ANALISA JURNAL EBN (Evidence Based Nursing)

NUTRISI ENTERAL YANG TEPAT TERHADAP PASIEN STROKE

DENGAN DISFAGIA

Proposal Ini Disusun Untuk Memenuhi Tugas

Keperawatan Medikal Bedah Program S1 Keperawatan

Disusun Oleh:
Tiara Maghfiratin Jannah
11212139

PROGRAM STUDI S1 KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN PERTAMEDIKA
2018
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Puji syukur penulis panjatkan kehadirat Allah

SWT yang telah melimpahkan rahmat dan Hidayah-
Nya, salam kepada Nabi Muhammad SAW, sehingga
penulis dapat menyelesaikan Laporan dengan judul
“EBN SISTEM ENDOKRIN”.
Makalah ini disusun untuk memenuhi tugas
mata kuliah disusun untuk memenuhi tugas mata
kuliah Evidance Based Nursing (EBN) Magister
Terapan Keperawatan. Dalam pembelajaran dan
penyusunan makalah, kami banyak mendapatkan
bimbingan, arahan, dan dukungan dari berbagai
pihak.
Banyak literature yang membahas teori dan
penerapan dari sistem farmakologi dan telah kami
klasifikasikan sesuai perkembangan yang ada, baik
dari penerapan dan capaian yang telah teraplikasi
dalam dunia keperawatan, khususnya di lapangan.
Kemudian kami coba untuk menelaah dan menarik
kesimpulan serta saran dari pembahasan yang ada.
Namun kami merasa masih ada kekurangan sehingga
kritik dan saran sangat diharapkan.

Kamis, 4
Oktober 2021

Penulis
 DAFTAR ISI
HALAMAN JUDUL ..................................................................................... i
KATA PENGANTAR ................................................................................... ii
DAFTAR ISI .................................................................................................. iii
BAB I PENDAHULUAN .............................................................................. 1
1.1 Latar Belakang ........................................................................................ 1
1.2 Tujuan ...................................................................................................... 2
1.3 Mnafaat ................................................................................................... 2
BAB II PEMBAHASAN ............................................................................... 3
A. Jurnal Utama ........................................................................................... 3
1. Judul Jurnal ..................................................................................... 3
2. Peneliti ............................................................................................ 3
3. Populasi, Sample dan Teknik Sampling ......................................... 3
4. Desain Penelitian ............................................................................ 3
5. Insrtrumen Penelitian ...................................................................... 3
6. Uj Sstatistik ..................................................................................... 3
B. Jurnal pendukung ................................................................................... 4
C. Analisa PICO ........................................................................................... 4
BAB III Tinjauan Teoritis ............................................................................ 7
BAB IV Telaah Jurnal .................................................................................. 10
BAB V Analisa SWOT .................................................................................. 12
BAB VI Penutup ............................................................................................ 13
A. Kesimpulan ............................................................................................... 13
B. Saran .......................................................................................................... 13
DAFTAR PUSTAKA .................................................................................... 14
LAMPIRAN ................................................................................................... 15

ii
 BAB I
PENDAHULUA
N

1.1. Latar Belakang

Diabetes Melitus Gestational adalah salah satu jenis DM yang terjadi
pada ibu hamil sebagai derajat apapun intoleransi glukosa dengan onset atau
pengakuan pertma selama kehamilan (WHO 2013).
Diabetes melitus gestasional (GDM) didefinisikan sebagai derajat
intoleransi glukosa yang diamati pada awal, atau pertama kali diketahui
selama kehamilan. Prevalensi GDM diperkirakan sekitar 15% secara global
dan diperkirakan akan meningkat karena meningkatnya jumlah kelebihan
berat badan dan obesitas pada wanita di usia reproduksi mereka. Manajemen
keperawatan GDM dalam hal modifikasi gaya hidup (olahraga, diet dan
nutrisi) dan minum obat diabetes, jika diperlukan, dan kepatuhan
terhadapnya sangat penting untuk mencegah komplikasi ibu dan neonatal-
perinatal. Oleh karena itu penelitian kualitatif ini bertujuan untuk
mengeksplorasi dan menggambarkan pengalaman wanita mengenai
manajemen keperawatan yang mereka terima setelah didiagnosis dengan
GDM; dan persepsi bidan perawat tentang manajemen keperawatan GDM
mereka di Ghana.
Berdasarkan fenomena yang terjadi menurut American Diabetes
Association memprediksi, ada sekitar 7% kehamilan yang dipersulit karena
GDM. Di dunia, kasus diabetes gestasional telah mencapai 200ribu setiap
tahunnya. Dan penelitian yang dilakukan oleh McDonald, Karahalios, Le
dan Said (2015) menyatakan bahwa suku bangsa mempunyai hubungan
dengan kejadian DM Gestasional, wanita asia lebih berisiko terkena DM
Gestasional daripada wanita Eropa. 1,9-3,6% ibu hamil di Indonesia
mengalami diabetes gestasional.
Penelitian ini dilakukan di institusi kesehatan militer di Ghana, yang
mencakup satu rumah sakit dan sembilan klinik satelit yang disebut sebagai

1
Stasiun Penerimaan Medis yang menyediakan perawatan antenatal dan

2
 postnatal untuk pasien militer maupun sipil. Penelitian tentang GDM di
Ghana sangat terbatas.
Penggunaan evidence based dalam praktek akan menjadi dasar scientific
dalam pengambilan keputusan klinis sehingga intervensi yang diberikan
dapat dipertanggungjawabkan. Sayangnya pendekatan evidence base di
Indonesia belum berkembang termasuk penggunaan hasil riset ke dalam
praktek. Tidak dapat dipungkiri bahwa riset di Indonesia hanya untuk
kebutuhan penyelesaian studi sehingga hanya menjadi tumpukan kertas
semata.
1.2. Tujuan
Dengan mengambil jurnal ini dapat mempelajari tentang bagaimana
manjemen pada penderita gestasional dan menjadi tenaga kesehatan masa
depan yang mampu mengelola dan memberi tindakan pada ibu hamil dengan
gestasional secara komprehensif, sehingga dapat mengurangi dampak buruk
bagi ibu hamil dan janin yang dikandung.
1.3. Manfaat
Menambah pengetahuan dan wawasan mahasiswa mengenai konsep
Evidence Based Nursing.

3
 BAB II
ANALISA JURNAL

A. Jurnal Utama
1. Judul Jurnal
Nursing management of gestational diabetes mellitus in Ghana:
Perspectives of nurse-midwives and women
2. Peneliti
Gwendolyn Patience Mensah, Dalena R.M. van Rooye, Wilma ten Ham
Baloyi
3. Populasi, Sample dan Teknik Sampling
Tujuh (n = 7) perempuan berusia antara 28 dan 45 tahun, dengan masing-
masing 1 hingga 3 anak, berpartisipasi. Sebagian besar wanita (n = 5) tidak
memiliki riwayat diabetes keluarga. Delapan (n = 8) bidan perawat yang
berpartisipasi berusia antara 32 dan 50 tahun dengan pengalaman antara 2
dan 12 tahun..
4. Desain Penelitian
Menggunakan pendekatan fenomenologis deskriptif untuk melakukan 15
wawancara individu yang tidak terstruktur dengan wanita yang telah
didiagnosis dengan GDM (n = 7) dan bidan perawat (n = 8) memberikan
manajemen keperawatan GDM selama periode enam bulan (Desember).
2014 hingga Mei 2015).
5. Instrumen Penelitian
Data rekaman audio ditranskripsikan, dikodekan, dan dianalisis
menggunakan versi adaptasi dari delapan langkah Tesch.
6. Uji Statistik
Kualitatif Deskriptif dengan pendekatan Fenomologis.
B. Jurnal Pendukung
Guidelines for the nursing management of gestational diabetes mellitus: An
integrative literature review.

