trial. The overview of the studies included in this review is pre-
sented in Table 2. Half of the studies employed qualitative de-
signs,25–27 ,31–34 with interviews and focus group discussions as
the predominant approaches for data collection. Two of the stud-
ies were quantitative,29,30 one was a randomised controlled trial35
and four employed mixed-method designs.36–39 The sample size
of the papers included ranged from 10 to 3080, while the total
sample size from the 14 studies was 4006.
In terms of geographical location, five studies were conducted
in Southern Africa,25,26 ,32,33,36 four in either West27,29 ,31,35 or East
Africa,30,34 ,37,38 two in Central Africa37,38 andoneinNorthAfrica.
39
In addition, two of the studies were multi-country (Cameroun,
Kenya, Sudan),37,38 yielding data reported from 16 countries in
14 studies overall.
Demographic characteristics of participants diagnosed
with GDM and DIP
Participants in the eligible studies were women diagnosed with ei-
ther GDM26,27 ,31,33 or DIP.32,36 Other studies generally focused on
pregnant women attending antenatal clinics where an adjunct
objective was to explore barriers related to GDM screening, diag-
nosing or management.29,30 ,35,39 The age of the women ranged
from 15 to 49 y. Despite the limited evidence on how marital sta-
tus could influence screening and diagnosis of GDM, one study re-
ported that women who were not in any relationship had a higher
chance of not returning for a confirmatory test such as an oral
glucose tolerance test (OGTT) and fasting plasma glucose.30
Healthcare context
In Table 2, we provide details of the contexts under which the
studies were conducted, thus indicating the level of healthcare
at which GDM services are often provided. A key factor that fa-
cilitated service provision for the detection and management of
GDM was the availability of skilled healthcare providers at vari-
ous healthcare levels. Utz et al. and Mukona et al. demonstrated
that women in Morocco and Zimbabwe were referred to tertiary
or advanced levels of healthcare where specialists such as en-
docrinologists and gynaecologists are stationed. However, the
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Figure 2. Prisma flow diagram illustrating studies included during the selection process and the reasons for the exclusions.
low socioeconomic status of some pregnant women, poor road
networks and work schedules could discourage women from
accessing healthcare at tertiary levels.25,32,36 ,39 Meanwhile, Utz
et al. suggested that decentralising screening, diagnosis and non-
pharmacological management of GDM to the primary level of
care would improve access and mitigate the risk of complica-
tions.39 In six of the eight studies included, healthcare providers
constituted the study participants. In these studies, obstetricians,
nurses, midwives and nurse-midwives were the professionals
most frequently involved in the screening and diagnosing of GDM,
even at tertiary levels of healthcare.29,31,32 ,34,36,39 The healthcare
experience of some of these healthcare providers ranged from 1
to 42 y.25,27
GDM screening, diagnosis and management practices
Detection and management practices for GDM varied substan-
tially across healthcare facilities in Africa. Except for the studies
conducted by Mensah et al., Njete et al. and Nielsen et al., who
reported universal screening in some health facilities in Ghana,
Tanzania and Cameroun,27 ,30,37,39 a selective screening approach
dominated the majority of healthcare settings.25,26,29 ,32,33 ,35,37,38
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Tab le 2 . Overview of studies included in the review
Authors/
year/
country Focus of the paper
Design and sampling
approach
Population and
sample size
Age, y
(range)
Sampling
context
Quality
rating
(Mensah et al.,
2019)27
Ghana
