Quality of care can be improved by decreasing unnecessary practice variation between professionals. One way to reduce practice variation is by moving evidence-based knowledge into daily practice. To facilitate the translation of the most recent evidence into practice, guidelines are developed and implemented  .
Clinical guidelines are set to ensure and assure homogeneity as well as the quality of provision of care. Utilization of guidelines is influenced by many factors. Clinical practice guidelines are “statements that include recommendations intended to optimize patient care that is informed by a systematic review of evidence and an assessment of the beneﬁt and harms of alternative care options”. Guidelines contain practical evidence-based advice for professionals and patients and aim to improve the quality of care, guidelines are useless when they are not used or adhered to  .
Adherence has been defined as “conformity to, accomplishing or following official or institutional requirements, guidelines, protocols, recommendations or standards”  .
Antenatal care (ANC) is an effective measure that provides care to the pregnant women, quality is still a problem. Quality in maternal services involves providing a minimum level of care to all pregnant women, yet adherence of recommended ANC content to a minimum level appears to be unmet, adherence to clinical guideline is important especially in pre gestational complication like gestational diabetes mellitus  .
Gestational Diabetes Mellitus (GDM) is defined as any degree of glucose intolerance with the onset or first recognition during pregnancy, and it is associated with several maternal and fetal effects includes development of type II diabetes, preeclampsia during pregnancy, increasing the risk of fetal loss, stillbirth and perinatal death   .
Globally GDM complicate about 1% - 14% of all pregnancies, the prevalence rate in most European countries including United Kingdom is about 1% - 2% while among Asian women prevalence rate was higher nearly 11.9% especially Chinese and Indian women  . The prevalence of Diabetes in the Palestinian population in the West Bank, Gaza and E. Jerusalem is high around 15.3%, average prevalence of GDM in Gaza was 1.8% and is increasing   .
The aim of this literature review was to critically analyze data from existing studies and explore the themes identified in relation to the adherence to clinical guideline during antenatal management of GDM, focus on assessment to adherence international and national level, the problem her according to literature non-adherence to clinical guidelines. Adherence has critical role in the determination of therapeutic outcomes and is considered a key factor in achieving therapeutic success. Therefore, a need to investigate this problem in our country exists. Guideline dissemination alone does not change practice; assessment of barriers/enablers an implementation design must be theory-driven  .
2. Materials and Methods
In this review, the search was performed by different international databases including: Google Scholar, PubMed, Medline, CINAHL, EBSCO and the Jordanian Database for Nursing Research using the keywords of “adherence”, “clinical practice guidelines”, “antenatal care”, “gestational diabetes mellitus”, “prenatal care”. These words were searched in combination with each other and in separated form. For example, during the initial search, the keyword “adherence” was combined with “clinical practice guideline”. Later, during each new search a new keyword added until including all keywords in the last search. However, the searching process was limited to following inclusion criteria: full text, written in English, published between 2008 and 2018, and specifically related to adherence to clinical guidelines during GDM treatment in antenatal care.
However, review papers and incomplete reports in the form of editorials, opinion pieces, and conference abstracts have been excluded. Furthermore, a total of 1260 articles were retrieved and after removing the duplicated articles 900 articles remain, the initial evaluation for their titles abstracts took place, 579 excluded by title, 276 excluded by abstract, only 45 were found to be related to the topic of interest. Then, related articles were printed and read in full, following a secondary evaluation, 15 articles were exactly identified to cover the inclusion criteria. As a result, those fifteen articles were included in this review (Figure 1).
Fifteen relevant articles have been reviewed. From each article the following data have been extracted: Title, author, study purpose, design, sitting and findings.
Figure 1. Search strategy and outcomes. PRISMA guideline.
Then, the authors compared articles, interpreted findings to identify themes, and grouped them based on their similarities. Overall, the fifteen reviewed research articles published between 2008 and 2018 (three systematic review, eight cross sectionals quantitative study, one survey study and three descriptive). All articles presented in Appendix.
On the international level two study was conducted in Ghana, two study was conducted in Australia, one study was conducted in Malaysia, one study was conducted in each of Sweden, Netherlands, Korea. In the Middle East country one study was conducted in Riyadh, Saudi Arabia the other in Morocco, the third one in Palestine, the reaming studies was systematic review done in different countries. However, to address the purpose of this review, the findings (highlight adherence to clinical practice guidelines) were categorized into common themes, using a color-coding method to highlight similarities across the literature. After sorting and grouping the data, three thematic areas were identified these includes the following: adherence to clinical practice guidelines in GDM patient’s; barriers and enablers, adherence to clinical GDM guidelines in studies from international countries, adherence to clinical GDM guidelines in studies from middle east countries.
3.1. Theme One: Adherence to Clinical Practice Guidelines in GDM Patient’s Barriers and Enablers
Diabetes is a global health problem, in both developed and developing countries, the prevalence of gestational diabetes (GDM) in low and lower middle income countries (LLMIC) is increasing. Although its associated with short and long term complications for mothers and their newborns, there is a lack of knowledge about how to detect and manage GDM. Although, guidelines for GDM screening and management are available and freely downloadable from the internet from high income setting, there is a lack of knowledge about the degree to which guidelines developed in high income settings are appropriate foruse in low income settings or less developed countries, where resources are scarce and access to care is limited   .
