The healthcare providers face a variety of re- fusals including refusals of blood transfusions, vac- cines, screening and diagnosis tests and cessation of life-sustaining treatment in the terminal illnesses. Ac- cording to a review, the causes of the parents to re- fusing, delaying or hesitating to vaccinate their children can be grouped into 4 overarching cate- gories: religious, personal belief or philosophical, safety concerns and the demand of more informative approach from healthcare providers.1 In obstetrics and gynecology, refusing an inves- tigation, treatment or intervention may raise medical, legal and ethical concerns for both the mother and the fetus. In a population-based study, the patients who refused a medically indicated intervention were older, had higher parity and labor complications than those who approved the intervention. The refusal of treat- ment was an independent risk factor for perinatal mortality.2 Gestational diabetes mellitus (GDM) is carbo- hydrate intolerance that is first diagnosed in preg- nancy. The prevalance of GDM worldwide varies between 1 and 45% of pregnancies.3,4 Similar to the obesity and Type 2 DM, the incidence of GDM con- tinues to increase in the world over the past years.5 GDM can cause maternal and fetal complications such as abortion, large for gestational age, polihy- dramnios, intrauterine growth restriction, intrauter- ine fetal death, pre-eclampsia, delivery complications including cesarean section, birth trauma, neonatal hy- poglycemia, hyperbilirubinemia, polycythaemia and the need for neonatal intensive care unit admission, JCOG. 2022;32(4):127-34 127 Gestational Diabetes Screening Refusal in Pregnant Women: A Cross-Sectional Survey Study Nazan USAL TARHANa, Habibe AYVACI TAŞANa, Erbil ÇAKARa, Gülnaz Nural BEKİROĞLUb aDepartment of Obstetrics and Gynecology, University of Health Sciences Zeynep Kamil Women’s and Children’s Disease Training and Research Hospital, İstanbul, Türkiye bDepartment of Biostatistics, Marmara University Faculty of Medicine, İstanbul, Türkiye ABS TRACT Objective: Recently, some pregnant women in Türkiye are hesitant to undergo gestational diabetes mellitus (GDM) screening tests and this trend is more common. The objective of the study is to assess the pregnant women’s knowledges, decisions, reasons for hesita- tions about having the GDM screening tests and test rejection rates. Material and Methods: This cross-sectional study included 647 preg- nant women who applied for an antenatal outpatient clinic and who had not yet been diagnosed with GDM and a survey was conducted using questionnaire designed by the authors. Results: At the beginning, 287 (44.4%) of the participants declared that they would have glucose chal- lenge test, 169 (26.1%) would not and 191 (29.5%) were undecided. The rejection rate was lower in those who had knowledge about the screening tests. After a short information about the content of tests, 30% of the women who decided not to have the test and 78.3% of those who were undecided at the beginning, decided to have the test (p=0.001). Conclusion: The knowledge level of pregnant women about dia- betes screening and diagnosis influences their decision-making. Organizing well-planned trainings for patients and healthcare professionals using public institutions and media may be effective in reducing the burden of diabetes on social health and the economic indicators. Keywords: Decision making; diabetes, gestational; diagnostic screening programs; patient education as topic; refusal to participate DOI: 10.5336/jcog.2022-91549 Correspondence: Nazan USAL TARHAN Department of Obstetrics and Gynecology, University of Health Sciences Zeynep Kamil Women’s and Children’s Disease Training and Research Hospital, İstanbul, Türkiye E-mail: nazantarhan@gmail.com Peer review under responsibility of Journal of Clinical Obstetrics & Gynecology. Re ce i ved: 26 May 2022 Ac cep ted: 26 Oct 2022 Available online: 28 Oct 2022 2619-9467 / Copyright © 2022 by Türkiye Klinikleri. