A Study on Knowledge, Attitude and Practice Regarding Gestational Diabetes Mellitus (GDM) and Its Control with Medical Nutritional Therapy among Antenatal Patients in a Tertiary Care Hospital in a Semi Urban Area

Introduction: Gestational diabetes mellitus is a condition in pregnancy which can cause foetal and maternal complications. After delivery the newborn may have life threatening metabolic complications and later in life may suffer from obesity, glucose intolerance and Diabetes in early adulthood. The mother might also be at the risk of developing type-2 diabetes mellitus. So, the knowledge among the antenatal women will result in disease prevention and early detection. Aim and Objective: The present study was aimed to assess the knowledge, attitude and practice regarding Gestational Diabetes Mellitus (GDM) and its control with medical nutritional therapy among antenatal patients in a tertiary care hospital in semi urban area. Materials and methods: A cross-sectional study was conducted in Saveetha Medical College and hospital, Chennai, with a participation of 190antenatal patients attending the hospital for regular antenatal check up and admission for delivery. The study was conducted between the months of January and June of 2021. Original Research Article Shafaiyaz and Rohini; JPRI, 33(47B): 497-505, 2021; Article no.JPRI.75018 498 Results: In total of 190 study participants, 38(20%) participants acquired the knowledge about Gestational Diabetes Mellitus from family, 73(38.42%) participants acquired from friends, 47(24.73%) participants acquired from medical professionals and 32(16.85%) participants from neighbour. Conclusion: There was a paucity of knowledge among pregnant women about GDM and its complications. Attitude and practices of antenatal women should be improved through various programs and channels for better antenatal outcomes.


INTRODUCTION
Pregnancy is a distinctive, thrilling and often cheerful moment in a woman's life as it creates a bond between women and her unborn baby during her transition towards motherhood. At the same time, it is also a critical period in which a proper care and attention is needed for ensuring the health of the mother and the baby which is influenced greatly by that of maternal nutrition. Along with all the worries and obstacle faced during pregnancy, Gestational Diabetes Mellitus (GDM) is one of the most serious complications which are due to some abnormal metabolic activities occurring in pregnant women. Gestational Diabetes Mellitus is defined as "glucose intolerance that is detected during pregnancy" [1] or "carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first acknowledgment in the course of pregnancy" [2].
Moreover, the prevalence of GDM has increased among various race and ethnicity in just past 20 years [3]. The prevalence of Gestational Diabetes Mellitus in southern India was 17.8% in urban, 13.8% in semi-urban and 9.9% in rural areas [4]. A good knowledge of GDM will play a major role in preventing the complications. Though the mother's glucose levels return to normal after birth, the mother is at a high risk for development of Type 2 diabetes mellitus, and the child of a woman with GDM is also at risk for manifesting metabolic syndromes [5]. So a well informed patient, by proper management of her diet and by adhering to the medical management as advised by her physician, will have good pregnancy outcome for herself and her baby. As the antenatal period is a perfect opportunity for detecting and preventing complications of GDM, two generations can be protected from adverse effects of diabetes mellitus. Many patients are unaware of the conditions of GDM.
Even after diagnosis, they are unaware of the importance of adhering to strict diet and medication and present late in pregnancy with complications. In the view of the above, this study is aimed to assess the knowledge, attitude and practice regarding Gestational Diabetes Mellitus (GDM) and its control with medical nutritional therapy among antenatal patients in a tertiary care hospital in semi urban area.

METHODOLOGY
The present cross-sectional study was conducted in Saveetha Medical College and hospital, Chennai with aim to assess the knowledge, attitude and practice regarding Gestational Diabetes Mellitus and its control among antenatal patients in semi urban area. The required Sample size was calculated using formula, N=4pq/L2 where p was 13.8% (based on the study previously done in Chennai by V Seshiah et al. [4] with allowable error of L = 5% and the total sample size required was rounded off to 190. The antenatal patients attending the hospital for regular antenatal check-up were included in this study. In this study, convenient sampling method was used for selecting the study participants. A pretested semi-structural questionnaire was prepared which included socio-demographic information and specific question with the aim to assess the knowledge, attitude and practice regarding Gestational Diabetes Mellitus and its control among antenatal patients. The questionnaire was validated by esteemed professionals. The purpose of the study was explained to the participants, and they were given the prepared questionnaires to fill out. The questionnaire contained four sections with section-A comprising the information regarding the sociodemographic details, section-B contained the questions regarding knowledge on GDM, section-C comprised of questions regarding attitude towards GDM and section-D the questions regarding the practice to control GDM during pregnancy. After obtaining the data, it was entered in the excel spreadsheet and was analyzed using SPSS software version 16 and statistical analysis was done using Chi square test and frequencies and percentages were obtained.

