Compliance to gestational diabetes mellitus screening guidelines among healthcare professionals in primary healthcare institutions in Oman

Background: In Oman, gestational diabetes mellitus is an increasingly common complication of pregnancy, with the prevalence estimated to have risen from 5.7% in 2013 to 18.3% in 2018. Gestational diabetes mellitus is associated with an increased risk of adverse perinatal outcomes such as macrosomia which is associated with birth trauma. Guidelines for the screening and diagnosis of gestational diabetes mellitus were available at all Omani healthcare institutions since 2010 and revised in 2015. This high prevalence of GDM suggested a need to explore the implementation of GDM screening guidelines in a primary healthcare setting in Oman and propose recommendations for increasing compliance. Method: This was a mixed-methods study, with two phases: Phase 1: A retrospective review of gestational diabetes mellitus screening in Oman, utilising routinely collected data (case records). The sample for this study comprised the records of all pregnant women who registered for ante-natal care at primary and secondary healthcare centres in Muscat in 2014. Phase 2: Face-to-face interviews with healthcare professionals working in two antenatal clinics in Muscat, to explore practice in screening and diagnosis of gestational diabetes mellitus in these two institutions. Also, to identify barriers and facilitators of compliance with GDM screening guidelines in these two primary healthcare centres. Results: The retrospective review of notes and records revealed poor compliance with gestational diabetes mellitus screening guidelines. A particular weakness was the lack of consistency with which an oral glucose challenge test and/or oral glucose tolerance test was offered to appropriate women. All women underwent a random blood sugar test when registering their pregnancy, and the guideline determined the screening pathway women with a normal or abnormal result should follow. A proportion of women, who before registration had a normal), or abnormally high glucose results were not subsequently offered the appropriate screening(28.1% and (25.6%) respectively. Of 942 women who completed a random blood sugar test before registration at the antenatal clinic, 91.3% (n = 860) had a normal result and 8.7% (n = 82) had abnormally high blood glucose. Amongst the 860 women with a normal screening result at registration, only 28.9% (n = 248) received follow-up screening in line with the guidelines using the oral glucose challenge test. 51.6% (n = 444) were administered an oral glucose tolerance test. Ten face-to-face interviews were conducted to explore barriers faced by healthcare professionals in two primary healthcare institutions when implementing the screening guidance. Thematic analysis indicated three themes. These were: organisational barriers; poor inter-professional communication that were evident in both clinics, and confusion and lack of understanding that was evident in one clinic. These barriers presented challenges to the accurate implementation of the gestational diabetes mellitus guidelines. However, facilitators were also evident, including utilisation of the available resources, working experiences, and professional teamwork. Study Outcomes and Impact: The study has made a unique contribution to the body of knowledge on how to best utilise the facilitators available within the healthcare system to improve the implementation of GDM screening in Oman. This study found a discrepancy in the implementation of GDM guidelines between two PHC institutions in Muscat. There is a lack of clarity around the job descriptions of nurses and midwives, the consequences of staff rotation within different clinics in the health centre that has a direct effect on the continuity of care provided for pregnant women. There is the potential for improving compliance with GDM guidelines implementation by HCPs if they are provided with a clear interpretation of these same guidelines. This thesis offers recommendations to improve the gestational diabetes mellitus screening services for pregnant women in Oman. Improved implementation of the guidelines may be achieved by encouraging life-long learning training and keeping healthcare professionals up-to-date with current trends in screening for gestational diabetes mellitus, monitoring, and evaluation