Experience with GDM
diagnosis and
management
Descriptive
phenomenological,
purposive sampling,
semistructured
interviews
10 women with
GDM
30–42 Primary
hospital
*****
(Muhwava et al.,
2019)33
South Africa
Experiences of lifestyle
changes among GDM
women
Qualitative study,
in-depth interviews,
focus group
discussion
30 women with
GDM
25–35+Tertiary
hospital
*****
(Nwose et al.,
2019)29
Nigeria
Barriers to GDM
diagnosis
Mixed method study,
clinical observational
of records and
procedures, focus
group discussion
c119 pregnant
women and
health
professionals
≤34 and
≥35
Tertiary
hospital
and
primary
hospital
***
(Woticha et al.,
2019)34
Ethiopia
Barriers to detection
and management of
GDM
Qualitative descriptive
study, in-depth
interviews
18 obstetricians,
midwives,
nurses and
health officers
26–48 Secondary
hospital
*****
(Muhwava et al.,
2018)26
South Africa
Perspectives on the
barriers and
opportunities for
delivering an
integrated
mother–baby health
service
Descriptive study,
in-depth interviews
11 key
informants
NR Secondary
and
tertiary
hospitals
*****
(Njete et al.,
2018)30
Tanzania
Challenges of GDM
screening
Multisetting
cross-sectional
study, purposive
sampling
433 pregnant
women
15–49 Tertiary
hospital
Primary
health
centre
*****
(Mensah et al.,
2017)31
Ghana
Experience and barriers
with nursing
management of
GDM
Descriptive
phenomenological,
purposive sampling,
semistructured
interviews
8 women with
GDM, 7 nurse-
midwives
Women
28–48,
Nurse-
midwives
32–50
Tertiary
hospital
Primary
hospital
*****
(Mukona et al.,
2017)32
Zimbabwe
Barriers and solutions
of adherence in
antidiabetic therapy
in pregnancy:
patients’ perspective
Descriptive qualitative
study, purposive
sampling, focus
group discussion
35 women with
GDM
19–49 Tertiary
hospital
*****
(Mukona et al.,
2017)25
Zimbabwe
Barriers and facilitators
of adherence in
antidiabetic therapy
in pregnancy:
healthcare workers’
perspective
Descriptive qualitative
study, purposive
sampling with focus
group discussion
28 obstetricians,
dieticians,
midwives and
medical
doctors
20–60 Tertiary
hospital
*****
*(Mukona et al.,
2017)36
Zimbabwe
Barriers of adherence
of antidiabetic
therapy in pregnancy
Mixed sequential
design done in two
phases
I57 women with
DIP and 8
health
workers
Women
18–44
Not specified ****
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Tab le 2 . Continued.
Authors/
year/
country Focus of the paper
Design and sampling
approach
Population and
sample size
Age, y
(range)
Sampling
context
Quality
rating
*(Utz et al.,
2016)39
Morocco
Challenges of screening
and management of
GDM
Descriptive mixed
methods, document
reviews, exit
interviews, focus
group discussion
20 informants,
32 pregnant
women and
299 files of
women
diagnosed
with GDM
NR Primary
health
centre,
secondary,
tertiary
****
*(Nielsen et al.,
2012)37
Kenya,
Cameroun,
Sudan and
other LMICsa
Barriers to screening
and diagnosis of
GDM
Mixed methods,
questionnaires,
semistructured
interviews
8GDMcproject
partners
NR GDM projects
in selected
health
facilities
*****
*(Nielsen et al.,
2012)38
Sudan, Kenya,
Cameroon
and other
LMICsb
Barriers to screening,
diagnosis and
management of
GDM
Mixed methods
approach using
questionnaires and
interviews
10 GDM cproject
partners
NR GDM project
in selected
health
facilities
****
(Ugboma et al.,
2012)35
Nigeria
Importance of
screening and
incidence of
undiagnosed GDM
Randomised controlled
trial
3080 pregnant
women
NR Tertiary,
secondary
and
primary
hospitals
****
Abbreviations: DIP, diabetes in pregnancy; GDM, gestational diabetes mellitus; LMICs, low- and middle-income countries; NR, not reported.
aother LMICs, India, Cuba, China.
bIndia, Cuba, Jamaica, China.
cproject partners for the two projects were healthcare providers, pregnant women and women with a history of GDM.
Studies are arranged in chronological order.
