In this study a number of barriers to improving maternal health related to GDM were identified, including lack of trained health care providers - especially female doctors; staff turnover and lack of standard protocols, consumables and equipment; financing of health services and treatment; lack of or poor referral systems, feedback mechanisms and follow-up systems; distance to health facility; perceptions of female body size and weight gain/loss in relation to pregnancy; practices related to pregnant women’s diet; societal negligence of women’s health; lack of decision-making power among women regarding their own health; stigmatisation; role of women in society and expectations that the pregnant woman move to her maternal home for delivery.
According to our knowledge only a few studies have previously investigated barriers to management or postpartum follow-up of women with diabetes during pregnancy [28–32], and none of these are from LMIC. Although these studies were conducted in a setting very different from our study there are certain similarities between the findings of these studies and ours. Hence, Bennet et al., Collier et al., Mersereau et al. and Razee et al. reported lack of concern about women’s health – either because they feel healthy or because they have less time for self-care due to the demands of the baby or other responsibilities – as a barrier to GDM management or postpartum follow-up [28–31]. Fear of being diagnosed with overt diabetes was also identified by Bennet et al. as a barrier, although the reason behind this fear was not grounded in fear of stigmatisation, but more the prospect of having to follow a strict diet and regularly having to attend medical check-ups . Collier et al. also identified cost of health services, diabetic supplies and healthy foods as barriers . Finally, difficulties in accessing care and cultural issues impeding healthy diet and physical exercise were also identified by Razee et al., Mersereau et al. and Collier et al. as barriers to GDM management [29–31].
Considering that WHO in the 2006 World Health Report concluded that there is a global shortage of almost 4.3 million doctors, nurses, midwives and support workers  it is not surprising that turnover and lack of trained health care providers is mentioned as a barrier for GDM services. Seven of the projects included in this study are implemented in countries where WHO assess there is a critical shortage of health service providers . India is one of these countries and as only around 10% of doctors in South-East Asia are women  it is not surprising that respondents from India noted lack of female doctors as a particular problem.
However, as indicated by the respondents it is not only a problem of numbers it is also a problem of skills and training. Lack of knowledge has also been found to be a problem for the management of type 2 diabetes in LMIC [33, 34]. Thus, to ensure that women with GDM receive proper treatment, training of health care providers need to be initiated or scaled up. Lack of standard protocols on GDM diagnosis and management was also identified as a barrier to early detection and proper management of GDM. The lack of such protocols may reflect the limited attention that GDM has received in many LMIC, the lack of international consensus on the diagnostic criteria for GDM as well as existing protocols in their current form not being feasible to implement in many LMIC .
In addition, findings from this study also illustrate that health services and systems are disorganised and inadequately financed and can work as barriers for achieving specific health-related outcomes, in this case GDM detection and treatment. This is far from new, but health system planners and policy-makers should take these structures and aspects into account when initiating GDM services.
A substantial number of the barriers are societal or culture-related e.g. expectations that the woman transfers to her maternal home to deliver. While their relevance may vary, such barriers remain important according to our findings. Yet, they are largely beyond the realm of the health sector and therefore have to be addressed outside it through awareness and policies. Issues related to women’s role in society and how much emphasis is given to their health and well-being seems to be of particular concern and the findings from this study indicate that much still remains to be done to ensure women’s empowerment including the right to control all aspects of their health as stated in the Beijing Declaration adopted at the UN Fourth World Conference on Women in 1995 .
Finally, in this study all participants were WDF project partners and many of them are also practicing health care providers. In order to further illuminate the issue it would be important to undertake studies where women and their families are interviewed about barriers and facilitators for GDM services. Such a study should also focus on barriers within the control of the individual in addition to health system and societal/cultural barriers.