4
C. Analisa PICO
No Kriteria Jawab Pembenaran
dan Critical Thinking
1 P Ya Dalam jurnal ini, populasi atau problem yang
ditemukan yaitu :
1. Pasien yang terdiagnosa GDM selama
kehamilan mereka, telah melahirkan di
institusi kesehatan militer dan telah kembali
untuk tindak lanjut pasca-melahirkan enam
minggu mereka (berusia antara 28 dan 45
tahun).
2. Perawat dan bidan yang telah bekerja di
lembaga kesehatan militer selama minimal
dua tahun (memiliki pengalaman antara 2
dan 12 tahun).
2 I Ya Penelitian dilakukan secara kualitatif dilakukan
pengumpulan data selama
periode enam bulan, menggunakan wawancara
individu yang tidak
terstruktur yang berlangsung 20-40 menit
dengan kedua kelompok peserta.
Perlakuan yang dilakukan pada populasi :
1. Pertanyaan utama bagi para wanita yang
didiagnosis dengan GDM adalah sebagai
berikut: "Apa pengalaman Anda mengenai
manajemen / perawatan yang Anda terima
dari perawat-bidan terkait dengan diagnosis
GDM Anda?" Pertanyaan lebih lanjut
dilakukan mengenai tantangan yang mereka
mengalami ketika harus mengelola GDM,
serta apa yang diinginkan wanita untuk
dimasukkan dalam manajemen keperawatan
GDM.
2. Pertanyaan yang diajukan kepada bidan dan
perawat adalah sebagai berikut: "Apa
persepsi Anda tentang manajemen perawat
wanita dengan GDM?" Pertanyaan lebih
lanjut dilakukan pada pedoman atau bukti
apa yang digunakan bidan perawat-bidan
untuk mengelola wanita dengan GDM.
3. Intervensi pada populasi :
Empat tema utama yang terkait dengan
manajemen perawatan GDM dan
kepatuhan terhadap manajemen ini. Ini
adalah:

5
 a) Pendidikan tentang GDM;
b) Dukungan emosional;
c) masalah budaya;
d) sosial ekonomi
3 C Ya Perbandingan antara tidak dilakukan intervensi
dan dilakukan intervensi terkait manjamen
perawatan GDM Hasilnya adalah bahwa para
wanita ini tidak memiliki pengetahuan tentang
GDM dan tidak kooperatif selama manajemen
keperawatan GDM sebagai salah satu contoh
setelah dilakukan pemeberian pendidikan atau
edukasi respon dari pasien “Pada awalnya, saya
tidak tahu apa-apa tentang itu [pemantauan dan
injeksi glukosa darah]. Jadi, para perawat di
sekitar membantu saya untuk mengetahui
bagaimana cara melakukannya. Jadi setelah itu,
saya mulai melakukannya sendiri.” dan
Dukungan emosional untuk wanita sangat
penting Dukungan emosional disebut sebagai
aspek penting untuk dapat mengelola GDM
dengan lebih baik. Mereka yang tidak diberi
dukungan emosional rata-rata cenderung lebih
khawatir terkait dirinya dan janinnya, takut
untuk hamil lagi, dsb. Namun dengan adanya
dukungan emosional klien lebih paham lagi
terkait GDM, untuk itu perlunya juga diberikan
edukasi bagi kerabat dalam memberikaan
dukungan baik secara emosional namun juga
dengan mengatur dalam manajemen perawatan
GDM. Perbandingan dengan wanita yang telah
diberikan edukasi berdasarkan ungkapkan
dalam kesaksian dua bidan perawat: “kami
bahkan melibatkan pasien sendiri dengan
mendidik mereka. . . jadi mereka tahu waktu.
Dan
setelah makan. . . mereka akan datang lagi dan
memberi tahu Anda, "Saya sudah selesai makan
dua jam sekarang dan saya ingin gula darah
saya diperiksa." Untuk relasi yang telah
diberikan edukasipun dapat melakukan bantuan
manajemen yang dibuktikan oleh respon wanita
GDM terkait saudaranya yang melarangnya:
“Kadang-kadang bahkan jika saya mengambil
garam, dia akan memberi tahu saya bahwa
Anda tidak seharusnya mengambil ini”.
4 O Ya Hasil penelitian manajemen keperawatan GDM
membutuhkan pendidikan tentang GDM untuk

6
 wanita dan bidan perawat; membutuhkan
dukungan untuk wanita yang didiagnosis
dengan GDM; dan membutuhkan keterlibatan
orang lain yang signifikan. Selain itu, masalah
budaya tertentu (dalam hal kepercayaan budaya
tentang diet) yang berbenturan dengan
manajemen GDM yang direkomendasikan dan
masalah sosial- ekonomi yang menghambat
kepatuhan terhadap rejimen yang diperlukan
untuk pengelolaan GDM diidentifikasi.
Implikasi untuk praktik: Berdasarkan temuan
ini, rekomendasi diberikan yang dapat
membantu perawat-bidan dan praktisi kesehatan
lainnya untuk menyediakan manajemen
keperawatan yang komprehensif untuk wanita
yang telah didiagnosis dengan
GDM.

7
 BAB III
TINJAUAN TEORITIS

A. Diabetes Gestasional
Diabetes gestasional adalah diabetes yang muncul pada masa kehamilan,
dan hanya berlangsung hingga proses melahirkan. Kondisi ini dapat terjadi di
usia kehamilan berapa pun, namun lazimnya berlangsung di minggu ke-24
sampai ke-28 kehamilan.
Sama dengan diabetes yang biasa, diabetes gestasional terjadi ketika
tubuh tidak memproduksi cukup insulin untuk mengontrol kadar glukosa
(gula) dalam darah pada masa kehamilan. Kondisi tersebut dapat
membahayakan ibu dan anak, namun dapat ditekan bila ditangani dengan
cepat dan tepat.
B. Gejala Diabetes Gestasional
Gejala diabetes saat kehamilan muncul ketika kadar gula darah melonjak
tinggi (hiperglikemia). Di antaranya:
a) Sering merasa haus
b) Frekuensi buang air kecil meningkat
c) Mulut kering
d) Tubuh mudah lelah
e) Penglihatan buram
Tidak semua gejala di atas menandakan diabetes gestasional, karena bisa
dialami oleh ibu hamil..
C. Penyebab Diabetes Gestasional
Belum diketahui secara pasti apa yang menyebabkan diabetes
gestasional. Akan tetapi, kondisi ini diduga terkait dengan perubahan hormon
dalam masa kehamilan.
Pada masa kehamilan, plasenta akan memproduksi lebih banyak hormon,
seperti hormon estrogen, HPL (human placental lactogen), termasuk hormon
yang membuat tubuh kebal terhadap insulin, yaitu hormon yang menurunkan
kadar gula darah. Akibatnya, kadar gula darah meningkat dan menyebabkan
diabetes gestasional.

8
D. Faktor Risiko Diabetes Gestasional
Semua ibu hamil berisiko mengalami diabetes gestasional, akan tetapi
lebih berisiko terjadi pada ibu hamil dengan faktor-faktor berikut ini:
a) Memiliki berat badan berlebih.
b) Memiliki riwayat tekanan darah tinggi (hipertensi).
c) Pernah mengalami diabetes gestasional pada kehamilan sebelumnya.
d) Pernah mengalami keguguran.
e) Pernah melahirkan anak dengan berat badan 4,5 kg atau lebih.
f) Memiliki riwayat diabetes dalam keluarga.
g) Mengalami PCOS (polycystic ovary syndrome) atau akantosis nigrikans.
E. Diagnosis Diabetes Gestasional
a) Tes toleransi glukosa oral (TTGO) awal. Dalam TTGO awal, dokter akan
memeriksa kadar gula darah pasien, satu jam sebelum dan sesudah
diberikan cairan gula. Bila hasil TTGO awal menunjukkan kadar gula
darah di atas 130–140 mg/dL, dokter akan melakukan tes toleransi glukosa
oral lanjutan.
b) Tes toleransi glukosa oral (TTGO) lanjutan. Pada tes ini, pasien akan
diminta berpuasa semalaman sebelum menjalani tes darah di pagi hari.
Setelah darah pertama diambil, dokter akan memberikan air gula dengan
kadar gula yang lebih tinggi dibanding TTGO awal. Kemudian, kadar gula
darah akan diperiksa 3 kali setiap jam. Apabila 2 dari 3 pemeriksaan
menunjukkan kadar gula darah tinggi, pasien akan didiagnosis menderita
diabetes gestasional.
F. Pengobatan Diabetes Gestasional
Pengobatan diabetes gestasional bertujuan untuk mengendalikan kadar
gula darah dan mencegah terjadinya komplikasi saat hamil dan melahirkan.
Metode pengobatan diabetes gestasional meliputi:
a) Pemeriksaan kadar gula darah rutin. Dokter akan menganjurkan pasien
memeriksakan darah 4-5 kali sehari, terutama di pagi hari dan tiap selesai
makan. Pasien dapat memeriksakan darah secara mandiri, menggunakan
jarum kecil, dan meletakkan darah di cek gula darah.

