ABSTRACT
Objective
The purpose of this study was to assess how self-management education for gestational diabetes mellitus (GDM), given to pregnant women with a GDM diagnosis, influences their perceived risk, diabetes self-management abilities, and perinatal outcomes.
Methods
This study was carried out between February and September 2024 at maternity education and research hospital. A total of 40 pregnant women participated, with 20 assigned to the control group and 20 to the individual education group. All participants were diagnosed with GDM by physician based on screening tests conducted at 24-28 weeks of gestation, and were referred to the diabetes nursing clinic. The women in the individual education group received weekly 40-minute training sessions over four weeks, conducted by a certified diabetes nurse and a certified prenatal education midwife. All data were analyzed using SPSS version 25.0.
Results
After the four-week diabetes self-management education, a comparison of the total scores of the Perception of Pregnancy Risk Questionnaire (PPRQ) and the Diabetes Self-Management Questionnaire (DSMQ) between the control and individual education groups revealed no significant difference in pregnancy risk perception between the two groups. However, the total DSMQ score showed a significant increase in the individual education group (p<0.05). No significant differences were observed between the groups in the sub-dimensions of the PPRQ; however, the sub-dimensions of the DSMQ, specifically glucose management, dietary control, and health care utilization, along with overall diabetes self-management, showed statistically significant improvements in the individual education group. Although within normal limits, the height and weight of the babies born to the mothers in the control group were statistically significantly higher compared to those in the individual education group.
Conclusion
The study revealed that diabetes self-management education delivered by midwives and nurses -the health care professionals most closely engaged with pregnant women- enhanced dietary management and risk perception during pregnancy.
INTRODUCTION
Gestational diabetes mellitus (GDM) is the most common metabolic complication of pregnancy, characterized by hyperglycemia that is first identified during pregnancy in women without a prior history of diabetes, and presents potential risks to both the mother and fetus, necessitating careful management to mitigate adverse outcomes (1-3). According to the International Diabetes Federation, in 2021, there were 21.1 million pregnancies with excessive hyperglycemia, and 80% of these were GDM pregnancies (4). The rising prevalence of GDM is a leading cause of maternal and infant mortality and morbidity worldwide. Women with GDM face increased risks of pregnancy-related hypertension, preeclampsia, infections, preterm birth, and cesarean delivery (2, 3, 5). Additionally, their children are at a higher risk for adverse pregnancy outcomes such as macrosomia, congenital anomalies, neonatal hypoglycemia, shoulder dystocia, and respiratory distress syndrome, as well as long-term health issues such as hypertension, obesity, and diabetes (2, 5-7). To improve maternal and newborn health, women with GDM are required to adopt multiple, often challenging lifestyle changes (diet and exercise), monitor blood glucose levels, and use various hypoglycemic agents (2, 5, 7). Successful self-management is a crucial aspect of GDM care, requiring a reduction in caloric intake by substituting high-calorie foods with healthier alternatives, encouraging increased physical activity to enhance metabolism, and consistently monitoring blood glucose levels, which empowers pregnant women to effectively manage their GDM and minimize potential complications (5, 8, 9). The primary goal of GDM treatment is to maintain blood glucose within the recommended range, which can be achieved through these healthy lifestyle interventions (diet and physical activity) (3, 5). However, if self-management is not adequately addressed in women with GDM, the morbidity rates for both the mother and baby can be two to three times higher. However, these risks can be significantly reduced with proper management of GDM, emphasizing the importance of timely interventions and effective care strategies (10). Perception of risk during pregnancy and childbirth is a complex process influenced by multiple factors. For pregnant women, the primary concern related to risk perception shaped by pregnancy-specific risk factors is the well-being of their baby (11-13). Another significant source of anxiety is the worry that dietary programs may be too restrictive and fail to provide all the necessary nutrients for the baby (13). Risk perception can be influenced by various elements, including perceptions, expectations, previous life experiences, high-risk pregnancies, fear induced by stress, and information received from different sources (11, 13). The intensity of risk perception impacts attitudes towards treatment, maternal decision-making during pregnancy, and adherence to medical procedures and recommendations (11). A study involving women with GDM reported that a low-risk perception for developing type 2 diabetes mellitus hindered their ability to make lifestyle changes (14). Similarly, other studies indicated that low-risk perceptions led some women with gestational diabetes to believe that their condition was temporary (15, 16), which may cause them to disregard further interventions and treatments, ultimately leading to neglect in self-management (17). Therefore, it is essential that health care professionals, especially nurses, effectively manage risk perception to enhance self-management and self-efficacy among women with GDM (3). Given the risks posed by GDM to both mothers and babies, it is crucial to identify strategies that support women in managing their condition (5). Health education interventions are one of the key components in managing GDM, as they help improve self-management skills, blood glucose monitoring, healthy lifestyle changes, and decision-making (16, 18-20). In this context, education is one of the most effective strategies for supporting self-management in women with GDM. The closest and most effective sources of support for providing counseling and education to these women are diabetes nurses and midwife-nurses who monitor pregnancies. The purpose of this study was to assess how GDM self-management education influences pregnant women diagnosed with GDM, specifically examining its effects on their perceived risk, diabetes self-management skills, and perinatal outcomes.
