Background
OGTT screening for GDM commenced in Western Australia (WA) in 2012. Subsequent audits in 2013 and 2022 showed significant numbers of women were not screened with OGTT in rural WA. Additional issues in implementing a universal OGTT screening program include pre-analytical factors and patient factors.
Aims
This study explored challenges and enablers of universal OGTT screening from the clinicians’ point of view.
Methods
We interviewed eight health professionals delivering obstetric care in rural and remote WA. Participants included obstetric general practitioners, midwives, and specialist obstetricians in primary and secondary health care, including hospital-based clinics, Aboriginal Community Controlled Health Services, general practice, and remote clinics. Interviews were professionally transcribed into individual Microsoft Word documents, imported into NVivo 12, then coded and analysed using a directed qualitative content analysis approach.
Results
Participants reported diversity of patients based on ethnicity, socioeconomic status, geographic distribution, patient health views and clinical risk profiles. First trimester glucose screening involved a range of approaches including risk profiling, OGTT and alternative tests. Choice of test was moderated by local protocols and patient preference. Mid trimester screening comprised an OGTT, with alternative glucose measures if it was not completed. In third trimester clinicians used serial growth scans, four-point glucose profiles, and rarely the OGTT.
Participants made significant efforts in screening women, ensuring patient comfort (physical environment), safety (COVID, culturally safety), trust and good rapport with their healthcare provider. Participants reported several problems with the OGTT including nausea, vomiting, dumping syndrome after bariatric surgery, conflict with patients’ health beliefs, needle phobia, controlling partners, time constraints, and late antenatal presentation.
GDM screening in rural settings is complex requiring coordination across regional jurisdictions and clinical settings. Primary care was the commonest first point of contact. Participants felt the OGTT underdiagnosed GDM, commenting on discordance between clinical presentations during pregnancy and OGTT result, for example large for gestational age babies after normal OGTT. Some participants were aware of a continuum of glucose levels and risk of adverse outcomes and incorporated this into their practice rather than using a dichotomous risk assessment.
Conclusions
There is a need for better service level integration of GDM screening across rural populations and better recognition of the skills and complexity of care in rural centres. The dichotomous diagnostic model of GDM poorly reflects the observed clinical experience. GDM is better described by a graded paradigm of low, medium, and high risk.