9
 b) Diet sehat. Dokter akan menyarankan pasien untuk banyak mengonsumsi
makanan berserat tinggi, seperti buah, sayuran, dan biji-bijian. Pasien juga
disarankan untuk membatasi konsumsi makanan manis, serta makanan
dengan kandungan lemak dan kalori tinggi.
c) Menurunkan berat badan saat sedang hamil tidak disarankan, karena tubuh
sedang memerlukan tenaga ekstra. Oleh karena itu, bila ingin menurunkan
berat badan, lakukanlah sebelum merencanakan kehamilan.
d) Olahraga. Olahraga dapat merangsang tubuh memindahkan gula dari darah
ke dalam sel untuk diubah menjadi tenaga. Manfaat lain dari olahraga rutin
adalah membantu mengurangi rasa tidak nyaman saat hamil, seperti sakit
punggung, kram otot, pembengkakan, sembelit, dan sulit tidur.
e) Obat-obatan. Bila diet sehat dan olahraga belum mampu menurunkan
kadar gula darah, dokter akan meresepkan metformin. Bila metformin
tidak efektif atau menimbulkan efek samping parah, dokter akan memberi
suntik insulin. Sekitar 10-20 persen pasien diabetes gestasional
memerlukan obat-obatan untuk menormalkan kadar gula darah.
G. Komplikasi Diabetes Gestasional
a) Kelebihan berat badan saat lahir yang disebabkan oleh tingginya kadar
gula dalam darah (macrosomia).
b) Lahir prematur yang mengakibatkan bayi kesulitan bernafas (respiratory
distress syndrome). Kondisi ini juga dapat terjadi pada bayi yang lahir
tepat waktu.
c) Lahir dengan gula darah rendah (hipoglikemia) akibat produksi insulin
yang tinggi. Kondisi ini dapat mengakibatkan kejang pada bayi, namun
dapat ditangani dengan memberinya asupan gula.
d) Risiko mengalami obesitas dan diabetes tipe 2 ketika dewasa.

10
 BAB IV
TELAAH JURNAL

4.1 Study Appraisal Worksheet

No Judul Tempat Tujuan Desain Objek Populasi
Penelitian Penelitian Penelitian Penelitian dan
Sample
1 Postnatal Australia To explore and Qualitative In-depth 13 Women
gestational assess the Studies interviews diagnosed
diabetes communication between with GDM
mellitus experiences of twelve and at the main
followup: GDM women sixteen tertiary
Australian from postnatal weeks referral
women’s follow-up after birth hospital in
Experiences Queensland,
(Kilgour et Australia,
al., 2015) between
Q1 December
2012 and
July 2013.
2 Reasons for Denmark To understand Qualitative Semi- Seven
women’s women’s Studies structured women
non- experiences interview treated for
participation with gestational
in medication and diabetes at a
follow-up care during university
screening pregnancy and hospital in
after to understand northern
gestational how Denmark on
diabetes experiences 1 June 2012

11
 (Hyldgaard infl uence and 1 June
et al., 2015) participation in 2013 had
follow-up given birth
screening between one
and two
years
earlier.
3 Exploring English To explore Qualitative Focus 19 women
the needs, concerns, Studies Group took part in
concerns needs and Discussion fi ve focus
and knowledge of groups,
knowledge women with a aged 18-45
of women diagnosis of years and
diagnosed GDM currently
with pregnant
gestational with GDM,
diabetes: A or with a
qualitative history of
study GDM (up to
(Draffi n et 12 months
al., 2016) postnatal)
between
February
and July
2012

12
 BAB V
ANALISA SWOT

A. Analisis Situasi
Analisis SWOT merupakan metode untuk mengetahui segala
kemungkinan yang akan terjadi dalam suatu tahapprogram kerja/rencana
perancangan. Analisis SWOT kepanjangan dari Strengh (Kekuatan),
Weakness (Kelemahan), Oportunity (Peluang), Treatment (Ancaman).
Melaporkan masalah serupa yang dapat membantu dalam manajemen
GDM yang lebih baik. Mayoritas peserta menunjukkan perlunya pendidikan
tentang GDM, tetapi baik perempuan dan bidan perawat mengakui bahwa
pendidikan ini sangat kurang. Peserta umumnya merasa bahwa dukungan
emosional untuk wanita sangat penting dan itu termasuk dalam manajemen
keperawatan GDM. Kedua kelompok peserta mengakui bahwa melibatkan
perempuan dan orang lain yang signifikan dalam manajemen keperawatan
GDM adalah penting. Masalah budaya dan sosial ekonomi, seperti
kepercayaan budaya yang berbenturan dengan diet diabetes, kurangnya dana
keuangan dan sosial dan terbatasnya staf bidan perawat disebutkan oleh kedua
kelompok untuk mempengaruhi manajemen keperawatan GDM.

13
 BAB VI
KESIMPULAN DAN
SARAN

A. Kesimpulan
Pengelolaan GDM seoptimal mungkin untuk wanita yang didiagnosis
dengan GDM, sambil mempertimbangkan kendala yang ditetapkan dalam
hasil. Tantangan yang diidentifikasi, khususnya dalam hal kurangnya
pendidikan dan masalah budaya dan sosial ekonomi yang mempengaruhi
kualitas dan kepatuhan terhadap manajemen keperawatan GDM, perlu
ditangani untuk mengoptimalkan perawatan untuk wanita yang didiagnosis
dengan GDM di Ghana.
B. Saran
Hasil ini dapat membantu perawat-bidan dan praktisi kesehatan lainnya untuk
memberikan manajemen keperawatan yang komprehensif kepada wanita yang
telah didiagnosis dengan GDM.

14
 DAFTAR PUSTAKA

American Diabetes Association, 2010. Diagnosis and classification of diabetes

mellitus. Diabetes Care 33 (1), 62–69.

American Diabetes Association, 2018. Management of diabetes in pregnancy:

stan- dards of medical care in diabetes. Diabetes Care 41 (Suppl. 1), S137–
S143.

Alam, R., Speed, S., Beaver, K., 2012. A scoping review on the experiences and
preferences in accessing diabetes-related healthcare information and services
by British Bangladeshis. Health Soc. Care Community 20 (2), 155–171.

Anonymous. Annual report on the Ghana shared growth and development agenda
Retrieved from: http://www.peacefmonline.com.

Callaghan, W.M., 2010. Delivery is not the end of the story: Follow-up of women
with gestational diabetes mellitus. Contemp. Obstet. Gynaecol. 55, 40–46.

Carolan, M., 2014. Diabetes nurse educators’ experiences of providing care for
women, with gestational diabetes mellitus, from disadvantaged backgrounds.

J. Clin. Nurs. 23 (9–10), 1374–1384.AfricaPay. Minimum wage in Ghana

Retrieved from: http://www.africapay.org/ Ghana.