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Turkiye Klinikleri Journal of Internal Medicine Journal of Clinical Obstetrics & Gynecology ORIGINAL RESEARCH https://orcid.org/0000-0002-7571-4505 https://orcid.org/0000-0002-8517-0556 https://orcid.org/0000-0001-6147-4240 https://orcid.org/0000-0001-6471-6612 https://creativecommons.org/licenses/by-nc-nd/4.0/ 128 thus, early detection and treatment may provide blood glucose regulation and reduce these complications.6,7 GDM is usually diagnosed after 20 weeks of gestation, when placental hormones that have the op- posite effect of insulin on glucose metabolism in- crease substantially. In a study, the sensitivity and selectivity for the tests used in the diagnosis of GDM were 50% and 66% for screening based on risk fac- tors, 40% and 90% for random glucose measurement, 40% and 90% for HbA1c, 59% and 91% for 50 g glu- cose challenge test (GCT), 79% and 83% for 75g oral glucose tolerance test (OGTT); based on this finding, OGTT is currently the most sensitive test for diag- nosing GDM.8 It has recently been observed that, pregnant women in Türkiye are hesitant to undergo GDM screening tests and this trend is becoming more com- mon. We conducted a cross-sectional survey study to assess pregnant women’s knowledge, thoughts and decisions about GDM screening/diagnosis tests as well as to investigate the factors that influence their decision not have these tests. MATERIAL AND METHODS This cross-sectional survey study was conducted in University of Health Sciences, Zeynep Kamil Women’s and Children’s Disease Training and Re- search Hospital between June 2016-December 2017. This study was approved by the Clinical Research Ethics Committee of Zeynep Kamil Women’s and Children’s Disease Training and Research Hospital (date: 08.04.2016, no: 95). We performed this study consistent with the Declaration of Helsinki ethical principles. The study was conducted with 647 pregnant women who applied to the antenatal outpatient clinic. Pregnants who were literate in Turkish language and not yet diagnosed with GDM between 24-28 weeks of gestation were included in the study. They were invited to take part in the survey and the informed consent was obtained from each participant who ac- cepted to fulfill the survey. The survey was con- ducted using a 4-page questionnaire which was designed by the authors. The questions and items in the questionnaire were generated on the basis of the experiences related to the hesitations and possible reasons encountered in the follow-up of pregnant women regarding the test recommended for GDM screening in our daily practice. Pregnants who were diagnosed with diabetes or glucose intolerance and who have a disability to take the survey were ex- cluded from the study. QuESTIONNAIRE On page 1, pregnant women were briefly informed about the purpose of the study, the importance of di- agnosis and treatment, possible maternal and fetal complications of diabetes in pregnancy and how the planned tests for screening and diagnosis of GDM will be performed. Following 3 questions were designed to deter- mine whether the pregnant women have knowledge about the tests and whether they were considering having them. Pregnant women who answered “no” or “undecided” to Q3 were asked to respond to 3 questions on page 2. It was intended to look into the reasons why people did not want to take the test. On page 3, following information was provided: Fifty grams of sugar used in the screening test by drinking sugary drinks has the same amount of calories as one of the following foods you eat in your daily life for the purpose of diagnosing diabetes: 1 slice of cake, 3 slices of bread, 2 tablespoons sugar, 3 tablespoons of honey, 2 glasses of lemonade, 2 glasses of cherry juice, 1 serving of rice pudding. After this informa- tion, 4 questions were asked about the frequency of consuming these foods, participants’ thoughts about having the test and other methods they found safe to diagnose GDM. On page 4, in addition to maternal demographic and clinical characteristics, current body mass index (BMI), gravidity, parity, level of ed- ucation, profession, 3 questions were asked to inves- tigate the presence of diabetes in herself and her family. The questionnaire is given in Table 1. STATISTICAL ANALYSIS Statistical analysis was performed using the SPSS for Windows version 17.0 software (SPSS Inc., Chicago, IL, USA). Descriptive data were expressed as mean±standard deviation for continuous random variables and number (%-percentage) for discerete Nazan USAL TARHAN et al. JCOG. 2022;32(4):127-34 128 129129129 random variables. The chi-square test was used to compare categorical variables between the groups. The one-way ANOVA test was used to compare groups’ means for continuous random variables. A p value of <0.05 was considered