We analyzed 25 studies for this review. Among the 25 studies on GDM, 6 (12, 13, 18–21) were on screening, 7 (10, 11, 13, 20, 22–24) on diagnosis, 9 (10, 11, 23, 25–30) on management, 8 (26–29, 31–34) on awareness, and 5 (31, 35–38) on epidemiology. The increase in the total number of studies is due to the single studies that focused on more than one topic. Of the 25, 8 studies (12, 20, 21, 25, 27, 28, 30, 32) were literature reviews/editorials, 13 (10, 13, 19, 22, 26, 31, 35–38) epidemiological studies and surveys, and 4 (11, 18, 23, 34) reports/practice guidelines. The characteristics of these studies are also listed in Table 1.

Overall, three studies furnished data on self-monitoring of glucose levels and regulation of diet and exercise, adherence to medications, and periodic follow-up with the health-care provider. Similarly, 12 studies discussed GDM awareness among patients, management guidelines (prepartum to postpartum), patient compliance, and the need for educational and behavioral counseling. The data from 13 studies highlighted GDM care in India and discussed cultural tailoring of interventions, inconsistencies in screening, diagnosis and management guidelines across practices, individualized assessment and reassessment, and use of treatment algorithms by various health-care providers.

We analyzed data from these studies and categorized the challenges under two key themes covering the vital aspects of GDM care (Figure 2):

Challenges in self-management

In addition, we provided recommendations for the outlined challenges based on relevant information extracted from these studies (Table 2).

Health-care system in India is categorized into two major sectors: public and private (Figure 3). The public health-care system chiefly includes secondary and tertiary care institutions in key cities and primary health-care centers in rural areas (39). On the other hand, the private sector provides majority of care through secondary, tertiary, and quaternary institutions with a major focus in tier I and tier II cities (39). Thus, the health-care infrastructure in urban and rural India is not evenly distributed and not at proximity, mostly in case of rural areas. Although, health-care services in the public sector are offered free of charge to all citizens, people often end up with high out-of-pocket expenditures because they often prefer services from private health care due to quality of care (40). Further, the health-care costs vary within the private sector based on the facilities and care offered, leading to issues related to affordability. On the whole, the total expenditure for health in India was 4.7% of GDP in 2014 of which public and out-of-pocket health expenses were 30 and 62.4%, respectively (41).

Apart from public and private health-care providers, non-profit organizations and non-governmental organizations also play a pivotal role for GDM-related advocacy. Currently, organizations, both national and international, such as IDF, Bill and Melinda Gates Foundation, Jagran Pehel, Women and Children First, Public Health Foundation of India, and others work toward promoting maternal and child health (9, 42–45). Another coalition in India that strives toward the same goal is the reproductive, maternal, newborn, child, and adolescent health (RMNCH+A) coalition, which is led by Save the Children India under the support of the Government (46). The coalition includes central and state government agencies, academia, research and training institutes, health-care professional associations, local bodies (Panchayats and Nagarpalikas), non-governmental organizations, civil society organizations, faith-based organizations, media, corporate organizations, bilateral and multilateral donors, and United Nations agencies (46). RMNCH+A aims to work more effectively in collaboration with multiple stakeholders to enhance joint action and accountability and to support the implementation of national commitments and policies (46). In 2005, a global alliance “The Partnership for Maternal, Newborn & Child Health” of more than 700 organizations in 77 countries representing the sexual, reproductive, maternal, newborn, child, and adolescent health communities, as well as health influencing sectors, was established (47). This partnership provides a platform for organizations in India to align objectives, strategies, and resources and to achieve consensus on interventions to improve maternal, newborn, child, and adolescent health (47).

To establish the existing challenges and recommendations for GDM care in India, the study researchers performed a narrative review using available literature on GDM in India. The key challenges identified during this review with regard to self-management and provider management included awareness, accessibility, compliance issues, and cultural context of care. The study researchers discussed the identified challenges and suggested recommendations based on the findings from the literature. Also, the researchers have provided additional recommendations in context of the findings after reviewing the most recent guideline documents and several international publications to suggest the best practices for GDM management.