15
 Midwifery 71 (2019) 19–26

Contents lists available at ScienceDirect

Midwifery
journal homepage: www.elsevier.com/locate/midw

Nursing management of gestational diabetes mellitus in Ghana:

Perspectives of nurse-midwives and women
Gwendolyn Patience Mensah a,b, Dalena R.M. van Rooyen b, Wilma ten Ham-Baloyi b,∗
a
Department of Adult Health, School of Nursing and Midwifery, University of Ghana, Legon, Ghana
b
Nelson Mandela University, Faculty of Health Sciences, Summerstrand, 6031, Port Elizabeth, South Africa

a r t i c l e i n f o a b s t r a c t

Article history:
Background: Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance that is
Received 19 July 2018
observed in the beginning of, or first acknowledged during pregnancy. The prevalence of GDM is esti-
Revised 22 December 2018
mated to be approximately 15% globally and is expected to increase due to growing numbers of over-
Accepted 2 January 2019
weight and obesity in women in their reproductive age. The nursing management of GDM in terms of
lifestyle modifications (exercise, diet and nutrition) and the taking of diabetes medication, if required,
Keywords: and adherence thereto is crucial to prevent maternal and neonatal-perinatal complications. This quali-
Nursing tative study therefore aimed to explore and describe the experiences of women regarding the nursing
Gestational diabetes mellitus
management they received after being diagnosed with GDM; and the perceptions of nurse-midwives on
Management
their nursing management of GDM in Ghana.
Midwifery
Interviews
Setting: This study was conducted in the military health institutions in Ghana, which includes one hos-
Women’s health pital and nine satellite clinics referred to as Medical Reception Stations providing antenatal and
postnatal care to both military as well as civilian patients. Research on GDM in Ghana is extremely
limited.
Design: We used a descriptive phenomenological approach to conduct 15 unstructured individual inter-
views with women that have been diagnosed with GDM (n = 7) and nurse-midwives (n = 8)
providing nursing management of GDM during a six months period (December 2014 to May 2015). Audio-
recorded data was transcribed, coded and analyzed using an adapted version of Tesch’s eight steps for
coding.
Participants: Seven (n = 7) women between 28 and 45 years of age, with 1 to 3 offspring each, partic-
ipated. Most women (n = 5) did not have a family history of diabetes. The eight (n = 8) nurse-
midwives that participated were between 32 and 50 years old with between 2 and 12 years of
experience.
Findings: Participants in this study reported similar issues that could assist in better management of
GDM. The majority of participants indicated the need for education on GDM, but both women and nurse-
midwives acknowledged that this education is hugely lacking. Participants generally felt that emotional
support for women is critical and it was included in the nursing management of GDM. Both groups of
participants acknowledged that involving women and their significant others in the nursing management
of GDM is important. Cultural and socio-economic issues, such as cultural beliefs that clashed with dia-
betic diets, lack of financial and social grants and limited nurse-midwifery staff were mentioned by both
groups to affect the nursing management of GDM.
Key conclusions: The results demonstrate that, despite the reported challenges experienced by nurse-
midwives and women, it was evident that the aim of nurse-midwives was to manage GDM as optimally
as possible for women diagnosed with GDM, while considering the constraints established in the results.
The challenges identified, specifically in terms of lack of education and cultural and socio-economic issues
that affect the quality of and adherence to the nursing management of GDM, need to be addressed in
order to optimize care for women diagnosed with GDM in Ghana.
Implications for practice: Based on our findings, recommendations are provided that can assist nurse-
midwives and other health practitioners to provide comprehensive nursing management to women that
have been diagnosed with GDM.
© 2019 Elsevier Ltd. All rights reserved.