Four studies about management of GDM in low and lower middle income country in Africa, South Asia, and Latin America. The results demonstrated high diversity in screening and management practices.
According to Utz, Kolsteren  they stated that management of GDM was found to take place mainly at the tertiary level, A cross-sectional survey was conducted between November 12, 2014 and May 11, 2015. Questionnaires were distributed to gynecologists, medical doctors and endocrinologists who were involved in providing care to patients with GDM. Questionnaires were sent to 182 individuals and 77 healthcare providers from 26 countries completed the survey. The results demonstrated high diversity in screening and management practices. Only 52 (68%) participants reported that any guidelines were available in their setting.
According to Utz, Delamou  , there is a lack of knowledge on how the women with GDM are managed in low resource settings. A scoping review conducted of published literature, all articles containing information on clinical practices of detection and management of gestational diabetes published until April 24, 2016 included. Results: 23 articles identified mainly from Asia and sub-Saharan Africa. All studies show that lack of uniformity in the management of gestational diabetes requires a focus on the promotion of universal guidelines on GDM screening and management that are applicable to low resource settings.
3.1.1. Barriers to Adherence
According to Utz and De Brouwere  , both providers and patients poses a substantial barrier to detection and management of GDM due to unavailability of guidelines combined with lack of knowledge about GDM, leading to deficiencies in screening and counseling. Additional expenses related to specific tests and changes in diet were identified as important challenges, limited access to regular monitoring and follow-up care as a result of distance and costs are also considered. Services were not available at all levels nor was adequate testing equipment. Lack of communication and collaboration between different specialists and treatment delays as a result of patients being seen by multiple providers.
According to  , reasons for failure to adhere to best practice are multifactorial and include: unfamiliarity with Nutrition Practice Guidelines Among relevant staff; insufficient dietetic resources; and women’s lack of awareness of the benefits of regular dietetic counselling. Barriers have been grouped into the theoretical domains of: Knowledge; Beliefs about consequences; Intentions; Social influences; Social/professional role and identity; Environmental context and resources; and Memory, attention and decision processes.
Four main categories of barriers to physician guideline adherence:
1) The payment system; Lack of uniformity leads to diffusion of the effects of Pay for Performance programs.
2) Lack of information technology systems; Insufficient access to guidelines at the point of care
3) Physician culture, beliefs and habits; physicians base clinical decisions on their personal experience, physicians generally believe that their own clinical practice is good
4) The guideline development process and utility and function, development process of guidelines presents their own obstacles to adherence, mainly:
a) The lack of sufficient flexibility and relevance to physician practice; and
b) The lack of transparency in guideline development  .
3.1.2. Enablers and Strategies to Adherence
Adherence to guidelines is associated with better outcomes among patients with gestational diabetes. Enablers, identified through clinic observation and team discussion, project funding for dietetic clinic time, a positive research and audit culture of the organization. To improve adherence many strategies includes Engage physicians in guideline development and review process; Expedite new research to support guideline development; and Make guidelines actionable   .
According to previous studies guidelines dissemination alone does not change practice; assessment of barriers/enablers and implementation design must be theory-driven. Policy makers need to address these challenges by strengthening their health care system as a whole, relevant and effective strategies to apply guidelines in clinical practice are needed to improve patient outcomes.
3.2. Theme Two: Adherence to Clinical GDM Guidelines in Studies from International Countries
According   guidelines are developed to ensure quality, uniformity and consistency of care for clients .Engagement of providers during the process of developing guidelines is important in ensuring that they adhere to the guidelines. There is discrepancy between provider knowledge and practice, especially in low and middle income settings, and reasons for this need to be explored. In a two study in Ghana, a cross-sectional analysis of a prospective cohort study on adherence to guidelines was carried out. Complete provider adherence to first antenatal guidelines was 48.1%. Complete provider adherence to first antenatal visit guidelines is low across different facilitytypes in the Greater Accra region of Ghana, providers should be trained to adhere to the guidelines during provision of care to all pregnant women since adherence to the guidelines at first visit play a major role for the quality of care of the pregnant woman.
In Australia according to   one study was conducted in two developed high-income countries to compare Austrian and Australian national guidelines for gestational and pre-gestational diabetes and evaluate the level to which physicians comply with their country’s guideline. The other one to identify barriers and enablers that confront GDM management and treatment. When guidelines compared between Austrian (ÖDG, Austrian Diabetes Society) and Australian guidelines (ADIPS, Australasian Diabetes in Pregnancy Society), they show that National and international consensus has yet to be achieved in the management of diabetes in pregnancy.
Several studies was done by     In Malaysia , Korea, Netherlands, Sweden ,all studies focus on adherence to clinical practice guidelines ,focus on adherence to antenatal guidelines during GDM care and outcomes in patients. Result show many different ways to measure adherence, adherence to guidelines varies widely. Adherence is positively related to: evidence base of guideline, practicality of guideline, automated support system, a positive attitude of professionals.