A quality rating of ***** means that 100% quality criteria were met, **** 80%, *** 60%, ** 40% and * 20%.
Regarding diagnostic approaches, 2013 WHO diagnostic criteria
were adopted by some facilities. However, pregnant women ex-
pressed concerns with the tolerability and acceptability of the
test and shortage of diagnostic resources.30,34,37 In a study con-
ducted by Nielsen et al. on compliance and acceptability of
screening and diagnosing procedures, health professionals in
Kenya raised concerns about the nauseating effect of the 75 g
glucose load used for the OGTT. Hence they experimented with
300 ml of sprite (a non-alcoholic drink), which by comparison had
a less nauseating effect.37 In terms of the gestational age for
screening, while some health facilities screened pregnant women
at 24–28 wk, others were screened at 16–34 wk.35 Three studies,
from Morocco, Nigeria and South Africa, reported screening for
GDM at the initiation of antenatal care and sometimes after the
first trimester.26,29 ,39
In assessing management practices, two studies reported in-
sulin and metformin as the medications of choice for manag-
ing GDM and emphasised dietary and lifestyle modification as
an alternative to achieving glucose control.26,39 Beyond medi-
cal intervention, healthcare providers in South Africa mentioned
comprehensive non-pharmacological interventions such as peer
group teaching and group or individual counselling with a dieti-
cian or healthcare professional as effective GDM management
practices.26
Themes generated from the review
We present the findings in line with the review objectives: (1)
barriers to screening and diagnosis, (2) hindrances to imple-
menting management interventions and (3) the experiences of
women regarding GDM diagnosis and management. Through
the thematic content synthesis, we generated three themes
that contextualised women’s experiences regarding the contin-
uum of GDM care overlapping the three objectives of the review.
These three themes comprised health system, patient-related
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and sociocultural barriers limiting GDM screening, diagnosis and
management. Essentially, most of the experiences stemmed
from lack of empathy and inadequate interaction with health
providers coupled with inadequate social support from family and
friends.26,27 ,30,31,35 ,37,38
Barriers to GDM screening and diagnosis
In Supplementary Table 1, we summarise the health system-
and patient-related barriers to initiating screening and diagnostic
strategies for GDM.
Health system-related barriers to GDM screening and diagnosis
Overall, seven studies reported barriers to screening and diag-
nosis of GDM.29,30 ,33,34,37 –39 Two studies reported barriers from
the perspective of pregnant women and women previously di-
agnosed with GDM,30,35 whereas the remaining five studies in-
cluded views of GDM programme implementors, as well as health
professionals, in addition to women diagnosed with GDM or
DIP.30,34 ,37–39 A few of the studies reported on the shortage of
trained health professionals as a barrier to GDM screening and di-
agnosis,33,34 ,39 which led to healthcare professionals’ inability to
comprehensively provide health education and counselling sup-
port throughout pregnancy.25,27,29 ,30,32 ,33,36 Beyond this, the few
healthcare professionals at post do not have the requisite skills to
provide GDM services.31,33,34,38 Some studies attributed the lack
of requisite skills among professionals to the limited opportuni-
ties for in-service training on the GDM care process33,34,38 ,39 due
to the emerging nature of guidelines on its management.