∗
Corresponding author.
E-mail addresses: abusbaby2003@yahoo.co.uk (G.P. Mensah), wilma.tenham-
baloyi@mandela.ac.za (W. ten Ham-Baloyi).
https://doi.org/10.1016/j.midw.2019.01.002
0266-6138/© 2019 Elsevier Ltd. All rights reserved.
20 G.P. Mensah, D.R.M. van Rooyen and W. ten Ham-Baloyi / Midwifery 71 (2019) 19–26
Introduction
The majority of women tend to have normal physiological pro-
cesses during pregnancy, labor and delivery. However, some preg-
nant women develop gestational diabetes mellitus (GDM) during
this period and, if not managed appropriately, this might affect
both mother and foetus in utero. Some form of hyperglycemia in
pregnancy was reported in 21.3 million (16.2%) of global live births
in 2017, with an estimated 85.1% due to GDM (International Di-
abetes Federation, 2017). Although recent statistics on GDM in
Africa are lacking, this is the region with the highest percentage
(70%) of undiagnosed people with any form of diabetes, including
GDM (International Diabetes Federation, 2017).
GDM is defined as “any degree of glucose intolerance with on-
set or first recognition during pregnancy” (American Diabetes As-
sociation, 2010, p. 65). During normal pregnancy, women develop
a form of insulin resistance which is believed to occur to sup-
ply the developing foetus with enough energy for human devel-
opment (Evensen, 2012). In women with GDM, insulin resistance
occurs in reaction to placental hormones. This is consistent with
the observed worsening of GDM throughout pregnancy, as the size
of the placenta increases, and the subsequent rapid resolution of
GDM after the delivery of the placenta during labor (Cheng and
Caughey, 2008). During pregnancy, GDM might affect the woman
as she might develop gestational hypertension, pre-eclampsia and
polyhydramnios, leading to increased rates of induction (operative
delivery, chorioamnionitis, tachysystole, uterine rupture, cord pro-
lapse, and hemorrhage) (Evensen, 2012; Lee et al., 2017; Perveen
et al., 2015). Although these complications are not clearly associ-
ated with hyperglycemia, they are very common in GDM compli-
cated pregnancies (Evensen, 2012).
During delivery, there is a risk of birth injuries, such as shoul-
der dystocia and cervical, vaginal and perineal tears because of
macrosomic foetal growth resulting from the high production of
insulin, which is stored in the form of excessive fat (Kamana et al.,
2015; Reece et al., 2009). The neonate might also be affected by
the woman’s GDM as the baby might experience respiratory dis-
tress syndrome with bouts of dyspneic attacks because of imma-
turity of the lungs, cardiomyopathy, and the neonate is exposed
to an increased lifetime risk of developing diabetes mellitus and
obesity because of excessive foetal growth. Neurodevelopmental
changes might also occur in neonates, including attention and mo-
tor skills changes, hyperbilirubinemia, hypoglycemia, hypomagne-
saemia and poor feeding (American Diabetes Association, 2010;
Mitanchez et al., 2015). Further, there is a significant risk for off-
spring of mothers with diabetes mellitus to have an increased
risk of obesity during childhood and adolescence due to excessive
foetal growth (Dabelea et al., 2000; HAPO Study Cooperative Re-
search Group, 2002; Gomez et al. 2018).
Predisposing factors of GDM include advanced maternal age,
increased Basal Metabolic Index (BMI), multiparity, family history
of diabetes mellitus and a previous history of GDM (Khan et al.,
2013). All women should be screened in pregnancy for GDM. More
specifically, women that are at risk according to the predispos-
ing factors must be screened early (American Diabetes Associa-
tion, 2018). Screening is often done in the second trimester due
to the time of the onset of GDM. GDM can occur at any stage dur-
ing pregnancy, but usually later in pregnancy, during the second
trimester halfway through the pregnancy (University of Califor-
nia San Francisco, 2018). However, if the diagnosis is made in the
first trimester it should be considered if undiagnosed diabetes was
present prior to pregnancy. Women with a history of GDM should
have lifelong screening (American Diabetes Association, 2018).
Some authors recommend ‘universal’ screening, as opposed to
‘risk factor’-based screening, although the proposal is based on low-
quality evidence (Tieu et al., 2017). Nonetheless, it is impor-
tant that determination of risk of developing GDM should take
place at the first antenatal visit. Glucose screening of pregnant
women should be conducted—particularly of those who are at risk—
in order that prompt referral for management and care be initiated.
This would assist in reducing future health risks, such as type 2
diabetes mellitus, with rates of conversion as high as 50% after
five years in some populations (Callaghan, 2010). Further- more,
when the glycemic control in a GDM-complicated pregnancy is
improved, there are remarkable maternal and neonatal-perinatal
benefits. These include normal mode of delivery for the mother, as
well as normal weight gain during pregnancy, and reduced shoul-
der dystocia, bone fracture and nerve palsy in the baby (Crowther
et al., 2005; Keely and Barbour, 2014).
Nurse-midwives have an important role in the screening and
management of GDM in terms of counselling women in lifestyle
modifications (exercise, diet and nutrition) and the taking of di-
abetes medication, if required, and adherence thereto (Ko et al.,
2013). As lifestyle moderations are the first line of treatment, phar-
macological treatment should only be provided if lifestyle mod-
erations are inadequate to keep blood glucose targets within ac-
ceptable levels (American Diabetes Association, 2018; The Interna-
tional Federation of Gynecology and Obstetrics, 2015). Women di-
agnosed with GDM, play therefore an important role in their man-
agement of GDM by adhering to lifestyle modifications, or if nec-
essary, do self-monitoring of blood glucose and take their medi-
cation (National Institute for Healthcare and Excellence, 2015). In
Ghana, and specifically in the antenatal clinics of military health
institutions, as part of the routine laboratory investigations done,
fasting blood glucose levels, are determined during each woman’s
visit to the antenatal clinic. Two-hour postprandial blood glucose
levels are determined at 24–28 weeks gestation and anyone iden-
tified with any degree of glucose intolerance is made to undergo a
full Oral Glucose Tolerance Test. Furthermore, education and
coun- selling on lifestyle modifications are provided to women
during both the antenatal and the postnatal period. However, we
observed that women that were diagnosed with GDM, often
did not ad- here to the recommended lifestyle modifications.
Exploring the experiences of women diagnosed with GDM and
the perceptions of nurse-midwives rendering nursing management
of GDM would therefore be beneficial.
Internationally, similar studies have been done on the experi-
ences of women of the nursing management they received when
they had diabetes during pregnancy (Oster et al., 2014; Khooshe-
hchin et al., 2016), as well as nurse-midwives’ experiences related
to their management of GDM (Carolan, 2014). However, no study
has been conducted in Ghana that explored both views on the
nursing management of GDM. This study aimed to explore and de-
scribe the experiences of women regarding the nursing manage-
ment they received after being diagnosed with GDM; and the per-
ceptions of nurse-midwives on their nursing management of GDM.
Methods
A qualitative research design with a descriptive phenomenolog-
ical approach was used. This study was grounded in the construc-
tivist paradigm, in which reality is not believed to be a fixed entity
but is rather a construction of the diverse views of the study par-
ticipants. Thus, truth exists within a particular context and there
are therefore many possible constructions of reality (Polit and
Beck, 2014). The concerns and understandings of participants are
pivotal when it comes to the understanding of the phenomenon
under study, and the findings are normally a result of the in-
teractions between the researcher and the participants (Polit and
Beck, 2014).
We conducted the research study in military health institutions
in Ghana. The base institution was the 37 Military Hospital, which
 G.P. Mensah, D.R.M. van Rooyen and W. ten Ham-Baloyi / Midwifery 71 (2019) 19–26
is the largest military hospital in the Republic of Ghana. This is a
400-bed general hospital and a tertiary level health facility, with
a 48-bed maternity ward. This hospital is the major health facil-
ity for the Ghana Armed Forces, with nine satellite stations (re-
ferred to as Medical Reception Stations) that provide antenatal
and postnatal care to both civilian and military women, including
those that are diagnosed with GDM. The study was conducted
by the first author, under the supervision of the second and third
authors, both experienced in qualitative research. The first author
is a fe- male nurse-midwife, who, at the time the study was
conducted, was employed at the 37 Military Hospital and held a
Master’s de- gree in Nursing Science.
Study population and sampling
We used purposive sampling for recruitment of all study par-
ticipants. Women were selected based on the following factors:
they had been diagnosed with GDM, had attended the Medical
Reception Stations during their pregnancy, had delivered in mili-
tary health institutions and had returned for their six weeks’ post-
partum follow up. Nurse-midwives who were selected were work-
ing at the military health institutions in Ghana. Only those nurse-
midwives who had worked at the military health institutions for
a minimum of two years were interviewed to ensure adequate ex-
perience of working with women diagnosed with GDM or with a
history of GDM. The authors did not have any established relation-
ship with any of the participants prior to the study, which reduced
the risk of possible bias.
After we obtained ethical clearance and permission from the
37 Military Hospital (ethics number: GHQ/9109/A/MED), written
information about the researchers, and the study’s purpose, risks
and benefits was given to the heads of department of the hospi-
tal, who informed the nurse-midwives of the research study. We
recruited the women that were diagnosed with GDM during their
pregnancy, with the help of the nurse-midwives, during their post-
natal six-week follow up visits to the Medical Reception Stations.
The women were approached face-to-face and informed about the
study and those who agreed to be part of the study were requested
to sign an informed consent form. The participants’ concerns and
questions were answered prior to data collection. An appropriate
place and time to interview the identified women were selected.
Depending on their preference, the first author interviewed the
