Between May 2024 and July 2024, a cross-sectional multicentre study was carried out at four maternity hospitals in the Souss-Massa region of southern Morocco. This study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines relating to the design of cross-sectional studies.¹⁶

Four maternity hospitals in the Souss-Massa region were selected for the study: the regional maternity hospital at Hassan II Hospital in Agadir, the provincial maternity hospital in Inezgane Ait Melloul, the provincial maternity hospital at El Mouhtar Essoussi in Chtouka Ait Baha and the provincial maternity hospital at El Moukhtar Essoussi in Taroudant.

The study examined the delivery records of all pregnant women with GDM who delivered in these four hospital maternity units between January 2019 and December 2023. The delivery records of pregnant women with GDM who delivered at these four maternity hospitals were included in this study. However, delivery records of women with type I and type II diabetes prior to pregnancy, delivery records of women with other pathologies during pregnancy and delivery records with missing or empty data were excluded from this study.

The sampling technique used was a non-random sample stratified by quota (by province and by year) at the level of the four maternity units. The sample size was calculated based on a 2.5% margin of error and a 95% confidence interval (CI). This calculation considered the total population of live births in the Souss-Massa region, which amounted to 34 377 births recorded from 2017 to 2021, according to the Regional Health Observatory (2023).

We retained a prevalence of 23.7% based on a Moroccan study carried out in 2018 in the Marrakech Al Haouz region.

The calculation was performed on the sample size calculator website: OpenEpi (version 2013) (https://www.openepi.com/SampleSize/SSPropor.htm).

This number is broken down by province, taking into account the percentage of its population in relation to that of the region.

The study ultimately analysed 120 delivery records from women with GDM and 177 records from women without GDM after excluding incomplete or records meeting other exclusion criteria (Figure 1).

Qualitative variables were summarised using frequencies and percentages. Quantitative variables were described using mean ± standard deviation (s.d.) for normally distributed data or median (interquartile range [IQR]) for non-normally distributed data.

Bivariate analysis was performed using the Chi-square test or Fisher’s exact test for qualitative variables and Student’s t-test or Mann–Whitney U test for quantitative variables, as appropriate. Adjusted odds ratios (aOR) with 95% CI were calculated to quantify the relative risk of adverse outcomes associated with GDM (compared to women without GDM). In order to analyse the association between GDM and complications while controlling for potential confounders, multivariate analysis was performed using multiple logistic regression models. P-values below 0.05 were considered statistically significant. All data were processed using SPSS^® version 27.

Anonymity and confidentiality in the processing of data extracted from delivery records were upheld in accordance with the Declaration of Helsinki and its subsequent amendments. Authorisation for data collection was secured from the Direction Régionale de la Santé et de la Protection Sociale (Regional Health and Social Protection Directorate) to access delivery records and conduct this study in hospital maternity units. In addition, ethical approval was granted by the Ethics and Biomedical Research Commission of the Mohammed V University Faculty of Medicine and Pharmacy in Rabat (Reference: 78/24).

Women with GDM had significantly higher odds of developing pregnancy-induced hypertension during labour (aOR = 3.4; p = 0.002).

The odds of caesarean delivery were substantially elevated in the GDM group (aOR = 3.4; p < 0.001). Consequently, this lowered the odds of spontaneous vaginal birth (aOR = 0.5; p = 0.003). This was largely driven by significantly higher odds of caesarean performed for macrosomia (aOR = 6.0; p < 0.001) and preeclampsia (aOR = 7.1; p = 0.002).

Gestational diabetes mellitus was associated with a dramatically increased risk of shoulder dystocia (aOR = 12.2; p < 0.001) and a higher risk of perineal tears (aOR = 2.6; p = 0.04).

Conversely women with GDM had lower odds of receiving an episiotomy (aOR = 0.5; p = 0.01).

Table 3 presents findings from a multivariate logistic regression analysis evaluating the association between GDM and the occurrence of various obstetric complications. The associations for specific complications were as follows.

Gestational diabetes mellitus showed a trend towards increased odds (OR = 1.37; 95% CI: 0.70–2.69), but this association did not reach statistical significance (p = 0.352).

Gestational diabetes mellitus was strongly and significantly associated with an increased risk of preeclampsia (OR = 5.95; 95% CI: 1.21–29.22; p = 0.028).

A significant association was observed between GDM and shoulder dystocia (OR = 16.30; 95% CI: 3.32–79.95; p = 0.001).

Gestational diabetes mellitus was significantly associated with increased odds of perineal tear (OR = 3.037; 95% CI: 1.75–5.28; p < 0.001), with odds approximately three times higher for women with GDM.

A trend towards increased odds of immediate PPH was noted with GDM (OR = 1.82; 95% CI: 0.66–5.01), but this association was not statistically significant (p = 0.25).

