A hospital-based cross-sectional study was carried out in the Buea Health District (BHD), South West Region of Cameroon, from February to June 2024. This health district has a total population of 169,746 (2017). The BHD has seven health areas with over 48 health facilities, all of which offer antenatal care. A simple random sampling was used to choose two health facilities. This was done by writing down the names of all the eligible health facilities on slips of paper, which were put in a container, and two were randomly drawn out without replacement. The selection of the two health facilities was done as a representative sample in order to statistically project the coverage of antenatal care in the whole district. The results in these facilities can be used as a point estimate, indicating that the rate of pregnant women utilizing regular antenatal care may be used to give an indication of the probable percentage of coverage in the district.

This study used convenience sampling to recruit a total of 500 pregnant women aged 16 - 45 years attending regular antenatal clinics at two selected health facilities within the Buea Health District (BHD). The sample size was calculated using Cochran’s formula.

For a z-value of 1.96 as the standard normal variate at a 95% confidence level, an error margin of 5% (e), and a prevalence of 50% (this method was used because there were no previous conclusive studies on the issue in Cameroon), a minimum sample size of 384 participants was required; however, we finally recruited 500 volunteer pregnant women for this study.

Inclusion criteria

Pregnant women aged 16 - 45 years were received for regular antenatal care within two selected health facilities of the Buea Health District.

Exclusion criteria

Pregnant women with pre-existing diabetes.

Pregnant women who were not residents of the Buea Health District.

Data were collected using an interviewer-administered questionnaire built using Epi Info (Version 7.2.5.0). Data collectors with a minimum qualification of a BSc in Health Sciences were trained for one day prior to data collection. The objectives of the study, the questionnaire content, and the ethical principles of informed consent and confidentiality were explained to them. Pre-testing was done among 7 pregnant women to ensure validity and reliability. The questionnaire was then administered in the English language to collect data. It had three sections: socio-demographics, clinical/obstetric/lifestyle characteristics, and knowledge of GDM. A total of sixteen questions were asked to measure their knowledge of GDM and its risk factors. A score of 1 was assigned for each correct response and 0 for an incorrect response. An overall score of 10 and above was classified as good knowledge, using the Blooms criteria, and a score below the cutoff point was considered poor knowledge. This cutoff was established by analyzing the distribution of the scores, which was in line with thresholds of similar research to indicate a sufficient level of knowledge [14].

Data collected from participants were coded accordingly, and the questionnaire was double-checked for consistency. Missing values were replaced with the mean values. The data were entered into Microsoft Excel 2016 for cleaning and management. The cleaned data were imported to the Statistical Package for Social Sciences (SPSS version 26) for statistical analysis. Descriptive statistics were used to present frequencies and percentages. The chi-square test was used to test associations, and logistic regression analysis was used to determine predictors of good knowledge. The choice of the predictors to be included in the multivariate logistic regression model was done in two phases. To begin with, a simple logistic regression analysis was conducted; variables with p-values ≤0.2 cutoff were considered significant for the multivariate model to ensure that we do not dismiss some important potential confounding variables prematurely. A multivariate logistic regression model was then developed using a manual selection of variables that met the 0.2 cutoff. with a stricter significance level of p < 0.05 to determine the final predictors of the outcome. Odds ratio (OR) estimates and confidence interval (95% CI) with p values <0.05 were considered statistically significant.

Table 1 below shows the sociodemographic characteristics of the study participants. A total of 500 participants were recruited for this study, with a mean age of 28.87 years and a standard deviation of 5.33 years. The majority of the study participants were within the age group of 26 - 35 years, 274 (54.8%). Regarding gestational age, 372 (74.4%) were within a gestational age of 27 - 28 weeks. In terms of educational level, nearly half had tertiary education 224 (44.8%) had achieved a tertiary education. Looking at the number of children, most participants 238 (47.6%) had 1 - 2 children. Most of the study participants 272 (54.4%) were self-employed.

Table 1.Socio-demographic characteristics of pregnant women.