statistically signifi- cant. RESuLTS Six hundred and forty-seven pregnant women took part in the study. At the beginning of the question- naire, 287 (44.4%) of the participants declared that they would have 50 g GCT, 169 (26.1%) did not and 191 (29.5%) were undecided. The median age of the participants was 29 [interquartile range (IQR): 23-33] and the median current BMI was 26.4 (IQR: 23.2- 29.7). There was not any statistically significance among groups for age, gravidity and parity, pre-preg- nancy BMI, current BMI, profession and educational level (Table 2). The carbohydrate consumptions of the partici- pants were not statistically significant between groups (Table 3). When asked if they knew about the 2-step screening and diagnostic tests for GDM performed during pregnancy, 51.2% of those who said they would “not have the test”, 62.6% of those who said they “would”, and 40.6% of those who were “unde- cided” said they would. The difference between the groups was statistically significant (p=0.0001). When the benefits of diabetes diagnosis and treatment through the tests were questioned, it was discovered that 35.5% of those who decided “not to have the test”, 52.4% of those who said that they would “have it” done, and 33.9% of those who were Nazan USAL TARHAN et al. JCOG. 2022;32(4):127-34 129 Page 1 Question (Q)1 Do you have any information on 2-step diabetes screening and diagnosis tests for pregnant women? (Choices (C): Yes/No) Q2 Do you know what advantages you will have if diabetes is detected and treated as a result of these tests? (C: Yes/No). Q3 Will you have the 2-step 50 g screening and 100 g diagnosis tests recommended by your doctor along with a sugary drink? (C: Yes/No/undecided) Page 2 Q4 Can you write down the reasons why you did not accept your doctor’s recommendation, along with your own thoughts? (Optional) Q5 Was it your decision or desire to refuse 2-step diabetes screening and diagnostic tests while pregnant? Which of the following mediums influenced your decision? (The state of being influenced by at least one media such as television, radio, newspapers and the internet, friends’ and family members’ views, a physician) (C: Yes, I was influenced by a source/No, I wasn’t influenced by a source, it was my own decision) Q6 What kind of harm do you think 2-step diabetes screening and diagnostic tests during pregnancy will cause you or your baby? C: Diabetes emergence/fetal demise/declaration of other consequences (Optional) Yes/No Page 3 On page 3, following information was provided: 50 grams of sugar used in the screening test by drinking sugary drinks has the same amount of calories as one of the following foods you eat in your daily life for the purpose of diagnosing diabetes: 1 slice cake, 3 slices of bread, 2 tablespoons sugar, 3 tablespoons honey, 2 glasses lemonade, 2 glasses cherry juice, 1 serving of rice pudding Q7 How frequently do you eat any of these foods? C: Any/once daily/more than once daily/once a week/once a month) Q8 After considering this information, would you refuse your doctor’s recommendation for a 50g GCT (test to screen for diabetes)? (C: Yes/No) Q9 Do you know of any other safe ways to detect diabetes during pregnancy? (C: Yes/No) Q10 If you answered yes to the previous question, could you please describe other methods that you believe are safe? (Optional, your own words) Page 4 Q11 Do you have a history of diabetes from a previous pregnancy? Q12 Do you have any other medical conditions from previous pregnancies? Q13 Is there a diabetic in your family? TABLE 1: The questionnaire. “undecided” had knowledge on the subject. A statis- tically significant difference was found (p=0.0001). The groups were found to be similar in terms of being influenced by TV shows, radio shows, news- paper articles, internet articles, public expert inter- views, friends, family members and physicians, all of which can influence test decision making (p>0.05). However, when the situation of being influenced by at least one of the media mentioned in the question was evaluated, it was detected that the rate in the group who decided “not to have the test” of being in- fluenced by one of the media, was found statistically significant and lower with 32,6% (p<0.0001). When asked about the risks of diabetes screening tests to the mother and infant, the groups were statis- tically identical. Nazan USAL TARHAN et al. JCOG. 2022;32(4):127-34 