Hypotheses
• H0: Individual education provided to pregnant women diagnosed with gestational diabetes immediately following their diagnosis does not affect diabetes self-management.
• H1: Individual education provided to pregnant women diagnosed with gestational diabetes immediately following their diagnosis does not affect perceived risk levels during pregnancy.
• H2: Individual education provided to pregnant women diagnosed with gestational diabetes immediately following their diagnosis does not affect perinatal outcomes.
• H3: Individual education provided to pregnant women diagnosed with gestational diabetes immediately following their diagnosis affects diabetes self-management.
• H4: Individual education provided to pregnant women diagnosed with gestational diabetes immediately following their diagnosis affects perceived risk during pregnancy.
• H5: Individual education provided to pregnant women diagnosed with gestational diabetes immediately following their diagnosis affects perinatal outcomes.
MATERIAL AND METHOD
This study aimed to assess the effects of GDM self-management education on pregnant women diagnosed with GDM, focusing on their perceived risk during pregnancy, diabetes self-management levels, and perinatal outcomes. Conducted between February and September 2024 at a maternity education and research hospital, the study included pregnant women who were diagnosed with GDM by a physician following screening tests performed at 24-28 weeks of pregnancy, and subsequently referred to the diabetes nursing clinic. Ethical approval was obtained from the University of Health Sciences Türkiye, Başakşehir Çam and Sakura City Hospital Ethics Committee (approval no.: 78, date: 31.01.2024), and the study was carried out in compliance with the Helsinki Declaration. The researchers provided a verbal explanation of the study’s purpose and procedures to all participants, and written informed consent was obtained from each volunteer before data collection was completed.
Population and Sample
The population of this study consisted of pregnant women diagnosed with GDM who visited the relevant institution during the study period. To determine the minimum required sample size, a power analysis was conducted based on similar studies (5, 9). According to the power analysis, with an effect size of 0.754, a significance level of 0.05, a confidence level of 95%, and a test power (1-β) of 80% for a two-tailed hypothesis, the optimal number of female participants was calculated as 20. Therefore, the total sample size for the study was determined to be 40 pregnant women (20 in the control group, 20 in the individual education group). Inclusion criteria for the study were as follows: (i) being diagnosed with GDM, (ii) having a singleton pregnancy, (iii) being 18 years or older, (iv) volunteering to participate, (v) being able to read and understand Turkish, and (vi) having no communication problems (such as hearing or speech impairments), and (vii) not having any diagnosed psychiatric disorders. Exclusion criteria included: (i) twin pregnancies, (ii) the presence of an additional risk factor along with GDM during pregnancy, and (iii) giving birth before 36 weeks of gestation.
Randomization
For the pregnant women who met the sample selection criteria, randomization was conducted using the random integer generator available on the website random.org. Columns were created within the 1-40 range (Random.Org). The numbers 1 and 2 were assigned to each participant randomly, representing the allocation to either the intervention or control group. At the beginning of the study, these numbers were designated to represent the experimental and control groups through a lottery method. The pregnant women assigned the number 1 were placed in the individual education group, while those assigned the number 2 were placed in the control group. The study’s CONSORT diagram is presented in Figure 1.