Out of the 500 participants that were interviewed, the majority, 168 (33.6%), didn’t know what gestational diabetes (GDM) was; 150 (30%) said it was diabetes during pregnancy; 96 (19.2%) said it was a condition where blood sugar is stable; and 86 (17.2%) said it was a high blood sugar level after birth (Figure 1).

Figure 1.Distribution of knowledge responses about the meaning of GDM in pregnant women.

When evaluating the level of knowledge on screening, treatment, and complications of GDM among pregnant women (Table 2), the majority, 338 (67.6%), said they had never heard about GDM. A great proportion, 432 (86.4%) of the women believed that diabetes cannot occur during the first pregnancy. Regarding family history of diabetes as a risk factor of GDM, 342 (68.4%) of the participants did not believe a family history of diabetes could be a risk factor for diabetes during pregnancy. The majority of the participants, 448 (89.6%), believed that excessive consumption of sugar could cause GDM. A significant proportion of the pregnant women 408 (81.6%), were aware of blood tests for diabetes. More than half of the participants were of the opinion that testing for diabetes during pregnancy is necessary. Furthermore, 208 (41.6%) believe that diet and exercise can prevent GDM, while 184 (36.8%) acknowledged insulin can treat GDM. A significant majority of the participants 480 (96%), believed that the mother cannot be harmed, 316 (63.2%), if GDM is left untreated. In terms of the risk in developing GDM, almost all the participants, 374 (74.8%), did not believe mothers with GDM are at risk of developing diabetes in the future.

Table 2.(a) Knowledge on screening, treatment, and complications of GDM; (b) Knowledge on screening, treatment, and complications of GDM.

Nearly half of the participants (45%) who heard about GDM heard it from healthcare workers; 32.5% received their information about GDM from friends, while 22.5% obtained their information from mass media (Figure 2).

Figure 2.Source of information about GDM in pregnant women.

Overall, 16 questions were asked to evaluate knowledge on GDM; the computed score showed that, of the 500 participants interviewed, with a mean of 5.66 (SD = 4.48), only 162 (32.4%) had good knowledge on screening, treatment, and complications of GDM (Figure 3).

Table 3 shows a bivariate analysis to identify factors associated with overall good knowledge of GDM. Age category, number of children, and educational level were found to be significantly associated (p < 0.05) with good knowledge of GDM.

Figure 3.Overall knowledge about GDM in pregnant women.

Table 3.Factors associated with good knowledge of GDM in pregnant women.

A logistic regression analysis model was done (Table 4) to identify predictors of good knowledge of GDM. A simple logistic regression model was done with cutoff p ≤ 0.2 being considered as significant for the multivariate. After controlling for confounders, using the manual method multivariate logistic regression, participants aged 18 - 25 years had 3.2 times higher odds of good knowledge (aOR = 3.2, 95% CI: 1.52 - 6.75, p = 0.002) compared to those aged 36 - 45 years. Similarly, individuals with 1 - 2 children (aOR = 4.0, 95% CI: 1.174 - 13.775, p = 0.027) and 3 - 4 children (aOR = 4.8, 95% CI: 1.063 - 21.84, p = 0.041) had significantly higher odds of good knowledge than those with no children. Participants who were married exhibited higher odds of good knowledge compared to single individuals (aOR = 1.2, 95% CI: 1.072 - 1.762, p = 0.016). Educational level was also a significant predictor, with no formal education (aOR = 0.14, 95% CI: 0.124 - 0.991, p <0.001), primary education (aOR = 0.4, 95% CI: 0.245 - 0.641, p < 0.001), and secondary education (aOR = 0.11, 95% CI: 0.101 - 0.161, p < 0.001) all associated with substantially lower odds of good knowledge compared to those at the tertiary level.

Table 4.Predictors of good knowledge of GDM in pregnant women.

