This cross-sectional study was conducted to explore factors impacting diabetes management during and after Ramadan among Saudi pregnant women in the Aseer region. The study employed a descriptive correlational and analytic design to examine the relationships between diabetes self-efficacy, self-management behaviors, and self-care activities in this specific population during the holy month of Ramadan.

The target population consisted of pregnant women diagnosed with diabetes (gestational diabetes mellitus or pre-existing diabetes) residing in the Aseer region of Saudi Arabia. Participants were recruited from the Tertiary hospital “Abha Maternity Hospital,” a specialized hospital in Gynecology in the Aseer region, during the 2025 Ramadan period and continued until May 2025.

Pregnant women aged 18 years and above, diagnosed with gestational diabetes mellitus or pre-existing diabetes, residents of Saudi Arabia, able to read and understand Arabic, and willing to provide informed consent to participate during and after Ramadan, were included in the study.

Pregnant women with severe pregnancy complications, those with cognitive impairments that would prevent completion of questionnaires, non-Saudi participants, and those who refused to participate in the study and did not complete the participation before and after Ramadan, were excluded.

The sample size was calculated using Medcalc 15.8. The primary outcome of interest is the percentage of DM in pregnant women in Saudi Arabia. A meta-analysis of gestational diabetes mellitus in the Eastern Mediterranean region revealed that the prevalence of gestational diabetes mellitus in Saudi Arabia was 11.7% (8). Based on this study, with an alpha error of 5%, study power of 80, and 5% precision with a design effect of 1. The calculated sample size is 162 participants.

Data collection was conducted using structured self-administered questionnaires. The data collection period was during and after Ramadan till May 2025 to capture experiences both during and after Ramadan. Participants were recruited as they presented to maternal health clinics for routine prenatal appointments. Upon arrival at the clinic, potential participants were identified by healthcare staff based on the inclusion criteria. Research assistants approached eligible pregnant women in the waiting areas and provided them with detailed information about the study objectives, procedures, and their rights as participants.

After explaining the study purpose and addressing any questions or concerns, written informed consent was obtained from all participants who agreed to participate. The consent process ensured that participants fully understood their voluntary participation, the right to withdraw at any time, and the confidentiality measures in place to protect their personal information.

During the initial visit, a follow-up appointment was scheduled with each participant to complete the post-Ramadan assessment. Participants were contacted 3–5 weeks after the conclusion of Ramadan to arrange the follow-up data collection session. The follow-up assessment involved re-administration of the same instruments to evaluate any changes in diabetes self-efficacy and self-care activities following the Ramadan period.

Pre-Ramadan medical education was delivered through structured group classes (60–90 min) combined with brief individual counseling sessions (20–30 min). The group sessions, conducted by certified diabetes educators and obstetricians, covered four key domains: (1) safe fasting practices, including recognition of warning signs; (2) self-monitoring of blood glucose with demonstration devices; (3) management of acute complications like hypoglycemia; and (4) tailored nutritional guidance for pregnancy. Individual sessions focused on medication adjustments and personalized risk assessment. All participants received standardized take-home materials (illustrated booklets and glucose logs) to reinforce learning. While the core curriculum was consistent across clinics, minor variations in delivery style occurred based on available staff and resources.

Ethical approval for this study was granted by the Research Ethics Committee at King Khalid University (Approval No. ECM#2024–1,105; HAPO-06-B-001). All participants provided written informed consent after receiving comprehensive information about the study’s objectives, procedures, potential risks, and benefits. Participation was entirely voluntary, with the right to withdraw at any time without penalty. Data confidentiality and participant anonymity were strictly maintained throughout the study.

Data were analyzed using RStudio and Python programming languages to ensure a comprehensive statistical evaluation. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were calculated to describe participant characteristics and study variables at baseline during the Ramadan period and after. Given the paired nature of the data collected before and after Ramadan from the same participants, paired sample analyses were employed to examine changes in diabetes self-efficacy, self-management behaviors, and self-care activities. Paired sample t-tests were conducted to compare mean scores of continuous variables between the pre-Ramadan and post-Ramadan assessments. The normality of data distribution was assessed using the Shapiro–Wilk test, and when assumptions for parametric tests were not met, the Wilcoxon signed-rank test was used as a non-parametric alternative for paired comparisons.

Pearson correlation coefficients were calculated to examine relationships between continuous variables within each period, while Spearman’s rank correlation was used for non-normally distributed data. Missing data patterns were analyzed, and appropriate methods, listwise deletion, were applied based on the missing data mechanism. Statistical significance was set at p < 0.05 for all analyses. Confidence intervals were calculated at the 95% level to provide additional information about the precision of estimates.

A total of 162 pregnant women with diabetes participated in the study (Table 1). The average age of participants was 34 years (SD = 6). Most women had completed at least secondary education (66.7%), with a smaller proportion having higher education (9.3%) or no formal education (1.9%). Over half of the participants were homemakers (53.7%), followed by full-time employees (31.5%). The vast majority resided in urban areas (88.3%). Regarding pregnancy order, approximately 28% were experiencing their first pregnancy, while 14.2% had more than five previous pregnancies. Most participants received antenatal care from government health centers (61.7%), while 20.4% attended governmental maternity hospitals and 17.9% visited private clinics. A notable majority had no history of diabetes prior to pregnancy (71.6%), though 87% were diagnosed with diabetes either during the current or previous pregnancies.