The 20 pregnant women who met the inclusion criteria and were assigned the number 1 were placed in the control group. This group received standard care in accordance with hospital protocols, which included personalized instruction from a diabetes education nurse. The instruction covered self-administration of insulin (if prescribed), monitoring of blood glucose levels, and education on GDM management during pregnancy. The pregnant women assigned the number 2, who were placed in the individual education group, received a more comprehensive education program. This program was delivered by a certified diabetes nurse and a certified prenatal education midwife over a four-week period, with weekly 40-minute sessions. The sessions covered various self-management skills related to gestational diabetes and pregnancy, including blood glucose monitoring, insulin administration and tracking, GDM nutrition, weight control, diet, self-management, physical activity, healthy lifestyle behaviors, utilization of health care services, and follow-up care. Since the education was provided individually, the dates for each session were scheduled during the previous session based on the participant’s availability.
Training Program
Week 1: Definition and Symptoms of Gestational Diabetes
What is gestational diabetes? What are its symptoms? (What causes it? Is it permanent or temporary?)
The role of sugar in the body and its effects on pregnancy and fetal development.
Home blood sugar monitoring and evaluation, recording.
Special educational needs of pregnant women.
Week 2: Antidiabetic Medications Used During Pregnancy
What are the medications used, and how should they be administered?
Importance of insulin therapy, types and effects, injection sites and site rotation, as well as the side effects of therapy and storage considerations for insulin.
Special educational needs of pregnant women.
Week 3: Gestational Diabetes and Diet
Importance of nutrition, meal planning, essential nutrients affecting blood sugar levels: carbohydrates.
Snack options (sample menus, recipes).
Diet and fetal development.
Special educational needs of pregnant women.
Week 4: Effects of Gestational Diabetes on Maternal and Child Health
Acute complications and prevention of gestational diabetes.
Self-care and self-sufficiency in gestational diabetes (pregnancy-week appropriate exercise activities, self-care, hygiene).
Special educational needs of pregnant women.
Referral to Diabetes Nursing Clinic
All pregnant women who are diagnosed with gestational diabetes and visit the prenatal clinic are referred to the diabetes nursing clinic, where they receive education on topics such as gestational diabetes and blood sugar monitoring, and insulin usage. Additionally, information is provided regarding the weekly training sessions for the study group and they are notified that they may participate if they wish. Pregnant women who indicate that they cannot attend are included in the control group. Those who express they cannot attend are informed that they can join at any time, and the information is personally conveyed during pregnancy school registration. Moreover, information brochures on gestational diabetes are also provided to the women in the control group. Regardless of their group, pregnant women may receive postpartum follow-up care from the postpartum clinic at any time after delivery. This information is provided to all pregnant women during discharge education in the hospital.
Compliance with the Educational Program
Trainings for willing participants in the study group are scheduled based on the dates and times requested by the pregnant women, coordinated with prenatal clinic appointments and/or examinations like ultrasounds (scheduled half an hour before or after the appointments). Additionally, follow-up appointments for all participants of the pregnancy school and/or those attending these trainings are scheduled by the hospital for advanced ultrasounds, tests, etc.
Data Collection
The study data were collected through face-to-face interviews conducted by a diabetes education nurse in a room that ensured patient privacy. The Descriptive Characteristics Form for Pregnant Women’, the Diabetes Self-Management Questionnaire (DSMQ), and the Perception of Pregnancy Risk Questionnaire (PPRQ) were administered to the pregnant women who were referred to the diabetes nursing clinic after their initial diagnosis but had not yet begun education. For the individual education group, the scales were applied for the second time following the completion of a four-week education program, while for the control group, the scales were re-administered during the first hospital visit, which took place at least four weeks after the initial assessment. The data related to childbirth, including the baby’s weight, length, and appearance, pulse, grimace, activity, and respiration (APGAR) scores, were obtained from the postnatal information management system and recorded on the Descriptive Characteristics Form. The data collected through face-to-face interviews were gathered in approximately 25-30 minutes.