130 Decision to have a 50 g GCT Not to have the GCT test n=169 Have the GCT test n=287 Undecided n=191 Mean±SD Mean±SD Mean±SD p value Age 29.2±5.0 29.3±5.0 29.5±6.0 0.833a Pre-pregnancy BMI 24.8±4.7 25.3±5.3 24.9±4.8 0,575a Current BMI 26.9±4.6 27.2±5.3 26.8±4.5 0.628a Gravidity 2.0±1.3 2.3±1.3 2.2±1.5 0.207a Parity 0.7±0.8 0.9±0.9 0.8±0.9 0.151a n % n % n % Education level (n=631) Just literate 1 0.6 2 0.7 2 1.0 Primary school 37 22.4 33 12.0 32 16.8 Middle school 16.4 55 20.0 25 13.1 High school 47 28.5 76 27.6 64 33.5 0.165b Junior college 15 9.1 38 13.8 23 12.0 university & postgraduate 38 23.0 71 25.8 45 23.6 Profession (n=630) Official/worker 23 13.9 69 25.2 39 20.8 Housewife 127 76.5 183 66.8 127 66.8 Day worker 1 0.6 1 0.4 1 0.5 0.103b Other 15 9.0 21 7.7 23 12.1 TABLE 2: Maternal demographics and clinical characteristics. aThe One Way ANOVA test was used; bChi-square test was used; GCT: Glucose challenge test; SD: Standard deviation; BMI: Body mass index. Decision to have a 50 g GCT Not to have the GCT test Have the GCT test Undecided n=169 n=287 n=191 Question* 7 n % n % n % Total p value Any 0 0.0 0 0.0 1 0.6 1 Once a day 7 4.6 8 6.7 4 2.3 9 More than once a day 79 51.6 63 52.5 89 50.2 231 0.514a Once a week 31 20.3 26 21.7 47 26.6 104 Once a month 36 23.3 23 19.1 36 20.3 95 Total 153 100.0 120 100.0 177 100.0 450 TABLE 3: Pregnant women’s daily carbohydrate consumption. aChi-square test was used; *The clear version of the questions, their explanations and answer options are given in Figure; GCT: Glucose challenge test. Within the scope of the study, there was an in- formation paragraph in the questionnaire comparing the 50 grams of glucose used in the screening test with the food consumed daily. Following this brief- ing, the patients were again questioned at the same meeting about their decision to have 50 g GCT. Thirty percent of the women who decided “not to have the test” at the start of the study and 78.3% of those who were “undecided” at the start of the study decided to have the test. This result showed a statis- tically significant difference (p=0.001) The fourteen point 2 percent of those who did “not to have the test” thought there were safer meth- ods to diagnose diabetes in pregnancy. This rate was found to be statistically higher than that of the other groups (p=0.001). Three groups were detected to be similar in terms of diabetes history in previous pregnancy, his- tory of another obstetric complication in previous pregnancy and presence of diabetes in the family in cases who had a previous pregnancy (Table 4). DISCuSSION It has recently been observed that, some pregnant women in Türkiye are hesitant to undergo GDM screening tests and this trend is becoming more com- mon. In a study conducted in Türkiye, the prevalence of GDM was found to be higher among women who refused the GDM screening test than the control group (30.9%, 8.8%, respectively). The risk of poly- hydramnios in late pregnancy was also reported as 12% in women who did not accept the test.9 Ho- Nazan USAL TARHAN et al. JCOG. 2022;32(4):127-34 131 Decision to have a 50 g GCT Not to have the GCT test Have the GCT test Undecided n=169 n=287 n=191 Question (Q)* n % n % n % p value Q1 No 82a 48.8 107b 37.4 111c 59.4 Yes 86 51.2 179 62.6 79 40.6 0.0001 Q2 No 107a 64.5 136b 47.5 123a 66.1 Yes 59 35.5 150 52.4 63 33.9 0.0001 Q5 No 97a 67.4 21b 42.9 75b 45.2 Yes 47 32.6 28 57.1 91 54.8 0.0001 Q6 Diabetes emergence No 28 24.1 16 33.3 46 31.7 Yes 88 75.9 32 66.7 99 68.3 0.319 Fetal demise No 106 91.4 45 93.8 134 9.1 Yes 10 8.6 3 6.3 10 6.9 0.826 Declaration of other No 98 83.1 42 87.5 110 76.4 concequences Yes 20 16.9 6 12.5 34 23.6 0.169 Q8 I do not refuse 45a 30.0 109b 93.2 123c 78.3 I refuse 105 70.0 8 6.8 34 21.7 0.0001 Q9 No 126a 85.8 115b 98.3 158c 92.9 Yes 21 14.2 2 1.7 12 7.1 0.001 Q11 No 89 95.7 157 92.4 100 90.9 Yes 4 4.3 13 7.6 10 9.1 0.407 Q12 No 84 92.3 143 85.1 97 88.2 Yes 7 7.7 25 14.9 13 11.8 0.238 Q13 No 105 64.4 152 57.1 115 61.8 Yes 58 35.6 114 42.9 71 38.2 0.296 TABLE 4: Participants’ opinions on whether or not to have a gestational diabetes screening test. a,b,cDifferent upper letters denote groups with statistically significant difference; * The clear version of the questions, their explanations and answer options are given in Figure; GCT: Glucose challenge test. caoglu et al. from Türkiye conducted a study in which 312 pregnant women were polled on