Some major challenges in the self-management of GDM were social taboos, cultural habits, GDM awareness, adherence, lack of patient motivation, screening costs, and transportation to nearest centers. Many of these challenges do not require adequate resources, but simple policy changes to improve GDM awareness. In India, the growing concern of family and friends for a pregnant woman and her baby is a major factor. Almost everyone within the family has an opinion. This can confuse and complicate the pregnant woman’s decisions to follow the health-care professional’s advice. The lack of information in communities and sometimes cultural perspectives are barriers to GDM care. Myths like “exercise harms the baby” and “pregnant mothers must consume food for two” cause negative strongholds in pregnant women, preventing them from following the instructions of their health-care professionals to exercise and adhere to a certain diet. Some patients are even reluctant to ask questions, suggesting poor interaction with the health-care providers leading to misconceptions (48, 49). Hence, many women remain sedentary during pregnancy because of these perceived barriers. Many women crave certain food items during pregnancy, and the temptation for food that is not necessarily nutritious, especially carbohydrates, is a major obstacle to adherence (48, 49). Although studies suggest that exercise is good in pregnant women, in reality, compliance to diet, exercise, and medications is a major challenge to care in GDM patients, given one’s cultural habits. There is a need to increase awareness among patients on the importance of diet, exercise, and medication while educating them on myths and health facts (48, 49).

The lack of awareness on GDM among patients is a major hurdle to its successful management. Majority of patients know little about blood glucose monitoring and adherence to treatment. This affects the treatment process and benefits. The limited knowledge on dietary issues and disease management causes malnutrition for both the mother and the fetus due to poor glucose control (49). Therefore, it is vital to educate patients about the disease, its complications, management strategies, and the importance of adherence. Previous research also suggests that information is crucial for patient adherence to treatment and self-management of the disease (48). However, the sources of information must be reliable. At all times, health-care providers are the greatest source of valid, reliable, and comprehensive information on GDM and its management.

Although pregnant women try to meet their nutritional needs and are careful about their own health, they disregard the importance of medicine. Studies show that GDM patients often encountered fear and emotional disturbances when informed about the consequences of the disease (48, 49). So, educating them on the importance of medicine and adhering to dietary recommendations improves their medicine intake and makes them more likely to embrace a healthier routine (49, 50).

Adding to the disease burden, the costs associated with GDM management are a barrier for pregnant women seeking consultation with the doctor and antenatal care. In India, many patients do not have health insurance and everything is out of pocket for major health services during pregnancy. Equipment such as glucometers and related supplies, medications, and diet modifications cause financial burdens. Low income, limited availability of public health centers at close proximity, and periodic travel to hospital for follow-ups also add to the financial burden of pregnant women in rural areas. Thus, there is a need to increase access to health-care services to reduce GDM burden in India.

Some of the major challenges encountered in provider management were getting pregnant women to visit in a fasting state, getting blood samples, lack of trained phlebotomists, and standardized laboratories for blood glucose estimations, conflicting guidelines across practices and patient compliance (12). Screening should be made mandatory for all pregnant women due to the high prevalence of GDM among Indian women. The GDM status should be a part of a physician’s routine history assessment, irrespective of the pregnancy or parity, as GDM is a precursor for type 2 diabetes (51). Therefore, early screening and diagnosis can prevent obesity, impaired glucose tolerance, and diabetes in the progenies and mothers (52).

Most researchers shared the same opinion that GDM screening is widely deliberated, more specifically on selective versus universal screening, timing of testing, methods, and the diagnostic criteria. Some of the controversies surrounding this subject remain unresolved (53). First, getting a pregnant woman to undergo a GDM screening in a fasting state is challenging, particularly in a country like India. Second, multiple screening tests to diagnose GDM coupled with factors such as low awareness, less accessibility, and low affordability are a concern in resource-limited settings. Therefore, the World Health Organization 1999 criteria, which require only a single sample in comparison to the three samples required by the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria and four samples required by the Carpenter and Coustan criteria, became very popular in India initially (54). In 2014, the Ministry of Health and Family Welfare had developed technical and operational guidelines for identification and management of GDM in India. The national guidelines for diagnosis and management of GDM recommend a single-step procedure using 75 g oral glucose in a fasting or a non-fasting state and measuring plasma glucose 2 h postingestion (23). This one-step procedure to diagnose GDM is preferred as it is simple, economical, and feasible. Although the criteria for screening and diagnosis are established, uncertainty still exists on the execution methods.