The association between GDM and puerperal infection was not statistically significant in this analysis (OR = 1.59; 95% CI: 0.68–3.73; p = 0.284).

Women with a history of gestational hypertension had a significantly higher risk of being diagnosed with gestational diabetes (aOR = 8.29; p < 0.001). Women with a family history of type 2 diabetes also had a significantly higher risk of being diagnosed with GDM (aOR = 21.38; p < 0.001).

Although there was a slight increase in risk for women who had undergone an appendectomy (aOR = 3.52), the p-value was not significant (p = 0.1069). There was no clear link between appendectomy and diagnosis. Women who underwent gallbladder surgery had a significantly higher risk of being diagnosed (aOR = 2.47; p = 0.0627).

Women with a history of abortion had a significantly higher risk of being diagnosed with GDM (aOR = 2.19; p = 0.0089). On the other hand, there was no significant association between a history of foetal death in utero and the diagnosis of GDM (aOR = 2.31; p = 0.1878). Similarly, there was no significant association between a history of stillbirth and GDM (p = 1.0000).

Women with a history of prematurity and macrosomia have a significantly higher risk of being diagnosed with GDM, respectively (aOR = 3.47; p = 0.0113), (aOR = 8.92; p = 0.0002).

Body mass index appears to play an important role in diagnosis. Obese women have a significantly increased risk, while women of normal weight have a reduced risk.

According to the multivariate logistic regression analysis in this table, advancing maternal age was highly significantly associated with increased odds of GDM (p < 0.001). Each additional year of age corresponded to a 7.9% increase in odds (OR = 1.08; 95% CI: 1.03–1.13).

Overweight (OR = 0.080) and obesity (OR = 0.34) were associated with marked risk reductions (92% and 66%, respectively). Similarly, family history showed a significant negative association (OR = 0.053; p = 0.013), corresponding to a 94.7% risk reduction.

Preterm birth shows β = –1.08 (OR = 0.340; p = 0.044), corresponding to a 66% risk reduction. Macrosomia demonstrates β = –1.43 (OR = 0.24; p = 0.052), equivalent to a 76% reduction; history of abortion shows a non-significant β (–0.105; p = 0.765).

This study highlights significant disparities in the screening and management of GDM in the south of Morocco, revealing persistent challenges and opportunities for improvement.

Early screening before 24 WA was performed in only 17.5% (95% CI: 11.5% – 25.6%) of patients (Figure 2), falling far below national recommendations.¹⁷

This study underscores the inadequacy of therapeutic management for pregnant women. In fact, screening before 24 weeks (WA) was conducted in only 17.50 of women diagnosed with GDM. This initial diagnostic delay contrasts with the 38.3% screening rate observed between 24 weeks and 28 weeks of WA (Figure 2), which significantly exceeds the 21% reported in an earlier Moroccan study.^5,18 While this improvement suggests better adherence to protocols during routine second-trimester visits, critical gaps remain.

This cohort (n = 120) exhibited classic GDM risk factors, including older maternal age (32.6 ± 6.4 years) and obesity (65.3% with BMI ≥ 30) (Table 1). Despite their high-risk profile, these women did not receive sufficiently early or systematic screening. Therapeutically, 47.5% of patients achieved glycaemic control through diet and lifestyle modifications alone, while 17.5% required insulin therapy (Figure 2). These findings confirm the efficacy of nutritional interventions as first-line therapy.¹⁹ Most pregnant women are able to successfully normalise their blood sugar levels.

However, in approximately 30% of patients inadequate response necessitates a step-up to second-line therapy, notably when glycaemic imbalances are identified.^11,20 At hospital admission, only 8.3% of women with GDM received fasting blood glucose testing. This represents a critical care gap, as admission glucose monitoring serves as a key intervention for hyperglycaemia detection. Current evidence demonstrates that blood glucose levels > 120 mg/dL during labour warrant intrapartum insulin therapy.²¹ Furthermore, even mild untreated hyperglycaemia has been associated with a 1.8-fold increased risk of caesarean delivery²² underscoring the importance of systematic glucose surveillance in this population.

Our study found that only 10.83% of women who delivered with gestational diabetes were followed by an endocrinologist, and fasting blood glucose testing was requested for only 5% of these women (Figure 3). These findings align with various studies indicating that postpartum screening is notably low and infrequent.^23,24 However, women with this pathology have a significantly increased risk (OR = 17.92) of developing type 2 diabetes.^11,25,26

In addition, 10% of women who have had gestational diabetes develop diabetes immediately after delivery.²⁷ Therefore, monitoring blood glucose levels in the immediate postpartum period is crucial for improving follow-up rates for women with GDM.²⁶ Implementing a reminder system for check-ups and educational initiatives could also help mitigate future risks for these women.²⁴

