Positioning gestational diabetes in low resource settings: from fragmentation towards integration

The purpose of this PhD was to illuminate the situation of gestational diabetes mellitus (GDM) in low resource settings and to propose specific solutions using Morocco as a case country. By applying a sequential approach to the topic, theoretical knowledge about the situation of GDM screening and management was gathered through a guideline review, a scoping review of the literature and a survey of providers in settings with limited resources. In a second step, a new model of integrating GDM into the existing maternal health care package through the primary level of care in Morocco was piloted. Following a situation analysis in two districts, we conducted from November 2016 to November 2017 a hybrid effectiveness-implementation study using a cluster-randomized controlled trial supported by a qualitative strand. Findings revealed that the intervention had a protective impact on the incidence of macrosomia. With a GDM prevalence of 23.7% in an urban and 18.3% in a rural setting, gestational diabetes presents an important health problem for pregnant women in Morocco. The intervention not only added value to existing antenatal care services but also increased the motivation of health care providers. Based on the findings of this research, it can be concluded that GDM screening and management of uncomplicated cases through the primary level of care can serve as a link between maternal health care and non-communicable diseases and thus reduce fragmentation while presenting a unique opportunity for a better continuity in care for GDM affected pregnant women and their children.