their thoughts and practices regarding 50 g GCT. Forty-two point five percent of women expressed their desire, 40.9% expressed their reluctance to have GCT who were £28 weeks of gestation and the most frequently stated reason for reluctance was the belief that GCT is harmful to both the mother and the baby.10 Similarly, in our study, 44.4% of the participants stated that they would have the test. Uy et al., investigated the most common themes of an outpatient diabetes consult, including diagno- sis of DM, lifestyle modification, the targets of treat- ment, precautions of hypoglycemia, complications of diabetes and safety of medication. Patients with higher educational attainment had a better under- standing of these themes; however, lower educational attainment is related to a paternalistic attitude toward diabetes care. The authors concluded that, the themes of outpatient diabetes consultation reflects the extent of diabetes care influenced by socio-cultural factors, patient-doctor relationships and adaptability to re- source limitations.11 In our study, it is noteworthy that the education and employment status were similar among the groups reporting the decision to have GCT. This suggests that pregnant women, from all socio-cultural levels in our study population experi- ence similar anxiety and lack of knowledge about GCT. It has been reported that maternal risk factors such as age and BMI are insufficient in diagnosing the majority of women with GDM.12 In our study, BMI and carbohydrate consumption were similar among groups that made different decisions about having the test. This finding suggests that women who consume an excessive amount of carbohydrates and are obese are not aware that their situation may increase their risk of developing diabetes. Structured studies on the perception of illness and health im- provement are required. Chen et al. reported that the frequency, quality and duration of primary care visits increased between 1997-2005. Modest relationships were noted between visit duration and quality of care. Providing counsel- ing or screening required additional physician time but ensuring that patients were taking appropiate medications seemed to be independent of visit dura- tion.13 Similarly, sufficient visit duration is required to provide adequate information about GDM screen- ing in pregnant women and postnatal care and follow- up are also important. In our country, the duration of the visit in healthcare services is limited to a maxi- mum of 10 minutes per patient. In our survey, the rate of decision to have the test was high among pregnant women who had knowledge about diabetes screening and diagnostic tests at the beginning and about the benefits of diagnosis and treatment if the test were performed. However, the rate of pregnant women who did not have the test and who were undecided was 55%. Therefore, it can be thought that making the time allocated to patients sufficient and of good qual- ity may have an impact on test acceptance rates. The importance of being informed by an experi- enced health professional has been reported. The need for information of pregnant women emerges most intensely right after the diagnosis of GDM. Women who applied to the secondary health facility, stated that they were better informed about diet and blood sugar monitoring than women who were in- formed in the primary health facility.14 In Türkiye, antenatal diabetes screening is recommended in the primary care and if it has not been performed during this period, in the secondary care. There is no re- search on screening rejection in primary care. Our study was conducted in the tertiary center and the test recommendation was made by the obstetrician. De- spite this, the test rejection rate was high. This may be due to the prejudice of the patient, which was formed before the application, rather than the inadequacy of the person providing the service. The positive aspect of the present study is that it reports the rejection rates and information status about the test in a tertiary cen- ter. The detection rates may be different in primary and secondary centers. This is a limitation of our study. The importance of adequate information of pa- tients and individualized shared decision-making was emphasized in determining the duration of treatment after unprovoked venous thromboembolism.15 In our study, similarly, the significantly high rate of having