On the other hand, Muhwava et al. concluded that healthcare
professionals do not satisfactorily explain GDM screening and
diagnostic procedures.33 Often, healthcare providers are unable
to follow up women after the first antenatal visit, even among
those who test positive for glucosuria or are scheduled for subse-
quent testing.30,34 ,39 Although this may be due to the high pa-
tient turnout that characterises many antenatal clinics, it may
be exacerbated by staff shortages, insufficient space or inade-
quate logistics and consumables.34,37 An absence of protocols
and guidelines also hamper screening and diagnosis, especially
among newly recruited health professionals who may not be ac-
quainted with the GDM care regimen.29,34,37 Nwose et al. found
non-adherence to GDM protocols and guidelines despite their
availability in some health facilities.29 This could result in long
waiting hours at antenatal clinics, which could deter pregnant
women who travel long distances from returning for subsequent
antenatal care services. Meanwhile, some pregnant women leave
the antenatal clinics without undergoing the prescribed test, es-
pecially if they are required to fast overnight for 8 h before the
test.29
Patient-related barriers to GDM screening and diagnosis
The intention to screen and diagnose GDM commences at the
initiation of antenatal care. However, some women begin ante-
natal visits beyond the 24–28 wk period recommended for GDM
testing.29,34 ,37 Also, pregnant women are unable to accurately
tell their last menstrual date,29 while others tend to under-report
their diabetes risk,37 which potentially affects the decision to test,
especially in settings where a risk-based approach to GDM screen-
ing is practised. Njete et al. reported lost to follow-up among
pregnant women as a significant barrier to GDM screening.29,30
In terms of acceptability of the diagnostic test, Nielsen et al. and
Nwose et al. deduced that the glucose solution used for the OGTT
and the 8-h prerequisite fasting are unbearable for some preg-
nant women.29,35 ,37
Barriers to GDM management
Health system- and patient-related barriers adversely affecting
the provision of management interventions for pregnant women
diagnosed with GDM are summarised in Supplementary Table 2.
In all instances, the gaps we identified were related to the man-
agement of GDM.
Health system-related barriers to the management of GDM
Seven studies sampled the experiences of health professionals,
pregnant women and women previously diagnosed with GDM or
DIP on barriers to the management of GDM.25–27 ,32,34,36 ,39 Four
studies highlighted inadequate health professionals at various
levels of care as a significant barrier to its management.25,26,38
Here, too, insufficient knowledge about GDM, its management
practices, as well as inadequate training on relevant skills for GDM
compared with HIV, malaria and TB in the subregion, were identi-
fied as significant barriers to GDM management.25,26 ,33,34,38 In a
study conducted by Nielsen et al., women diagnosed with GDM
cited inadequate knowledge of healthcare providers on menu
planning as the reason why dietary compliance remains a chal-
lenge.38 Regarding health service delivery, poor coordination and
communication lapses between health providers and pregnant
women disrupt the continuity of GDM care and treatment ad-
herence.25,27 ,33,36,39 Within the healthcare system, Nielsen et al.
identified a weak referral system and difficulty accessing special-
ist care as barriers to GDM care.39
Besides human resources, the shortage of medications, glu-
cose strips, glucometers and reagents also poses a significant
challenge to GDM care.25,34 ,38 In two studies conducted by
Mukona et al., healthcare providers mentioned the absence of di-
abetic medications as a hindrance to therapy compliance.25,36
Patient-related barriers to the management of GDM
Three studies identified financial constraints and the absence of
insurance systems as significant barriers to GDM management.