participants in a quiet room at the 37 Military Hospital or Medi-
cal Reception Stations. Alternatively, their telephone numbers were
requested so as to interview the women at their homes at a time
that was convenient for them.
The nurses-midwives who were willing to participate in the re-
search provided their telephone numbers and the first author con-
tacted them and provided further explanations regarding the
study. Appropriate times and a place for the interviews were
agreed on. Before commencement of the interviews, information
about the study was provided again and consent forms were then
signed by those who wished to be part of the study. Recruitment
of partic- ipants was done until data saturation was achieved,
which was after the 8th interview with the nurse-midwives and the
7th in- terview with the women. No participants refused to
participate or dropped out during the study.
Data collection
The first author conducted the data collection during a six-
month period (December 2014–May 2015), using unstructured in-
dividual interviews lasting 20–40 min with both groups of partici-
pants. The interviews were conducted in English as both groups of
participants were proficient in the language.
21
The main question for the women that were diagnosed with
GDM was as follows: “What are your experiences regarding the
management/treatment you received from the nurse-midwives re-
lated to your diagnosis of GDM?”
Further questioning was done regarding the challenges that
they experienced when having to manage GDM, as well as what
the women would have liked to be included in the nursing man-
agement of GDM.
The question posed to the nurse-midwives was as follows:
“What are your perceptions regarding the nursing management of
women with GDM?”
Further questioning was done on what guidance or evidence
the nurse-midwives use to manage women with GDM. The inter-
view question was pilot tested with two women and two nurse-
midwives. No changes were required in terms of the interview
questions or methodology used. Therefore, the same guiding ques-
tions were used for the main research and the results of the pilot
study were included with those of the main study. Field notes of
observations were recorded after each interview by the first
author.
Data analysis
Audio-recorded interviews were transcribed verbatim by the
first author within a week after the interview took place. An
adapted version of Tesch’s eight steps in the coding process, as de-
scribed by Creswell (2014), were executed in the following way:
The transcripts were read several times to gain familiarity with the
data and to improve the accuracy of understanding of the partici-
pants’ perspectives. Categories were not abbreviated and
alphabet- ized (according to step 6 of Tesch’s coding process) but
rather a list of similar topics was created and grouped together in
themes and subthemes. These were then coded and categorized. A
preliminary analysis was performed by grouping each code into
categories. The field notes were considered during data analysis in
order to be able to contextualize the data. An independent coder
conducted the same process independently in order to test the
reliability of the coding. The authors and independent coder
subsequently reached consensus on the final themes.
Ethical considerations
Ethical clearance from the Ghana Armed Forces (ethics number
GHQ/9109/A/MED) and permission from the head of department
in the military institutions was obtained. Ethical principles that
were adhered to included non-maleficence (as the study did not
cause harm to participants), autonomy (as the participants could
with- draw at any time during the study) and justice (as all
participants were treated the same).
Trustworthiness
Trustworthiness was adhered to as the interview question was
reviewed by an expert in qualitative data to ensure it generated
data needed to answer the aim of the study. Coding was done
by an independent coder and the main and sub-themes were dis-
cussed with the second and third authors to reach consensus on
the findings.
Results
The seven (n = 7) women that were diagnosed with GDM
that participated were between 28 and 45 years of age, with 1 to 3
offspring each. The number of times that women were diagnosed
with GDM was for most women (n = 5) once. Most women (n = 5)
did not have a family history of diabetes. The eight (n = 8) nurse-
midwives that participated in the interviews had between 2 and
12 years of experience.
22 G.P. Mensah, D.R.M. van Rooyen and W. ten Ham-Baloyi / Midwifery 71 (2019) 19–26
As there was synergy between the experiences of the women
that were diagnosed with GDM and the perceptions of nurse-
midwives, the themes and sub-themes are presented in an inte-
grated manner, using quotes from both women that were diag-
nosed with GDM (referred to as W) and nurse-midwives (referred
to as NM).
We identified four main themes that were related to the nurs-
ing management of GDM and adherence to this management.
These were: education on GDM is lacking; emotional support for
women is critical; involving the women and their significant oth-
ers is important; and cultural and socio-economic issues affect the
nursing management of GDM.
Education on GDM is lacking
Data gathered from the nurse-midwives made it evident that,
according to the nurse-midwives, some of the women diagnosed
with GDM had no information on the disease or did not have
enough information. This made it difficult for some of these
women to understand their state of health to better manage the
condition. The management of GDM involves many lifestyle mod-
ifications on the part of the woman. Whether the management in
terms of providing care the nurse-midwives provide will be suc-
cessful largely depends on the woman with GDM. This was ex-
pressed in the words of one of the nurse-midwives, as follows:
“. . . we get some people who . . . don’t understand the situation
they are in or the condition [GDM] that’s affecting them . . . and so
sometimes it’s a little difficult because the client is not cooperating
with the nurses on duty because they don’t understand why they
should have that disease.” (NM3)
Some women diagnosed with GDM emphasized the importance
of early education on GDM. Women do not always possess prior
knowledge, or sometimes have inadequate knowledge of the
condi- tion before the diagnosis of the disease, and this sometimes
causes women to be stressed or uncooperative during the nursing
man- agement. Some women in this study emphasized the
importance of health education about the disease condition at
early stages post-diagnosis. The following is an example of their
views:
“I think education is very, very important because . . . If there is
somebody who doesn’t know anything about it and the person is
not well educated, there are a lot of things she wouldn’t do . . . ”
(W1)
It is evident that there is a general lack of knowledge among
women about GDM and a need for education was expressed. It
seems that women that have not received comprehensive health
education from the nurse-midwives were more stressed and were
sometimes uncooperative during nursing management.
The nurse-midwives in this current study recognized the impor-
tance of educating nurse-midwifery students on the nursing man-
agement of GDM and the implications of poor management. One
of the professional nurse-midwives recalled how a newly qualified
nurse-midwife checked the blood glucose level of a woman with
GDM and discovered that the result was very low, which indicated
that the woman was becoming hypoglycemic. Although the newly
qualified nurse-midwife did well by documenting the reading, they
did not do anything about it. She was expected to have at least re-
ported it to a superior if she was not sure of what intervention
to institute. This was expressed in the words of one of the nurse-
midwives:
“Especially the new ones [nurse-midwives], they don’t even know
that when you check somebody’s sugar, it’s about 2, 1.5, they
don’t even know that you have to give. So, I think they should be
edu- cated on all that.” (NM6)
The nurse-midwives themselves also saw the need to be edu-
cated on GDM. Some of them lacked knowledge regarding, for ex-
ample, the current trends in the nursing management of GDM.
This was outlined by two nurse-midwives, as follows:
“I think we need more education on this Gestational Diabetes.
Honestly, the nurses, the [nurse-]midwives and everybody, we
need more education.” (NM6)
“And then I also think occasionally there should be updates with
the health workers so that we will be abreast with the changes
that is going on.” (NM2)
The need for in-service education, included clinical aspects in
terms of monitoring of blood glucose and when to administer in-
sulin to the women with GDM, was outlined by the following two
nurse-midwives:
“Some of the [nurse-]midwives don’t know what they are doing,
even when the patient is getting into hypo, 2 point something, 1
point something, she just records it and leaves. Move on.” (NM1)
“When I entered the ward, there was a woman who was really
snoring and the way she was snoring, you could see that this
patient, she is going into coma and nobody has noticed it. We
checked her sugar, it was one. I think we need more education.
The house officers [medical interns] also need more education on
this gestational diabetes.” (NM6)
Another example cited related to education was the need for
nurse-midwives to be trained in educating the woman about GDM,
as outlined by one of the women diagnosed with GDM:
“I was able to come into terms when I was told about how it
[GDM] can be managed. But somebody should be there to do that,
so that the person or the patient will not be all that scared about
the whole thing. So I think maybe the nurses can be educated on
it so that they give it [education] to the patients.” (W6)
The findings indicate that there is lack of knowledge, skill
and awareness of the women’s emotional needs among nurse-
midwives, which challenges the nursing management of the
women with GDM. The result is that these women lack knowledge
about GDM and are uncooperative during the nursing
management of GDM. This was evident from the expressed need
for education on GDM on the part of both women and nurse-
midwives.
Emotional support for women is critical
Emotional support was mentioned as a critical aspect of be-
ing able to better manage GDM. The experiences reported related
to the mind or mental activities and the women’s expression of
their emotions. The nurse-midwives observed the reactions of the
women to their new awareness of the existence of GDM and of
having to live with it throughout their pregnancy. This observa-
tion helped the nurse-midwives and other members of the multi-
professional team to manage the women better. Thus, being di-
agnosed with GDM often is connected with feelings of being dis-