Data Collection Tools
The data for the study were collected using the Descriptive Characteristics Form for Pregnant Women, the DSMQ, and the PPRQ (21, 22).
Descriptive Characteristics Form for Pregnant Women
This form was developed by the researcher based on relevant literature. It consists of 30 questions related to personal, obstetric, and gynecological characteristics. The personal characteristics section includes questions regarding age, education level, marital status, occupation, income level, family type, height-weight, smoking/alcohol use, family history, and the presence of chronic diseases. The obstetric and gynecological section covers questions about the number of pregnancies, gestational week, weight gained during pregnancy, number of live births, and age at first menstruation. The section for data obtained from patient files includes information related to childbirth, such as the baby’s weight, length, and APGAR score.
Diabetes Self-Management Questionnaire (DSMQ)
The DSMQ is a 16-item self-assessment scale widely used in studies to evaluate the relationship between diabetes self-management and glycemic control among diabetic patients. The scale is in a four-point Likert format and consists of four sub-dimensions: glucose management, dietary control, physical activity, and healthcare use. Scores range from 0 to 10, with higher scores indicating better diabetes self-management. In the Turkish adaptation of the scale (21), the Cronbach’s alpha value was found to be 0.85 study, and the Cronbach’s alpha value of the scale was calculated as 0.86.
Perception of Pregnancy Risk Questionnaire (PPRQ)
The PPRQ was developed by Heaman and Gupton in 2009 to assess the risk perception of pregnant women. The scale consists of nine items and is a visual analog measurement tool. It has two sub-dimensions: risk to baby and risk to self. Below each item, there is a 0-100 mm linear line with labels ranging from “no risk at all” to “extremely high risk”. The total score is calculated by summing the scores for each of the nine items and dividing the total by nine. A higher score indicates an increased perception of risk related to the woman and her baby. In the Turkish validity and reliability study of the scale (22), the total Cronbach’s alpha coefficient was found to be 0.84. For this study, the Cronbach’s alpha value of the scale was calculated as 0.95.
Statistical Analysis
The data obtained from the study were analyzed using the SPSS 25.0 (IBM, Armonk, NY, USA) software. Since the data followed a normal distribution, descriptive statistics, independent t-test, One-Way ANOVA, and Pearson correlation tests were applied. The results were evaluated at a 95% confidence interval, and the significance level was set at p<0.05.
RESULTS
The distribution of the descriptive characteristics of the pregnant women in the individual education and control groups, along with their comparisons, is presented in Table 1. No statistically significant differences were found between the groups in terms of age, education level, employment status, or income level (p>0.05), indicating that the two groups were similar in terms of their descriptive characteristics. However, it was observed that the body mass index (BMI) was higher in the individual education group, and that this difference was statistically significant between the groups (p<0.05). There is no smoking or alcohol use in the control and individual education groups.
There were no statistically significant differences between the groups regarding age at first menstruation, total number of pregnancies, gestational week, weight gained during pregnancy, the week of referral to the diabetes clinic, mode of delivery, family history of diabetes, regular blood glucose monitoring during pregnancy, and insulin use (p>0.05), indicating that the two groups had similar descriptive characteristics. However, it was found that the gestational week at delivery in the control group was two weeks later than that in the individual education group, and that this difference was statistically significant (p<0.05) (Table 2).
When comparing the babies of the pregnant women in the control and individual education groups in terms of birth weight and length, as presented in Table 3, it was observed that although both groups were within the normal range, the babies in the control group had higher birth weights and lengths compared to those in the individual education group. This difference was found to be statistically significant (p<0.05). In contrast, the APGAR scores were similar between the two groups, with no statistically significant difference observed (p>0.05).
It was found that the women in the individual education group demonstrated significantly higher engagement in pregnancy-related information-seeking behaviors compared to the control group, and that this difference was statistically significant (p<0.05). However, no statistically significant differences were found between the two groups in terms of paying attention to healthy eating habits, exercising regularly, or developing good sleep habits (p>0.05), indicating that both groups exhibited similar characteristics in these aspects (Table 4).