For example, in healthcare settings where the cost of maternal
health services is not covered by any form of insurance, women
within the lower wealth index are constrained in purchasing med-
ications, glucose strips and following the prescribed nutritional
guidelines for managing GDM.27,32 ,36 Also, difficulty in compre-
hending the treatment regimen and painful insulin injections hin-
der adherence to antidiabetic therapy.32,36
Beside medication, women with GDM cited family and societal
support in GDM care. Some studies have linked the absence of
significant support from family, peers and other social networks
with poor treatment compliance and adverse outcomes.27,32 ,36
Patient support goes beyond family to healthcare providers
with whom patients interact regularly. The need for treatment
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International Health
support from significant others emerged in two studies from
Ghana, where women mentioned support from healthcare pro-
fessionals and close relatives, particularly husbands, as a cru-
cial component of GDM management.27,31 Utz et al., who as-
sessed GDM screening and management practices in Morocco,
documented a lack of empathy and understanding by healthcare
providers as a significant setback to its management.39
Sociocultural barriers
Three studies explored how finances, culture, customs and tra-
ditions influence GDM/DIP management. The cheaper cost of
herbal medicine encouraged some diagnosed women to consult
traditional healers. Others mentioned pressure from family and
friends, who believe that GDM is caused by spiritual or mystical
forces, as the reason for consulting herbalists.25,32,36
Furthermore, some cultures and religions forbid women from
eating certain foods, even if they have positive implications for
GDM treatment outcomes.31 Concerning societal barriers, Nielsen
et al. reported the perceptions of women regarding their body
size, particularly during pregnancy, as a barrier to GDM manage-
ment.38 In typical rural settings, losing weight during pregnancy
creates an impression of ill-health and poverty. In such settings,
compliance with dietary guidelines that require optimum weight
gain during pregnancy is often low.38
Experiences of GDM women on detection and
management
As summarised in Supplementary Table 3, women experience
sadness, anxiety and mixed feelings while accessing GDM ser-
vices, particularly before and after GDM diagnosis, largely due to
the failure of health professionals to explain test procedures.31,33
The mixed feelings were attributed to inadequate interaction with
health providers and a lack of reassurance concerning positive
treatment outcome.36 Given the perceived spiritual connotation
behind GDM, some women might keep the condition a secret for
fear of stigmatisation.31 Few authors have indicated the need
to prioritise the psychological well-being of women diagnosed
through counselling and health education.27,31
Discussion
This review highlights barriers to screening, diagnosis and man-
agement of GDM and experiences of women with GDM in Africa.
Perspectives obtained from healthcare providers and patients re-
veal barriers to the detection and management of GDM within
the health system. Other key barriers included sociocultural and
religious dimensions that affect health-seeking behaviour. Gener-
ally, the barriers are consistent across the studies included in this
review, except for sociocultural barriers, which differed according
to the country context.
Although the findings of this review cannot be universally ad-
judged, it establishes systematic gaps and inadequate attention
to GDM, which constitutes one of the most significant burdens to
diabetes in Africa.2The foremost barrier to GDM detection and
management is inadequate knowledge. Awareness of the condi-
tion among both healthcare providers and pregnant women will
limit progression to diabetes type II. Other reviews have estab-
lished evidence that a shortage of healthcare providers hinders
GDM detection and management. However, the problem extends
to a lack of knowledge resulting from limited opportunities for
skills-based training.40 Because the majority of health services
are concentrated at primary levels, this review proposes the need
for capacity building at lower levels of care, alongside providing
the essential equipment and consumables necessary to enhance
GDM care.
Prioritising other diseases and programmes such as the pre-
vention of mother-to-child transmission of HIV and intermittent
preventive treatment of malaria at the expense of GDM is a con-
cern. These programmes are prioritised and provide health pro-
fessionals with an opportunity for training, but the same cannot
be said of NCDs in pregnancy. While efforts have been made to
improve NCD surveillance and response in LMICs, such interven-
tions need to start from antenatal care clinics, where screening
and diagnostic services start.
The multidimensional nature of the problems associated
with GDM service provision require a comprehensive systemic
revision to improve detection and management practices. As
seen in this review, even in settings where protocols and guide-
lines exist, the feasibility of implementing WHO-recommended
universal screening is problematic due to the scarcity of resources
that characterises many healthcare settings in Africa. Therefore,
there is a need for context-applicable screening and diagnos-
tic protocols that are informed by cost, tolerability, availability,
accessibility and sustainability to increase the uptake of GDM
services.17,37 Otherwise, several pregnant women may go un-
screened, to the detriment of the mother and baby. The few
who test positive and require further testing or treatment are
often not followed up or are lost to follow-up. Poor coordina-
tion of referral pathways is a significant factor given that most
of the cases are managed at tertiary levels, which are grossly in-
accessible to the majority of pregnant women. Inadequate con-
tact and interaction with healthcare providers reduce chances for
health education and counselling, which limit the effectiveness
and satisfaction with care received. Moreover, patient education
and counselling41,42 has been associated with positive treatment
outcomes and facilitates postpartum care, which is key to early
detection of type II diabetes.43 As antenatal care offers an op-
portunity for screening, diagnosing and management, healthcare
providers should leverage this opportunity to enforce behavioural
change through evidence-based interventions such as peer coun-
selling and dietician consultation.