Screening remains vital to prevent GDM-related complications during perinatal period and delivery. Evidence suggests that universal screening improves pregnancy outcomes compared to selective screening (55). Many guidelines recommend universal screening, while others exempt patients categorized as low-risk groups. Low-risk patients are younger than 25 years, have normal body weight, have no first-degree relatives with diabetes, show no history of abnormal glucose metabolism or poor obstetric outcomes, and are not from an ethnic group with a high diabetes prevalence (Hispanic American, Native American, Asian American, African American, and Pacific Islander) (56). Contrarily, a few researchers argue that selective screening based on the clinical characteristics of a pregnant woman facilitates efficient screening for GDM (57). The risk for GDM varies among different pregnant women based on marked obesity, previous history of GDM, glycosuria, or family history of diabetes. Nonetheless, all pregnant women should be screened for GDM during their first antenatal visit (51). Although few experts object to the screening of low-risk patients routinely, research suggests that non-screening omits approximately 4% patients with GDM (58). Universal screening for GDM detects more cases and improves maternal and neonatal prognosis compared to selective screening (59). The US Preventive Services Task Force (2014) also recommends that all asymptomatic pregnant women be screened for GDM after 24 weeks of gestation (53).

Many International medical associations like the American College of Obstetricians and Gynecologists, the American Endocrinology Society, the Canadian Diabetes Association, Australian Diabetes Association, and the Diabetes in Pregnancy Study Group of India also endorse that screening for GDM should be universal. Although certain organizations like the American Diabetes Association (ADA) and the National Institute for Health and Care Excellence recommend selective screening, even they agree that Asians, especially Indians, are a high-risk ethnic group (12). Therefore, Indian pregnant women should be universally screened at their first registration. The benefits of universal screening cannot be ignored in the long term given the high prevalence of GDM across India in spite of the increased screening costs for the government and individuals (51, 59).

Gestational diabetes mellitus patients ideally need counseling about the disease from the time of diagnosis. The education should cover recommended diet, exercise, treatment, self-care, and monitoring. There is also a need to train them efficiently to use monitoring equipment for self-management. The patients’ family members should also be educated on emotional and psychological support, the needs associated with GDM, and general pregnancy care. It is vital to highlight the importance of antenatal care and that GDM management requires a holistic support system. The first line of management for women with GDM is medical nutrition therapy (MNT) or dietary modification, followed by physical activity and monitoring of blood glucose levels. MNT reduces pregnancy and perinatal complications and brings glycemic control (8). A study by Jovanovic-Peterson et al. showed that exercise (arm ergometer training) coupled with dietary modifications improved glycemic control compared to dietary modifications alone (60). Home-based exercise training improved capillary glucose profile in women with gestational diabetes. A study by Halse et al. showed that home-based cycling is effective in maintaining daily postprandial normal glycemic levels in women with diet-controlled GDM. Further, the researchers noticed that the compliance to the supervised exercise training was good, and capillary glucose concentration reduced in response to each cycling session despite high consumption of dietary carbohydrates (61). Exercise proved to be beneficial in GDM patients, but there are no guidelines for the same until recently. In 2015, Padayachee and Coombes drafted the first guidelines on exercise for GDM management (62).

Further, in women prescribed with insulin, hospitalization proved to be effective in achieving treatment compliance to regulate glucose levels (48). Although it is not possible to hospitalize every GDM women to regulate glucose levels in resource-limited settings, it can be inferred that managing GDM requires a collaborative approach. Well-trained professionals play a crucial role in screening, diagnosis, and treatment. A team approach is ideal to manage women with GDM usually comprising an obstetrician, diabetologist/endocrinologist, health education provider, dietitian, and neonatologists/pediatrician (18).

Intensive monitoring, diet, and insulin are the cornerstones of GDM management. Until there is absolute evidence that ignoring maternal hyperglycemia is acceptable when the fetal growth patterns appear normal on the ultrasonogram, it is prudent to achieve and maintain normal glycemic levels in every pregnancy complicated by GDM. The maternal health and fetal outcome depend on the care by a committed team of health-care professionals. A short-term intensive care gives long-term benefits in preventing obesity, impaired glucose tolerance and diabetes in the offspring, as the preventive medicine starts before birth. The future solutions offered by physicians should focus on tangible and simple ways to better monitor patients and standardize care across practice.