The fact that just 32.4% of the pregnant women had good knowledge of the screening, management, and complications of GDM suggests a substantial knowledge gap in this population. This is, indeed, a concern given the rising global burden of GDM and the associated maternal and foetal complications, including preeclampsia, macrosomia, and higher caesarean section rates. Related studies conducted in the sub-Saharan African region report similarly low awareness of GDM. For example, research conducted in Uganda at the Kawempe National Referral Hospital discovered that awareness of GDM was low, and only a proportion of the women had satisfactory knowledge based on their level of education and exposure to health education [15]. In Southern Nigeria, research noted that women in their reproductive years had low awareness of GDM, and a high percentage lacked knowledge of the effects of the condition [13]. The similarities in knowledge levels across Uganda, Nigeria, and Cameroon can be explained by regional issues, including inadequate and uneven health education in the course of antenatal care, the lack of consistency in GDM screening policy, and socioeconomic obstacles, including low female literacy rates, which hinder understanding of health information about GDM [16].

In Cameroon, the health system limitations, such as the lack of professional staffing, insufficient medical equipment, and evidence-based practices, once again restrict the opportunities for GDM education during antenatal visits [17]. Although this study did not measure the impact of some external factors, our findings of poor knowledge must be related to Cameroon’s challenging healthcare system. In politically unstable areas like Buea in the South-West Region of Cameroon, it is possible for access to healthcare and routine antenatal care to be disrupted, limiting potential opportunities for health education [18]. Traditional food taboos in pregnancy, beliefs about obesity signifying wealth and status, and use of traditional healers are some of the cultural practices that could lower biomedical knowledge of GDM in Cameroon because indigenous beliefs reign supreme in Cameroon over the biomedical facility-based information [19]. Healthcare professionals were the leading but not majority source of knowledge, similar to findings in Kenya, wherein one-third of informed pregnant women identified health facilities as their primary source of information [14]. This underscores the vital importance of antenatal care (ANC) visits in the distribution of health-related information. The dependence on mass media and peers as significant sources suggests a possibility of misinformation, as these media might not always offer evidence-based or correct information. One study in Bangladesh stated that while mass media can enhance health literacy, it is not always in-depth for full comprehension of diseases like GDM [20]. This indicates the importance of facility-based education programs that are structured and adapted to local conditions in Buea, including incorporation of literacy-sensitive resources, conducting community work to tackle cultural beliefs, and the enhancement of health systems to address the barriers of accessibility.

The recognition of age, number of children, marital status, and level of education as important predictors of good GDM knowledge is in line with previous studies. The level of education, specifically, has been consistently proven to affect health literacy and knowledge of GDM. A Tanzanian study revealed that educationally more advanced women were likely to be familiar with GDM, due to greater exposure to health information through media and health-related literature [21]. Likewise, South Indian research noted that higher educational levels were related to increased knowledge of GDM, most likely because of greater understanding of information on health made available during ANC [22]. Parity as a predictor may reflect life exposure to health information through repeated ANC visits. Multiparous women may have had more exposure to interactions with healthcare systems, as seen in one study in Ghana, where multiparity was associated with higher GDM awareness [23]. Unexpectedly, younger women showed higher knowledge levels compared to older women, which may reflect exposure to digital media and social networks. This was in line with a study carried out in Samoa, where younger women had more knowledge [24]. Marital status as a predictor could be linked to social support systems, where married women have the advantage of spousal or familial support in seeking health information, a trend observed in a Malaysian study of GDM knowledge [25].

The low knowledge level among pregnant women highlights the urgent need for structured educational interventions during ANC visits to improve the screening and management of GDM. Healthcare providers, being major sources of information, must equip themselves to provide simple, evidence-based education during antenatal care (ANC) visits. In addition, mass media can effectively spread accurate health campaigns to reach women who rely on such media, as suggested by studies on public health education [20]. The critical function of education as a marker suggests that interventions should be specifically designed for women with lower levels of education, who may have difficulty interpreting complicated health information. Community-based interventions, particularly those using community health workers, have been found to be effective in enhancing diabetes knowledge among vulnerable populations and can be modified for gestational diabetes mellitus (GDM) education in Buea [26]. With the late booking of ANC, which mostly had gestational age 27-28 weeks visits as seen in Buea, policy should encourage early ANC booking to allow for maximum opportunities for education and screening [27].