When comparing the initial evaluation scores of the PPRQ and DSMQ and their sub-dimension, it was found that the total DSMQ score was higher in the individual education group, and that this increase was statistically significant (p<0.05). However, no significant differences were observed in the scores of the other sub-dimensions (p>0.05). After the four-week diabetes self-management education, a comparison of the total PPRQ and DSMQ scores between the control and individual education groups revealed no significant difference in pregnancy risk perception. However, the total DSMQ score showed a statistically significant increase in the individual education group (p<0.05). While there were no significant differences between the two groups in the sub-dimensions of the PPRQ (p>0.05), there were statistically significant differences in the DSMQ sub-dimensions, including glucose management (Graph 1D), dietary control (Graph 1E), health care use (Graph 1G), and diabetes self-management (Graph 1H) (p<0.05) (Table 5, Graph 1).
When comparing the initial and final evaluations of the PPRQ and DSMQ scores in the control group, it was observed that the PPRQ scores decreased and that the DSMQ scores increased; however, these changes were not statistically significant (p>0.05). In the individual education group, an analysis of the PPRQ and DSMQ scores before and after the four-week self-management education revealed a decrease in PPRQ scores and an increase in DSMQ scores. Furthermore, there were statistically significant changes in all sub-dimensions, except for risk to self and physical activity (p<0.05). Comparison of pre-test and post-test mean scores for PPRQ and DSMQ, including overall scores and sub-dimension results.
DISCUSSION
Tight glycemic control and self-monitoring of glucose levels, along with adopting healthy lifestyle behavior changes, are essential for reducing pregnancy complications related to GDM. These interventions require women to quickly learn and adopt challenging self-management skills in a short time. Health education is a fundamental component of care for successful GDM management and rapid adaptation to these changes (23-26).
This study was conducted in light of the need for research and evidence on the impact of component face-to-face nursing education and counseling on self-management in pregnant women with GDM, a condition with high prevalence in Türkiye and known to have negative effects on maternal and infant health.
Controlling weight gain during pregnancy, which is a modifiable risk factor for adverse pregnancy outcomes, contributes to the early detection, prevention, and intervention of negative perinatal outcomes (25, 26). In a study conducted in China involving a retrospective review of prenatal medical information from 41.845 pregnant women, a high BMI in early pregnancy was identified as a risk factor for gestational diabetes, whereas an increase in BMI before gestational risk screening was not found to be associated with an increased risk of GDM (27). In the present study, the BMI of the pregnant women in the individual education group was higher at the start of the study compared to the control group. Given that an increase in BMI before gestational risk screening was not linked to an increased risk of GDM in the literature, this difference was not expected to affect the study’s outcomes.
Studies have described pregnancy as a “window of opportunity” both for identifying women at risk of future health conditions and for promoting lifestyle changes (28, 29). In women with a history of GDM, a perceived low risk may act as a barrier to adopting risk-reducing lifestyle changes, while a well-managed and perceived level of risk can play a significant role in adopting preventive health behaviors (29). When examining the results of various studies, it has been found that women often experience anxiety, fear, and panic upon receiving a GDM diagnosis, with many expressing that changing their eating habits and engaging in exercise are particularly challenging adjustments (30). A statistically significant positive correlation between risk perception and exercise behavior has also been identified (31). Moreover, many women diagnosed with GDM tend to underestimate their personal risk of developing diabetes later in life (29). The literature indicates that pregnancy risk perception may be related to factors such as the number of births, maternal age, and pregnancy complications, underscoring the importance of individualized assessments (32). At the beginning of this study, risk perception scores were similar for both groups. However, as the study progressed, the individual education group showed a decrease in sub-dimension scores related to the perception of risk to baby and overall pregnancy risk, while the control group exhibited an increase in these scores. This result was attributed to the ability of the women in the individual education group to express themselves and their concerns more comfortably, directly address their uncertainties and anxieties, and receive answers, leading to better management of their risk perception.
