Insulin anxiety and workplace barriers complicate gestational diabetes care

By Dr. Liji Thomas, MDReviewed by Lauren HardakerJan 20 2026

Fear of insulin cognitive overload and workplace constraints can derail gestational diabetes care, but education, support, and motivation to protect the baby help pregnant people manage their condition effectively.

Study: Barriers and facilitators to insulin management in pregnant people with gestational diabetes mellitus: A qualitative study. Image credit: Sk Elena/Shutterstock.com

A recent paper in the journal Pregnancy explores hindrances to and promoters of gestational diabetes mellitus (GDM) self-management, with a particular focus on insulin use and adherence to treatment plans. This could help to frame more effective interventions in this high-risk population.

Nearly 14 % of pregnancies, involving approximately 18 million babies, are affected by GDM. The prevalence has risen over the past thirty years. GDM increases the risk to both the mother and baby, making stringent self-management essential, often including insulin therapy. 

Why gestational diabetes demands rapid lifestyle and treatment changes

GDM increases maternal risk of pre-eclampsia and Cesarean delivery. Over the long term, it predisposes to type 2 diabetes and cardiovascular disease. Infants born to mothers with GDM are more likely to develop hypoglycemia and several other health complications.

Pregnant people with GDM are advised to begin self-management to minimize these risks. This involves:

• The regular measurement of blood glucose levels, both fasting and after meals
• Adjusting habitual food intake patterns accordingly
• Physical exercise
• Glucose-lowering drugs, when required

Dietary recommendations in GDM are encompassed by the term “medical nutrition therapy” (MNT). This involves three meals and two or three snacks a day, adjusted to achieve the target post-meal blood glucose levels. If this dietary manipulation fails to achieve euglycemia, insulin therapy is the treatment of choice.

Intensive self-management is difficult for many women with GDM for multiple reasons. Identifying these difficulties could improve intervention strategies.

Capturing real-world insulin management experiences

The Gestational Diabetes and Pharmacotherapy (GAP) study is a randomized controlled trial (RCT) designed to evaluate the safety and efficacy of initiating insulin therapy in GDM when 20 % of blood glucose readings are elevated, followed by titration to maintain elevated readings below this threshold. The current paper reports a qualitative study conducted as an adjunct to GAP.

The study obtained data from 20 RCT participants recruited through purposive sampling to ensure a diverse mix of participants. All participants received routine prenatal care throughout. Appropriate medical specialists on GDM, MNT, and exercise educated all participants.

For this qualitative study, the researchers interviewed GAP participants after 34 weeks of gestation on topics such as insulin use and treatment plan compliance. This provided them with rich in-depth data on the lived experience of people managing GDM, including both those already using insulin and those anticipating its initiation.

This was analyzed using thematic analysis, based on hermeneutic phenomenology. This is an interpretative approach that considers participants as experts at unraveling the meanings of their personal and social spheres and delves into phenomena from an experiential perspective.

The aim of the study was to identify barriers and promoters of self-management in GDM, particularly those affecting insulin initiation and adherence.

Participant profiles reveal real-world pressures of GDM

Of the 20 participants, 80 % were in their first GDM pregnancy, while 50 % were prescribed insulin. They came from Black, Asian, and White backgrounds for the most part. Most were employed and were 35 to 38 weeks pregnant at the time of the study.

Hurdles

The first major barrier to insulin treatment was fear. Patients feared having to inject themselves with insulin, the perceived complexity of insulin regimens, or dying in their sleep from insulin-induced hypoglycemia, as well as potential harm to the baby.

The second involved reluctance or inability to invest enough time and mental effort to master the elements of GDM self-management, which has a steep learning curve. Many women reported it took them surprisingly longer than expected to gain confidence in self-managing their condition. Repeating therapeutic steps appeared to flatten this curve.

The third challenge was regulating the negative feelings about being diagnosed with GDM and about self-management, with several participants describing an initial sense of shock, self-blame, or moral responsibility for the diagnosis.

The fourth dealt with finding time and opportunity to self-manage GDM, in addition to or while performing other jobs. Participants described difficulty testing glucose at exact prescribed times, administering insulin at work, and safely disposing of needles and lancets in workplace settings.

Rather than a simple lack of information, many participants described the burden of learning and applying complex self-management instructions within a short time frame, which made it more difficult to comply with treatment plans.

Promoters

Among the factors that eased the path to self-management of GDM, including insulin use, the medical team’s role in training and educating the patient was key. For instance, being introduced to the insulin pen calmed self-injection-related fears. Clear, hands-on education helped reduce anxiety and improve confidence in insulin use.

The authors note, drawing on broader diabetes literature, that teaching patients to adjust insulin dosage based on glucose monitoring results can help achieve blood glucose targets more accurately.

Secondly, support from family and friends was helpful, as they monitored and encouraged compliance with the self-management plan.

Last but not least, concern for the baby motivated more intentional self-management of GDM. One mother said, “I feel like it was very easy to be motivated once you think, ‘I'm doing this for my baby.’ And I think everyone just wants to do what's best for their baby. So it makes it very easy to make those changes quickly.”

These findings agree with existing literature suggesting significant emotional distress in women who receive a GDM diagnosis. This includes feelings of self-blame, failure, and sorrow. The diagnosis also prompted many women to take charge of their lifestyle with medical and social support.

The study thus highlights the central role of education about GDM and its self-management in achieving self-management targets.

Workplaces may benefit from focusing on providing time and opportunities for GDM self-management, for instance, by allowing for timely meal and snack consumption amidst a busy schedule and by providing space and time for insulin use at prescribed times.

Despite facing many obstacles, women were consistently dedicated to managing their GDM for the sake of the baby’s well-being. While strongly corroborating earlier literature, this underlines the need for continued motivational efforts after childbirth, given the higher risk of diabetes mellitus in these patients.

This was an urban, single-center study, limited to English-speaking participants, and conducted within a structured RCT environment. Future research should use more diverse settings. The authors also note that participation in a clinical trial and reliance on self-reported experiences may have influenced responses. The study emphasizes the importance of patient education, covering the multiple aspects of GDM that concern patients, the need to set up and include a support network in the education and treatment plan, and the need to frame better workplace policies for women with GDM.

Supporting insulin self-management requires more than prescriptions

Self-management of GDM is a taxing process. Challenges involve fear of using insulin, practical difficulties linked to employment and household responsibilities and constraints, and the need to achieve drastic lifestyle changes in a very short window of time. Conversely, education about the condition and its management by healthcare providers can mitigate these challenges, especially when coupled with family and social support and the strong maternal desire to do what is best for the baby.

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