Cultural diversity within the African context is more pro-
nounced, and management of GDM is not spared its conse-
quence. Although several interventional studies have established
the importance of dietary adherence for GDM management,44,45
lifestyle modification is disadvantaged by negative perceptions
about weight gain during pregnancy and taboos and customs
surrounding foods, thereby affecting adherence to the therapeu-
tic regimen. Even in low-resource settings in developed coun-
tries including the UK, it is recommended that health educa-
tion on diabetes in pregnancy incorporates culturally appropri-
ate messages, as there are potential cultural issues, such as lan-
guage and myths or ‘old wives tales’ that affect GDM treatment
compliance.46
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T. Hinneh et al.
Strength and limitations
This paper is the first review on barriers to GDM care in Africa and
shows how GDM has received little attention in Africa. However,
because of the growing interest in GDM research globally after
the Hyperglycemia and Adverse Pregnancy Outcomes study in
2008, which reported adverse pregnancy outcomes per unit in-
crease in maternal glucose,47 we observed that the eligible stud-
ies included in this review were published recently (during 2012–
2019). The eligible studies included in the review represent the
five subregions and different ethnic groups in Africa. More im-
portantly, the included articles cut across qualitative, quantita-
tive and mixed-method designs, which complementarily provide
a contextual understanding of the challenges to GDM care. A con-
siderable number of studies sampled diverse stakeholders con-
cerned with GDM, thereby allowing a comprehensive description
of the barriers to GDM service provision. All these elements en-
hanced the validity and generalisability of the findings across
Africa.
Nevertheless, this review has some limitations. Generally,
there was missing information on the gestational age of preg-
nant women at screening and the context of healthcare from
which participants were recruited. The cultural and religious barri-
ers identified may be unique to specific ethnic or religious groups
and could be misleading if generalised because they vary from
country to country and from one ethnic group to another, even
in the same country. Nevertheless, they provide an insight that
some barriers may be culturally inclined.
Conclusions
This review shows the multidimensional factors that interact at
different health systems and societal levels to hinder the detec-
tion and management of GDM in Africa. Insufficient clinical lo-
gistics, inadequate coordination of GDM care, limited human re-
sources capacity and funding deficits grossly affect the testing
and management of GDM in Africa. Women diagnosed experi-
ence anxiety, sadness, stigmatisation and uncertainty regard-
ing treatment outcomes. Family support, customs and taboos
are pertinent at the societal level. Broader consultation with key
stakeholders to address these multifactorial challenges is essen-
tial in improving maternal and child health. The coexistence of
infectious diseases continues to direct training needs, resource
allocation and prioritisation of interventions. Nonetheless, preg-
nancy complications associated with GDM and its linkage with
other NCDs is well established. Therefore, addressing these bar-
riers is key to improving maternal and neonatal outcomes and
promoting NCD-prevention strategies in Africa.
Supplementary data
Supplementary data are available at International Health online.
Authors’ contributions: TH, FA and AJ conceived the study. The study
protocol was designed by TH and reviewed by FA and AJ. The study de-
sign, initial literature search and study selection, quality assessment and
data extraction were carried out by TH and independently reviewed by
FA. Discussions were held with FA and AJ until consensus was reached at
every stage. All the authors read and approved the final version of the
manuscript.
Acknowledgements: We are thankful to Dr. Daniel Boakye, Dr. Nkorika
Chiamaka Ilechukwu, Dr. Nicholas Kyei, Edmund Yeboah, Sneha Bhusari
and Tracy Osei Bonsu for their immense support throughout the conduct
of this review.
Funding: This review received no funding.
Competing interests: The authors have no competing interests to
declare.
Data availability: None.
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