Self-efficacy scores remained relatively stable during and after Ramadan, with a mean of 4.8 (SD = 2.2) during Ramadan and 4.9 (SD = 2.1) post-Ramadan (Table 2). This slight increase was not statistically significant (p = 0.2). In contrast, self-care activity scores decreased significantly after Ramadan, dropping from 32.5 (SD = 18.1) during Ramadan to 29.8 (SD = 17.2) post-Ramadan (mean change = −2.7, p = 0.001).

Figure 1 illustrates the distribution of participants’ last measured HbA1c levels during and after Ramadan. The most common HbA1c category was 6.5–7.9% in both periods, reported by 44 participants during Ramadan and 46 after. There was a slight decrease in the number of participants with HbA1c < 5.7% after Ramadan (from 17 to 9) and a slight increase in those within the 5.7–6.4% category (from 4 to 10). The number of participants with HbA1c > 8% remained unchanged (n = 19) in both periods. Notably, a substantial portion of the sample (n = 78) did not measure their HbA1c levels.

Figure 2 shows the distribution of diabetes management strategies used by participants during Ramadan. The most frequently reported method was a combination of oral drugs, diet, and exercise, used by 42% of participants. This was followed by insulin-only management (19.8%) and insulin combined with diet and exercise (12.3%). Smaller proportions reported using only diet and exercise (7.4%) or no specific treatment (7.4%). Other less common regimens included insulin with oral drugs and lifestyle modifications (4.3%), insulin with oral drugs only (3.7%), and oral drugs only (3.1%).

Women who received medical education about diabetes before Ramadan demonstrated significantly higher self-care activity scores (35.4 vs. 17.8, p < 0.001), although no significant difference in self-efficacy was observed (p = 0.60) (Table 3). Participants who prepared for Ramadan by fasting in advance reported significantly higher self-efficacy scores (6.2 vs. 4.5, p = 0.001), suggesting that proactive fasting preparation may boost confidence in managing diabetes. However, self-care scores did not differ significantly between those who prepared and those who did not (p = 0.44). Those who were advised not to fast had significantly lower self-efficacy scores (4.3 vs. 5.2, p = 0.012), although their self-care activity scores were not significantly different (p = 0.3).

There were no significant differences in the frequency of daily blood glucose monitoring before and after Ramadan (p = 0.8) (Table 4). Most participants monitored their blood sugar levels three to four times per day, with 22.2% checking three times and 40.7% checking four times during Ramadan, and 20.4 and 42.6% doing so after Ramadan, respectively. However, perceived glycemic control showed significant improvement after Ramadan. The proportion of participants reporting difficulty in controlling their blood sugar decreased from 72.8% during Ramadan to 65.4% post-Ramadan (p = 0.001). Additionally, fewer women reported a change in their ability to manage blood glucose after Ramadan (41.4%) compared to during Ramadan (51.2%), reflecting greater stability in glycemic control (p = 0.020).

Figure 3 presents the self-reported reasons for breaking the fast among pregnant women with diabetes during Ramadan. The most commonly cited reason was categorized as “other reasons,” accounting for 45.7% of responses. Hypoglycemia (low blood sugar) was the second most frequent cause, reported by 26.5% of participants, followed by hyperglycaemia (high blood sugar) at 22.2%. Weakness or fatigue was the least reported reason, noted by only 5.6% of the women.

A bivariate correlation analysis revealed several significant associations among key variables influencing diabetes management during and after Ramadan among pregnant women (Figure 4). Age showed a moderate negative correlation with both self-efficacy scores (r = −0.268, p < 0.01) and self-care activities (r = −0.469, p < 0.001), indicating that older participants tended to have lower scores in both domains. Self-efficacy was positively associated with self-care activities (r = 0.517, p < 0.001) but negatively correlated with order of pregnancy (r = −0.600, p < 0.001), suggesting diminishing confidence with higher parity. Self-care activities were also positively related to receiving medical education (r = 0.359, p < 0.001) and perceived health status (r = 0.395, p < 0.001). Difficulty in controlling diabetes was positively correlated with breaking the fast due to health issues (r = 0.471, p < 0.001) and receiving prior medical education (r = 0.376, p < 0.001), while it was negatively associated with self-efficacy (r = −0.366, p < 0.001) and trial fasting before Ramadan (r = −0.388, p < 0.001). These findings underscore the multifaceted influence of education, self-perception, and previous experience on glycemic control and fasting behaviors.

This study has several limitations. The sample size was relatively small, particularly for pregnant participants, which may limit the generalizability of findings. Self-reported data on glycemic control and fasting behavior may be subject to recall bias or social desirability bias. Additionally, the lack of continuous glucose monitoring limited the ability to capture real-time fluctuations in blood glucose. Post-Ramadan follow-up was incomplete for a significant portion of participants, affecting the assessment of long-term outcomes. Cultural and healthcare system differences between regions may also influence results, and findings may not be universally applicable without considering local practices and healthcare access. A notable proportion of participants (n = 78) did not complete HbA1c testing during or after Ramadan, which may limit the generalizability of glycemic control findings. While reminders were provided, barriers such as logistical challenges (e.g., travel to testing facilities), financial constraints, or perceived stability of glucose levels may have contributed to non-compliance. This highlights a potential gap in real-world adherence to monitoring protocols among pregnant women with diabetes, particularly in such settings. Future studies could mitigate this by incorporating point-of-care HbA1c testing during clinic visits or using telehealth follow-ups to improve accessibility. While our findings demonstrate a positive association between medical education and improved outcomes, we recognize the potential for self-selection bias. Participants who actively sought or were more receptive to diabetes education may have been inherently more motivated to engage in self-care behaviors, which could have influenced their outcomes independently of the educational intervention.