Knowledge of GDM is crucial for its effective management. Health education provided to women is highly effective in increasing their knowledge about the disease, correcting any misconceptions, preventing complications related to the condition, and enhancing their self-management skills (16, 33). Studies on improving self-efficacy emphasize the importance of personalized and customizable approaches to enhance the effectiveness of GDM management practices, facilitate changes in habits, and make goals more achievable (34). Studies on improving self-efficacy highlight the importance of personalized and customizable interventions in increasing the effectiveness of GDM management practices, facilitating changes in habits, and making goals more attainable (34). A systematic review of 70 studies emphasizes that when pregnant women with gestational diabetes reach a certain level of self-management and self-efficacy, they can positively control their diet and body weight (3). Haron et al. (16) conducted a review of 19 studies to explore self-management strategies, educational content, and their effectiveness for women with GDM. Their findings highlight the significant positive impact these interventions have on the management of GDM. These include improved self-management behaviors, higher satisfaction scores, enhanced self-efficacy, better glucose control, and improved pregnancy outcomes. In this study, both the control and individual education groups showed an increase in total diabetes self-management scores and scores across all sub-dimensions, except for physical activity. However, in the intra-group comparisons, the self-management scores of the women in the individual education group increased significantly before and after the intervention. Despite the higher initial BMI of the women in the individual education group, their babies’ birth weights were lower compared to the control group, and the average birth weight was below the threshold for macrosomia, a common complication of GDM. In a randomized controlled study conducted in China, a couple-based intervention program was applied to the intervention group, while the control group received individual GDM education. At the end of the program, GDM knowledge and self-management improved significantly in both groups, but greater improvement was observed in the intervention group. Consistent with this study, the babies’ birth weights in the intervention group were also found to be significantly lower (2). A review of 30 qualitative studies that examined the self-reported barriers to self-management among pregnant women with GDM categorized the obstacles into three main themes: (a) knowledge and beliefs, (b) skills and abilities, and (c) environment and social support. Under the subtheme of physical limitations in the “skills and abilities” theme, it was reported that pregnant women were more prone to fatigue, may suffer from pelvic and perineal pain, and may experience more mobility issues compared to the general population. These factors were identified as barriers to maintaining a regular exercise routine for women with GDM (20). In this study, no progress was observed in the physical activity sub-dimension of diabetes self-management for either the individual education group or the control group. Although health care providers often recommend maintaining or increasing physical activity during pregnancy, these recommendations may not be persuasive enough to overcome traditional beliefs and perceptions that pregnancy requires extra care, rest, and recovery (35, 36). The lack of change in the physical activity sub-dimension in both groups could be linked to the prevailing cultural perspective in our society.
Study Limitations
This study has certain limitations. The study was conducted in a single center, which may limit the generalizability of the findings. Additionally, the small sample size and short follow-up period may have influenced the outcomes. Future multicenter studies with larger sample sizes and longer follow-up periods are recommended to confirm these results.
CONCLUSION
Women need to recognize their potential for a safe pregnancy, and one of the most effective ways to achieve this is through educational and counseling interventions. This study found that individualized GDM self-management education and counseling provided by nurses facilitated and positively impacted women’s management of perceived pregnancy risk. As women’s knowledge levels increased, their perceived risk decreased, which indirectly positively influenced the implementation of self-management skills training. It was observed that individual education significantly increased and positively impacted the scores on the diabetes self-management scale, with significant improvements in all sub-dimensions except physical activity. This lack of improvement in physical activity may be influenced by social beliefs and perceptions, where pregnant women are expected to rest and reduce movement. Therefore, promoting physical activities that are safe and will not adversely affect pregnancy could be beneficial for broader acceptance among pregnant women. National studies on the benefits of physical activity during pregnancy and its positive effects on pregnancy and GDM management could play a crucial role in raising social awareness. Similar to individualized education programs, there is also a need for physical activity planning and studies to promote physical activity during pregnancy. Additionally, the study demonstrated that self-management education was significantly associated with lower birth weights. Follow-up studies during the postpartum period are needed to determine whether the effects of the intervention are long-lasting or specific to pregnancy, as adopting healthy lifestyle behaviors after pregnancy could help reduce the risk of developing type 2 diabetes. In conclusion, diabetes self-management education provided by midwives and nurses, who spend the most time with pregnant women, positively influenced diet, lifestyle changes, and the use of health care services, as well as having positive effects on perinatal outcomes.