the GCT performed by pregnant women who stated Nazan USAL TARHAN et al. JCOG. 2022;32(4):127-34 132 that they were aware of the test at the start of the study and believed that it would be beneficial when the test was performed. Women’s experiences with a GDM diagnosis were investigated in a qualitative study which in- cluded 19 women from different cultural back- grounds. The diagnostic criteria were viewed as “confusing” by some women and they believe that the treatment for this “borderline” condition was un- necessary.16 In our study, those who thought that there were safer tests other than GCT for screening GDM had a significantly higher rate of test rejection. This suggests that patients’ knowledge on this sub- ject is in confusion. In our study, following the brief information paragraph about the carbohydrate consumption in our questionnaire, the decisions of the participants were re-evaluated. There was statistically significant change in the direction of having the test of the par- ticipants who are unstable. Although the purpose of the study was not an informational intervention, this brief information resulted in a statistically significant decision change. Dickens and Cook emphasized that there is a question in both law and ethics about nature of infor- mation when patients need information to decide to accept recommended treatments. Refusal of recom- mended treatment may pose increased risks to pa- tients’ well-being and may require more emphatic disclosure without pressure.17 The present study has some strengths and limi- tations. It was conducted in a tertiary referral center. Although the sample size is relatively enough for a single center, it would be better to conduct a nation- wide study, so that the results can be generalized to the entire pregnant population. CONCLuSION The healthcare decision-making is a collaborative process between healthcare professionals and pa- tients. The individual and cultural influences of the patients and their thoughts and feelings about the dis- eases, diagnosis and treatment methods should be taken into consideration by the healthcare profes- sionals. Clear, evidence-based and sympathetic pa- tient information can contribute to the correct decision-making of the patients and to the provision of an appropriate diagnosis and treatment process. In- forming patients about the planned tests for screening and treatment of the gestational diabetes which might result in a significant increase in maternal and fetal mortality and morbidity during pregnancy and orga- nizing well-planned trainings for both healthcare pro- fessionals and patients and using public institutions and media, which may be effective in reducing the burden of diabetes on social health and the economic indicators. Source of Finance During this study, no financial or spiritual support was received neither from any pharmaceutical company that has a direct con- nection with the research subject, nor from a company that pro- vides or produces medical instruments and materials which may negatively affect the evaluation process of this study. Conflict of Interest No conflicts of interest between the authors and / or family members of the scientific and medical committee members or members of the potential conflicts of interest, counseling, ex- pertise, working conditions, share holding and similar situa- tions in any firm. Authorship Contributions Idea/Concept: Nazan Usal Tarhan, Habibe Ayvacı Taşan; De- sign: Nazan Usal Tarhan, Habibe Ayvacı Taşan, Gülnaz Nural Bekiroğlu; Control/Supervision: Nazan Usal Tarhan, Habibe Ayvacı Taşan, Erbil Çakar; Data Collection and/or Process- ing: Nazan Usal Tarhan, Habibe Ayvacı Taşan, Erbil Çakar; Analysis and/or Interpretation: Nazan Usal Tarhan, Habibe Ayvacı Taşan, Erbil Çakar, Gülnaz Nural Bekiroğlu; Literature Review: Nazan Usal Tarhan, Habibe Ayvacı Taşan; Writing the Article: Nazan Usal Tarhan, Habibe Ayvacı Taşan, Gülnaz Nural Bekiroğlu; Critical Review: Nazan Usal Tarhan, Habibe Ayvacı Taşan, Erbil Çakar, Gülnaz Nural Bekiroğlu; References and Fundings: Nazan Usal Tarhan, Habibe Ayvacı Taşan. Nazan USAL TARHAN et al. JCOG. 2022;32(4):127-34 133 Nazan USAL TARHAN et al. JCOG. 2022;32(4):127-34 134 1. McKee C, Bohannon K. Exploring the reasons behind parental refusal of vaccines. J Pediatr Pharmacol Ther. 2016;21(2):104-9. [Crossref] [PubMed] [PMC] 2. 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