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Background: Gestational diabetes mellitus (GDM) is associated with an increased risk for a future type 2 diabetes mellitus in women and their children. As linkage between maternal health and non-communicable diseases, antenatal care plays a key role in the primary and secondary prevention of GDM associated adverse outcomes. While implementing a locally adapted GDM screening and management approach through antenatal care services at the primary level of care, we assessed its acceptability by the implementing health care providers. Methods: As part of a larger implementation effectiveness study assessing a decentralized gestational diabetes screening and management approach in the prefecture of Marrakech and the rural district of Al Haouz in Morocco, we conducted four focus group discussions with 29 primary health care providers and seven in-depth interviews with national and regional key informants. After transcription of data, we thematically analyzed the data using a combined deductive and inductive approach. Results: The intervention of screening and managing women with gestational diabetes added value to existing antenatal care services but presented an additional workload for first line health care providers. An existing lack of knowledge about gestational diabetes in the community and among private health care physicians required of public providers to spend more time on counselling women. Nurses had to adapt recommendations on diet to the socio-economic context of patients. Despite the additional task, especially nurses and midwives felt motivated by their gained capacity to detect and manage gestational diabetes, and to take decisions on treatment and follow-up. Conclusions: Detection and initial management of gestational diabetes is an acceptable strategy to extend the antenatal care service offer in Morocco and to facilitate service access for affected pregnant women. Despite its additional workload, gestational diabetes management can contribute to the professional motivation of primary level health care providers. Trial registration: clinicaltrials.gov; NCT02979756.
Between November 2016 and November 2017, we conducted a hybrid effectiveness-implementation trial to assess the clinical effectiveness of a GDM screening and management intervention and its implementation through first level health care providers [8]. Hybrid designs blend different research approaches and focus on the translation of research findings into clinical practice [14]. While GDM screening and management in the study intervention facilities followed clear algorithms based on the IADPSG/WHO criteria [15–17], national guidelines were applied in the control facilities. To explore opportunities and challenges of GDM testing and initial management through the primary level of care in Morocco and thus assess the feasibility of such an intervention, we conducted interviews and discussions with providers of the study facilities and with key informants. The study was carried out in 20 randomly selected PHC facilities from a list of health facilities in the districts providing at least 30 ANC consultations each month. Ten health centers were located in the district of Marrakech, a predominantly urban area and ten facilities were located in the neighboring district Al Haouz, which is mainly rural and mountainous. Both districts are part of the wider region of Marrakech-Safi and comprise of a total population of 1.9 million with 92 health centers and 53 dispensaries providing PHC services to the population [18]. The study facilities were equally distributed into urban/peri-urban and rural health centers. Although the service package offered in the public health centers did not differ between urban and rural locations, access to some of the rural sites was geographically limited. Between January and March 2017, we conducted four focus group discussions (FGD) with the health care providers in charge of ANC and GDM screening in all selected study health centers. Both ANC providers trained in GDM screening and management from the intervention sites were invited, while two providers in charge of the ANC services from each control health center attended. Overall, 15 providers from the ten intervention health centers and 14 providers from the nine control facilities took part in the FGDs. Each FGD was conducted with between five to nine participants and separate focus groups were led with providers from control and intervention sites in both study districts. In addition, we did seven interviews with key informants including clinicians involved in diabetes care (2) as well as program managers (public health/ maternal health/ NCDs) on national (2) and regional/district level (3). FGDs took place in a quiet room at the district/provincial directorates and were led by an experienced female moderator (BU, BA) and a research assistant taking notes. Interviews with key informants were conducted at the offices of the interviewees by BU and BA. Pre-tested topic guides were used to explore opportunities and challenges for GDM screening and management, and to assess perceptions about the feasibility of such an intervention as part of the existing service package at the primary level of care. Topics selected for discussion included the role of antenatal care to screen for GDM, providers views and their experience with women’s attitudes towards detection and management of GDM, the influence of such a GDM activity on their work and the role of communication with other actors. The topics for the questions were derived from the challenges identified by providers during a situational analysis conducted prior to this trial [13]. Mean interview duration was 39 min (min 17; max 80) and FGDs lasted on average 95 min (min 80; max 100). Before each interview and FGD, participants were requested to read the provided information letter and give their written informed consent. All interviews and discussions were conducted in French, digitally recorded and later transcribed ad verbatim. If some respondents switched during the interviews into Arabic, the bilingual transcriber, a qualified translator, translated these passages into French. The correctness of the transcription was cross-checked by BA on a sample of transcripts. All French transcripts were transferred into NVIVO software version 10. The authors who conducted the interviews also analyzed the data. After repeatedly reading all interview transcripts and to familiarize with the data, information was subsequently arranged into codes. Coding was done in a combined inductive and deductive approach, with the deductive coding oriented at the interview topic guide, while open coding was used for new emerging codes in an inductive way. Codes were then grouped into categories and overarching themes. Coding of all scripts was done by one researcher (BU), with intermittent cross-checking of scripts by BA. Categories and emerging themes were discussed by the two researchers involved in data analysis (BU and BA). Translation of the quotes, codes and categories from French into English took place after all data was analyzed (BU). Without summarizing or removing content, data was translated word by word, while assuring its original meaning. If translation revealed several options, the most suitable meaning was validated by the second researcher who was not directly involved in data collection nor analysis (VDB). Both researchers involved in translation are bilingual and have extensive contextual experience in Morocco.
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