turbed and scared, as indicated in the following quotes:
“I was a little worried . . . I was worried. Very worried. Very wor-
ried. Diabetes, I never had one but when I get pregnant I get it.
It just comes and when . . . the baby comes out, then it will just
go back. So I was worried; even thinking of giving birth, second
baby, I was getting worried to get pregnant again. So I was wor-
ried when it came.” (W2)
Nurse-midwives reported that they did recognize the women’s
emotional experiences, as the following interview extract shows:
 G.P. Mensah, D.R.M. van Rooyen and W. ten Ham-Baloyi / Midwifery 71 (2019) 19–26
“Hmmm, you know, they . . . come, umm, disturbed, moody, . . .
some are confused . . . total confusion because they don’t know .
. . you can see that they are scared of the unknown. “What has
become of me; does it mean that I’m going to have this sickness
for the rest of my life or what?” . (…). Mhmm, . . . they look very
worried.” (NM8).
Some nurse-midwives expressed how they were able to provide
emotional support to the women that were diagnosed with GDM
and to alleviate their worries about living with the disease by talk-
ing to the women:
“. . . usually it’s like when we talk to them, the [nurse-]midwives
talk to them, . . . we sort of alleviate their worries, their fears, their
anxieties.” (NM8)
However, sometimes referral to a clinical psychologist is re-
quired when women that are diagnosed with GDM are greatly
disturbed. There were a few instances where management of the
emotional and psychological reactions of some of the women be-
came a challenge and they needed additional psychological sup-
port. This was outlined by the same nurse-midwife:
“. . . a . . . small number of them do not get over their um psycho-
logical . . . disturbance . . ., so in that case, you tell the doctor to
refer to the psychologist . . . so a psychologist will come to talk to
the person.” (NM8).
Involving the women and their significant others is important
Involving the women and their significant others in the nurs-
ing management of GDM, through education and consistent feed-
back, was reported to be important for the women to effectively
manage GDM. If education was not properly given, the nursing
management of GDM was difficult. Consistent feedback through-
out the nursing management of GDM, in terms of test results and
treatment routines of women that were diagnosed with GDM, got
these women more involved in their care regimens and empow-
ered them to take control of their management of GDM. This was
expressed in the testimony of two nurse-midwives:
“we even involve the patients themselves by educating them . . . so
they know the time. . . . And after eating . . . they will come again
and tell you, “I have finished eating two hours now and I want my
blood sugar to be checked.”” (NM2)
“. . . most of the time we teach the patient so that, even when
the patient has gone home, she can do her own checking. We even
teach the patient how to give the injection so that when they go
home, they can give their own injection.” (NM3)
A woman explained her experience of being educated about
her condition as follows:
“At first, I didn’t know anything about it [blood glucose monitoring
and injecting]. So, the nurses around helped me to know how to go
about it. So afterwards, I started doing it on my own.” (W5)
The nurse-midwives also emphasized the involvement of the
women’s significant others in the management of the women’s
condition. Educating the significant others assisted the women to
effectively manage GDM themselves by, for example, adhering to
the correct dietary requirements. The following quotes reflect this:
“The first day . . . you might meet only the client and then later on
they will involve the relatives because when they bring food from
the house, they should know what they should bring them.” (NM8)
“My husband was doing the cooking and he’s a nurse so he know
about it and a sister [of the participant] too. So sometimes I do
23
chat with a relation, that’s my sister. I talk to her what I’m sup-
posed to take. Sometimes even if I’m taking salt, she will tell
me you are not supposed to take this.” (W3)
Cultural and socio-economic issues affect the nursing management of
GDM
Participants expressed various challenges in the management of
GDM related to their cultural background. For example, in man-
aging the diet of a woman with GDM, the food that the medical
team or the dietician might consider necessary for the manage-
ment of a woman’s GDM might be taboo in the area she hails from.
The role of culture in the nursing management of a woman with
GDM emerged during some of the interviews, as in the following
response from one of the nurse-midwives:
“......because what you might want the patient to eat might not be
what the culture wants the person to eat.......” (NM2)
The quote referred to the belief, held by some ethnic groups in
Ghana, that a pregnant woman should not eat meat and eggs so as
to avoid the risk that the newborn child might grow up to become
a thief. Owing to this belief, it can be difficult for a woman with
GDM to consume certain diets, even though they might contribute
to her well-being.
Another personal challenge was the socio-economic situation of
the women. Not having the needed financial and social support
can compromise the successful nursing management of GDM. This
was emphasized by the following nurse-midwives:
“Managing GDM is very expensive . . . because the glucose, the
test strip alone is not an easy thing. It is running into hundreds of
cedis now.” (NM1)
“The strips are very expensive and is not all of them that can af-
ford. What the hospital give is only a supplementary.” (NM2)
“In a day she uses more than six strips a day. And the strips, the
container is a little expensive and so sometimes it’s difficult for
the patients to afford the strips and makes the treatment of the
condition a little difficult.” (NM3)
In support of the aforementioned concerns reported by the nurse-
midwives, the women also emphasized the socioeconomic challenges
they encountered during the management of their GDM:
“When it comes to the strips, it’s very expensive and since we have
to check it like six times a day, and then it contains only twenty-
five pieces. So you have to be buying and buying and buying, so if
you don’t have money, it’s very expensive to manage it.” (W5)
“If you’re not having a good job, you’re not having money, you
can’t manage it [GDM]; with the strips and all that, even the in-
sulin is very expensive.” (W5)
Another socioeconomic challenge expressed by the participants
was institution-related and included the limited human resources.
For example, there were instances where women diagnosed with
GDM thought they were not given the much-needed attention be-
cause the nurse-midwives were busy attending to other patients.
This is outlined in the following quote:
“If you yourself you don’t learn how to inject yourself then you
will go hungry every day because the nurses will not get that time
for you.” (W2)
The health sector in Ghana faces challenges of being under-
staffed and under-resourced (Ministry of Health, 2015). The nurse-
midwives emphasized that attention to the women living with
24 G.P. Mensah, D.R.M. van Rooyen and W. ten Ham-Baloyi / Midwifery 71 (2019) 19–26
GDM could not adequately be provided, especially in terms of in-
sulin injections and diet monitoring, because of the nurse-patient
ratio. Women have to learn to inject themselves in order to be
able to eat and control their blood glucose levels. This enabled
the women to continue with their management at home after dis-
charge. However, nurse-midwives did not always have the time
to teach the women. Furthermore, sometimes women living with
GDM in Ghanaian hospitals are provided with food from their sig-
nificant others. This is often checked by the nurse-midwives as
quantities are large or high in carbohydrates and fat, which is
not recommended for a woman living with GDM. However, nurse-
midwives do not always have time to check what the woman is
eating at a particular point in time. A nurse-midwife expressed this
as follows:
“It will be best if the nurses are able to check whatever they
[women diagnosed with GDM] eat whilst on admission. But one
thing is the nurse to patient ratio, the gap is too much. So whilst
you are there doing something else, the patient is eating whatever
she feels like eating.” (NM2)
Discussion
With this study, we aimed to explore and describe the ex-
periences of women regarding the nursing management they re-
ceived after being diagnosed with GDM; and the perceptions of
nurse-midwives regarding their nursing management of GDM. Four
themes that were related to the nursing management of GDM
were identified in the data. Both groups of participants identified
similar aspects.
A general lack of and need for education on GDM was ex-
pressed by both women diagnosed with GDM and nurse-midwives.
Education of health care professionals is recommended by the
World Health Organization (WHO) to enhance the quality of care
in GDM (WHO, 2012) and the education of the women that are
diagnosed with GDM to assist them to properly manage the dis-
ease they live with. It is therefore recommended that the nurse-
midwives, nurse-midwifery students and the other health practi-
tioners that are involved with the nursing management of GDM
should be educated on GDM and the importance of lifestyle mod-
ifications. If the nurse-midwives themselves are educated, they
will be able to provide better health education to the women, as
this was not always the case. This should include education re-
garding blood glucose monitoring and insulin injections, and diet
and exercise requirements to provide quality care to the women.
Pamphlets or information leaflets could be designed that can be
provided to the women, as well as their significant others. How-
ever, with 25% of the adult population of Ghana being illiterate
(Knoema, 2015); this should be taken into consideration while de-
signing these educational resources. Education could entail guide-
lines for finding a sense of balance in terms of lifestyle modifica-
tions, such as physical activities and diet, and how components of
the identity sometimes need to be ‘re-found’ or ‘balanced’ accord-
ing to the new lifestyle they need to live to manage GDM prop-
erly (Lipworth et al., 2011). Appropriate and tailored education will
assist the women in adhering to the lifestyle modifications and
screening required to properly manage GDM and prevent compli-
cations in future (Daack-Hirsch et al., 2018).
The critical need for emotional support of women that are di-
agnosed with GDM was expressed by both women and nurse-
midwives, as being diagnosed caused a great deal of worry, anx-
iety, and irritability. The emotional impact of GDM, which affected
the women’s ability to properly manage their GDM, has been re-