3.3. Theme Three: Adherence to Clinical GDM Guidelines in Studies from Middle East Countries
There is a lack of study about adherence to clinical practice guideline for treatment of GDM in middle east countries. Diabetes in the Middle East: over the past two decades, there had been changes in the lifestyle of eastern Mediterranean countries, this led to an increase in non-communicable diseases, such as hypertension, cardiovascular diseases and diabetes mellitus.
In a study done in Egypt, using cross-sectional design, the glycemic control and prevalence of microvascular and neuropathic complications were described among Egyptians with diagnosed diabetes. The results were; blindness 5%, 21% albuminuria, 42% had retinopathy, 22% neuropathy, clinical nephropathy prevalence was 7%, foot ulcers were only 1%. Other studies were made in Egypt and Jordan to measure the prevalence of obesity and related diabetes. The results from Egypt were; 16% were obese and 4.9% had diabetes  .
Albarrak, Mohammed  conducted a study to assess diabetes care in primary clinics based on the guidelines of American Diabetes Association (ADA). A retrospective study of medical records and laboratory system was conducted between November 2011 and May 2012. In total, 200 diabetic patients from the database of Primary Care Clinics (PCCs) in King Khaled University Hospitals (KKUH) were randomly selected. Study revealed insufficiency of diabetes care, and proper guidelines are not followed in the care for diabetic patients in the PCCs in comparison to the ADA standards of care.
Utz, Assarag  conducted a study in Morocco to assess knowledge and practices of generalpractitioners, midwives and nurses working at primary health care facilities regarding screening and management of gestational diabetes (GDM). Antenatal care (ANC) attendance is high, ﬁrst level health care providers, mainly nurses and midwives, are usually the ﬁrst point of contact for pregnant women. Result show that public primary health care providers have a basic understanding of GDM but screening and management practices are not uniform. Most nurses and midwives lack pre-service training on gestational diabetes while 56.8% of the doctors had some pre-service training. After diagnosing GDM, 88.5% of providers refer patients to specialists, only 11.5% treat them as outpatients.
In Gaza strip in Palestine a study was conducted by Radwan, Elsous  to assess the level of good glycemic control, to examine factors influencing good glycemic control and to determine association between adherence to antidiabetic medications and glycosylated hemoglobin (HbA1c) .A cross-sectional design was employed among 369 patients with type 2 diabetes mellitus (T2DM). study showed that glycemic control was suboptimal. To improve glycemic control and prevent diabetes-related complications it’s important to get Knowledge of factors associated with that were: older age, high medication adherence, and better health literacy.
The current review showed that Gestational Diabetes Mellitus management is an essential constituent to prevent prognosis of GDM complications. The prevalence of gestational diabetes (GDM) in low and lower middle income countries (LLMIC) is increasing. These findings could provide valuable evidences to enhance concept of adherence to guidelines in international and middle east countries for GDM women. The findings were clustered in three themes as following adherence to clinical practice guidelines in GDM patient’s; barriers and enablers, adherence to clinical GDM guidelines in studies from international countries, adherence to clinical GDM guidelines in studies from middle east countries.
Fifteen studies conducted in the international level and middle east countries level to assess level of adherence to clinical practice guidelines in management and treatment of GDM, most of studies are cross sectional studies show no uniformity across guidelines so adherence more difficult to measure. Guidelines dissemination alone does not change practice, it’s important to develop a monitoring system and specific method to measure adherence. Many barriers and challenges that face health care providers to adhere to clinical guidelines one of them Lack of resources, insufficient dietetic resources; and women’s lack of awareness of the benefits of regular dietetic counselling, Physician culture, beliefs and habits.
Providers should be trained and supported to adhere to the guidelines during provision of care to all pregnant women.
No studies about adherence to clinical guidelines in Jordan or Palestine. In middle east countries in Morocco, Saudi Arabia two studies was conducted about Knowledge and practice related to gestational diabetes among primary health care providers, Evaluation of diabetes care management in primary clinics based on the guidelines of American Diabetes Association respectively. Further studies needed to assess adherence level of guidelines during antenatal care for GDM patients especially in developing countries.
To achieve a high quality of GDM management, national guidelines must be consistent and uniform; it must be integrated into local care processes. Adherence to clinical guidelines decrease prognosis of GDM complications. Complete provider adherence to first antenatal visit guidelines is low across different facility. Providers should be trained and supported to adhere to the guidelines during provision of care to all pregnant women.
An essential element in the success of the management plan is diabetes management standards. Most of the elements examined are not in full compliance with the ADA standard. Continues monitoring and self-review are recommended. There is a need of actions improving compliance to the local guidelines. Many barriers and enablers or facilitators to adherence present, we should consider it and try to overcome barriers in order to improve adherence to clinical guidelines and then improve quality of care and patient health.
Thank you to Prof. Muayyad Ahmad for reading an early copy of this paper.
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