RESULTS
In total, 190 antenatal patients were studied which comprised of subjects in various reproductive age groups. The socio demographic details of the antenatal patients have been listed below in Table 1.
From the data collected, 57(30%) subjects had heard about Gestational Diabetes Mellitus where as remaining 133(70%) pregnant women said they do not know about the condition. To the question, "From where did you get to know about Gestational Diabetes Mellitus?" the responses are accordingly depicted in Fig. 1.
Various other questions related to the level of knowledge of the participants regarding GDM are discussed in Table 2.  Table 3.
Similarly, 103(54.21%) subjects agreed that physical exercise during pregnancies is healthy whereas 87(45.79) subjects did not. 84(44.21%) participants among the total 190 of the study population said that they follow a specific dietary regimen during pregnancy whereas 106(55.79%) participants did not. When asked "how do you take your meals?" the responses are accordingly depicted in Fig. 3.
Questions asked to the participants in relation to the practices regarding GDM and its control during pregnancy are discussed below in Table 4.
Three association tables were constructed by ascertain the significance of certain factors associated with knowledge about Gestational Diabetes Mellitus, screening for GDM, following specific dietary regimens during pregnancy using Chi-square test, P-values less than 0.05 were taken as significant and values less than that of 0.0001 were taken as highly significant, these factors have been listed below in Table 5, Table  6 and Table 7.
When asked on how often they would visit hospital for fasting and post-prandial blood sugar testing, 43(22.63%) antenatal patients answered that they would visit once every week, 41(23.69%) antenatal patients would visit once every 2 weeks, and 51 (26.84%) antenatal patients would visit once a month and the remaining told they did not know.

DISCUSSION
In the current study which was performed among 190 antenatal mothers, it was found that only 30% of the subjects had good knowledge about GDM. 54.21% of the subjects had positive attitude towards screening for GDM and 44.21% of the subjects practice a specific dietary regimen during pregnancy. A similar study done in Iran, found a significantly higher knowledge and attitude towards Gestational Diabetes Mellitus [6], whereas the study done in Egypt found that only 18.9% have a practice of following a specific dietary regimen [7].
Our study was found to have a significant correlation (p=0.0114) between pregnant women and their lack of knowledge regarding GDM. Main source of knowledge for the antenatal mothers were from friends (38.42%), from the medical professionals (24.73%), family (20%) and from the neighbours (16.85%). Similar study was conducted in among antenatal mothers attending the primary health center (PHC) in the southern part of India where it was found that major sources of knowledge on GDM were from television/radio (40%), neighbours/friends (34.2%), and family members (29.2%) while doctors (13.3%), health-care workers (20.8%), or hospital charts/boards (18.3%) were less common sources [8].
Many antenatal mothers (54.21%) in our study accepted that all pregnancies should be screened on routine basis for GDM. A similar study in Vietnam also reveals that majority of the women went to hospital regularly to screen for GDM [9]. This regular screening for GDM by monitoring the fasting and post-prandial blood glucose levels has been associated with a reduction in rates of neonatal macrosomia [10].
Majority of the participants (55.79%) in this study did not follow a specific dietary regimen during their antenatal period and few among the antenatal mothers (28.94%) take their nutrition when they feel hungry. This was statistically significant (p=0.017).Antenatal mothers tend to ingest high-carbohydrate diet in the later stages of pregnancy which might increase the risk of Gestational Diabetes Mellitus. Thus there is a discrepancy in the attitude towards GDM and practice women follow. Even though majority gave importance to screening of GDM, most of them didn't have in-depth knowledge about the condition. As far as sticking to dietary regimen goes, majority of women in pregnancy do not follow healthy dietary modification.
The results of few studies on effects of dietary modification indicate a good dietary compliance even up to 77.6% [11,12]. A meta-analysis revealed that dietary intervention given throughout pregnancy along with physical activity tends to be more effective than following physical activity alone [13].
From the knowledge, attitude and practice of participants towards GDM and its control, it is evident that the antenatal mothers of this region lack knowledge and attitude towards GDM and they should be educated properly in order to have a better practices which in turn results in delivery of a healthy baby.

CONCLUSION
This study about the status of knowledge, attitude and practices towards GDM was revealed knowledge was insufficient among the participants. This might have an adverse effect on maternal and foetal well being. Education of antenatal women supporting the welfare of baby and the mother should be provided at all levels of Reproductive Health Program. There is a need to improve the antenatal patient's knowledge on GDM. If knowledge about GDM increases among pregnant women they may be motivated to have an attitudinal change resulting in better practices like compliance for management protocols including dietary modifications, not defaulting on medications and getting regular follow-up. This may result in improved pregnancy outcomes.

CONSENT
The consent of the antenatal participants was taken and confidentiality was ensured.

ETHICAL APPROVAL
Ethics clearance from the Institutional Ethics Committee (IEC) was applied for and sanctioned.