ported elsewhere (Parsons et al., 2014). Absolute respect for the
lived realities of these women, and what they require in terms
of support, is required as they have to manage both diabetes and
their pregnancy (Ge et al., 2017). Furthermore, even though nurse-
midwives indicated they talk to the women to alleviate their wor-
ries about being diagnosed with GDM, they should also be pre-
pared to listen so that these women might feel their emotions are
considered (Evans and O’Brien, 2005; Ge et al., 2017).
Support could also be given by nurse-midwives by being avail-
able and being willing to assist the women in the management
of GDM when required. Sharing information and believing in the
ability of the women to self-manage GDM properly are forms of
support that the nurse-midwives could offer (Coffman and Ray,
1999; Han et al., 2015). By doing so, nurse-midwives could as-
sist in enabling a supportive environment in which a care plan
for the nursing management of GDM is developed in collaboration
with the women. This will enable patient-centered nursing man-
agement which is aligned with the woman’s values and main con-
cerns and suits the situation the woman finds herself in Evans and
O’Brien (2005) and Epner and Baile (2012).
On the other hand, if such support is not given by the nurse-
midwives, the women might experience negative feelings, includ-
ing a lack of trust and powerlessness (Neufeld et al., 2008; Kopec
et al., 2015). This can, in turn, adversely impact on the woman’s
management of GDM. This was also experienced in this study, as
some of the nurse-midwives seemed to lack knowledge and skills
on the management of GDM and did not always provide health
education and emotional support for the women with GDM lead-
ing to the women not understanding the condition themselves and
being sometimes uncooperative during the management of GDM. In-
service training should thus be provided to the nurse-midwives on
how to provide a more supportive and patient-centered ap- proach.
The healthcare institute’s mission and vision could also in- clude this
approach so that policies could be aligned to this and a more
caring approach could be fostered within the entire institute.
However, adequate staffing norms must be considered to provide
the nursing care needed by the women.
Involving the women diagnosed with GDM and their significant
others in the nursing management of GDM through education and
consistent feedback was one of the aspects identified that were
im- portant and could assist women diagnosed with GDM. Similar
find- ings were outlined in previous studies (Carolan et al., 2010;
Pers- son et al., 2010). The involvement of women in the nursing
man- agement of GDM is an important aspect of contributing to a
suc- cessful pregnancy and post-delivery outcome. For example,
when self-monitoring of the blood glucose is done, the correct
amount of insulin is administered and the woman is aware of her
status throughout the process because she plays an active part.
Therefore, significance of test results after the self-monitoring of
the blood glucose and reasons for the dosage of insulin given must
be ex- plained. The status of the woman’s health and the nursing
man- agement thereof must be discussed with her throughout the
care and management process of GDM.
The involvement of significant others in managing the condition
has been highlighted elsewhere. For example, women affirmed the
involvement of their spouses, especially influencing life-changing
decisions, after they were told they had GDM (Persson et al.,
2010). It is also reported that women, after they were diagnosed
with GDM increasingly demonstrated a preference for
complementary care from family and friends (Hjelm et al., 2005;
Nielsen et al., 2017). Therefore, maternal health promotion
programs should be developed and implemented, with the aim of
identifying and meeting the long-term health needs of women who
have expe- rienced GDM, including peer support of significant
others (Evans and O’Brien, 2005; Ge et al., 2017).
The cultural background must be considered when women are
given advice regarding life style modifications that are necessary
to manage GDM effectively as they might contradict with cul-
tural beliefs (in this, study eating of eggs, which was taboo).
 G.P. Mensah, D.R.M. van Rooyen and W. ten Ham-Baloyi / Midwifery 71 (2019) 19–26
Ghaffari et al. (2014) confirmed this in a qualitative study on com-
pliance with treatment regimen in women with GDM and counsel
that, when recommending diets, cultural dietary conventions must
be considered. This is particularly important as possible stigma as-
sociated with a diabetic lifestyle could be alleviated (Ghaffari et al.,
2014). Therefore, nurse-midwives need awareness in providing
cul- turally appropriate care and education (Alam et al., 2012).
In addition, poverty has an impact on pregnancy and health
outcomes. Women from low social-economic backgrounds usu-
ally are dealing with what they believe to be more important
life issues, which take priority over their ability to, for example,
start a physical activity program to manage GDM (Darroch and
Giles, 2016). Furthermore, managing GDM requires appropriate
but costly medical equipment, such as blood glucose test strips (24
US Dollars per container of 25 strips) and insulin injections (11 US
Dollars). With a current national daily minimum wage in Ghana
of 2.17 US Dollars and a lack of social support (AfricaPay, 2018),
the socio-economic situation of the women in this study creates
a challenge to their management of GDM. A similar predicament
was expressed by women living with GDM during pregnancy from
Atlanta, in the United States of America (Collier et al., 2011).
There- fore, the social and economic support for women with GDM
must be considered and necessary structures and resources must
be ini- tiated and coordinated for a successful outcome of the
nursing management of GDM.
Socio economic challenges related to the institution, as ex-
pressed in this study, have an impact on the health delivery sys-
tem. For example, the limited human resources worldwide and
the increases in workload of the health sector results in decreases
in nurse-patient ratio (International Council of Nurses, 2015). A
mandatory nurse-to-patient ratio should therefore be in place.
In Ghana, where the research study was undertaken, the nurse-
population-ratio was 1:1251 (Anonymous, 2012).In countries such
as the United States of America, the recommended rate is 1:8
(Lintern and Merrifield, 2016). It is therefore recommended that
the nurse-patient ratio should be reviewed. However, despite this
rate, the nurse-midwives in this study did strive to provide the
best nursing management possible for women diagnosed with
GDM. Nurse-midwives should therefore get recognition for this to
keep them motivated to maintain a high standard of nursing man-
agement despite the socio-economic challenges experienced care.
One option would be a system of incentives which could be set up
in order to provide, for example, monthly awards for those nurse-
midwives who are recognized as ‘best employee of the month’ or
annual award ceremonies for those nurse-midwives that have con-
sistently showed high levels of leadership or have provided best
care. Financial incentives linked to these awards, such as vouchers
or scholarships, could also be provided.
Finally, there is no best practice guidelines for the nursing man-
agement of GDM in military health institutions in Ghana. The
findings of the study could therefore be used to develop such a
guidelines. The guidelines could be implemented to assist nurse-
midwives working in the military health institutions with the
nursing management of GDM during the antenatal and post-natal
periods, and in so doing reduce the risk for long-term complica-
tions.
Limitations
A number of limitations are observed for this study. One pos-
sible limitation is that the study was conducted only at military
health institutions in Ghana. Different results could have been ob-
tained from other health institutions. A second limitation could
be that only two groups of participants were included in the
study. These types of participants were used, as the focus was on
the nursing management of GDM. However, because the findings
25
showed that involving significant others in the nursing manage-
ment of GDM is important, the perceptions of these groups could
have shed more light on understanding the comprehensive nurs-
ing management of GDM. Furthermore, because emotional sup-
port was clearly an important factor in the nursing management
of GDM, and sometimes referrals to a clinical psychologist needed
to be done in this respect, it is recommended that the study be
replicated to include significant others as well as other health pro-
fessionals who are part of the inter-professional team, in both mil-
itary and non-military health institutions in Ghana.
Conclusion
Participants in this study reported similar issues that could as-
sist in better management of GDM. It was clear from interviews
that nursing management of GDM requires education on GDM for
both women and nurse-midwives; requires support for the women
diagnosed with GDM; and requires the involvement of signifi-
cant others. Furthermore, certain cultural issues (in terms of cul-
tural beliefs about diets) that clash with the recommended GDM
management and socio-economic issues that inhibit adherence to
the required regimen for the management of GDM were identi-
fied. With respect to socio-economic matters, it was identified that
lack of social and economic support resulted in them not being
able to afford the costly medical equipment (such as blood glu-
cose strips and insulin injections) and lack of human resources
and high workloads pose challenges to the nursing management
of GDM. These challenges must be considered and should be fur-
ther explored to provide the best possible nursing management for
women with GDM. Despite the reported challenges experienced by
nurse-midwives and women, it was evident that the aim was to
manage GDM as optimally as possible for women with GDM, con-
sidering the various constraints identified in the results. The find-
ings of this study can assist nurse-midwives and other health prac-
titioners to better manage GDM.
Conflict of interest
None declared.
Ethical approval
Ethical clearance and permission from the 37 Military Hospital
(ethics number: GHQ/9109/A/MED) was obtained.
Funding sources
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Acknowledgments
The authors would like to thank all the women with a history
of Gestational Diabetes Mellitus and nurse-midwives that partici-
pated in the study as well as Vicki Igglesden for editing the article.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.midw.2019.01.002.
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