Regarding capillary self-monitoring of blood glucose levels, the study found that only 25% of women who delivered with gestational diabetes performed this monitoring (Figure 2). This lack of postpartum monitoring may stem from insufficient knowledge and awareness about the importance of monitoring during this period to detect hyperglycaemia associated with GDM. Similarly, a study by Balaji et al. emphasised that this deficiency is largely related to emotional stress and difficulties in adapting to motherhood among new mothers.²³

Out of the 120 pregnant women with GDM in our sample, only 32 received dietary advice (Figure 2). Adhering to a healthy diet for all women with GDM can reduce the risk of developing type 2 diabetes and cardiovascular disease by 30%.^28,29

In this regard, the Moroccan healthcare system has yet to establish strategies for regular postpartum follow-up, especially for women who have had gestational diabetes. To address this, developing a telephone support system and implementing telemedicine consultations, particularly for educational purposes,²⁸ along with leveraging artificial intelligence, are key recommendations to ensure proper follow-up for women after delivery.

Various studies have indicated that the risk of caesarean delivery is elevated in women with GDM.^24,30 Our study demonstrated a significant association between caesarean delivery and GDM, with aOR = 3.42 (95% CI: 2.07–5.66; p = 0.007) than the comparison group (Table 2). In addition, a logistic regression model was utilised to assess the relationship between GDM and maternal complications at delivery (Table 3). The findings revealed that the increased risk of caesarean delivery among women with GDM was 2.52 (95% CI: 1.29–4.92) (Table 3). The primary reason for caesarean sections was macrosomia. occurring in 76.32% of cases (aOR: 5.94; 95% CI: 2.70–13.11; p < 0.001) (Table 2). These results align with a case-control study by Luhete et al.³¹, which reported that caesarean delivery for macrosomia occurred in 15.6% of cases compared to 9.8% in controls, yielding a twofold increased risk for macrosomia (adjusted OR = 1.7; 95% CI: 1.0–2.8; p = 0.0419).³¹

From another perspective, all study findings consistently indicate a strong association between GDM and preeclampsia.^14,32

To enhance our statistical analysis, a logistic regression model was employed to examine the relationship between GDM and predictor characteristics related to pregnancy outcomes in our study population. The analysis confirmed that gestational diabetes was significantly associated with several other delivery outcomes: preeclampsia (OR = 5.95; 95% CI: 1.21–29.21), shoulder dystocia (OR = 16.30; 95% CI: 3.32–79.95) and perineal tear (OR = 3.04; 95% CI: 1.74–5.28). The magnitude of the associated risk is particularly striking for shoulder dystocia and preeclampsia. Conversely, while trends towards increased risk were noticed for general complications during labour, PPH and puerperal infection, these associations did not reach statistical significance in this study (Table 3).

According to several international studies, macrosomia is one of the primary factors linked to perineal tears during childbirth.³³

Regarding immediate PPH, this study indicated a potentially elevated risk for women with GDM (OR = 1.82; 95% CI: 0.66–5.01); however, this association did not reach statistical significance (Table 3). This finding corroborates the results reported by Ye et al.,³⁴ who similarly found no statistically significant association between gestational diabetes and the risk of immediate PPH.

In another aspect, this study examined factors that may be associated with GDM among women from southern Morocco. The analysis confirmed maternal age as a significant risk factor for GDM (β = 0.076; OR = 1.08; 95% CI: 1.03–1.13; p < 0.001), indicating that each additional year increases the odds by about 7.9%, consistent with age-related declines in insulin sensitivity (Table 5). This aligns with other studies that recognise advanced maternal age (typically > 35 years) as a key risk factor for developing GDM.^12,35

Obesity (BMI ≥ 30 kg/m²) was identified as a strong risk factor for GDM (p < 0.001), affecting 65.3% of women in this category. Compared to normal weight individuals, obese women exhibited significantly higher odds – nearly five times greater – of developing GDM (OR = 4.81; 95% CI: 2.86–8.07) (Table 4). These findings align with a study conducted in Egypt, where 50% of women with GDM had a BMI greater than 30 (p < 0.001), compared to 21.2% of women without GDM. Thus, obesity is recognised as a major risk factor for the development of GDM.^12,27 These results underscore the importance of weight management in pregnant women to help prevent both maternal and foetal complications associated with GDM.

However, the logistic regression model (Table 5) reports, for overweight women, β = –2.530 (OR = 0.08; p < 0.001) translates to a 92% risk reduction. For obesity, β = –1.075 (OR = 0.34; p < 0.001) corresponds to a 66% risk reduction. These negative β values, while counterintuitive, show statistical robustness and may suggest the presence of specific protective factors in this population or differences in medical management.

Another factor examined was the family history of type 2 diabetes. The study found an aOR = 21.38 (95% CI: 2.76–165.79), indicating a significant association between this factor and GDM (p = 0.0001) (Table 4). This finding aligns with previous research that highlights family history of type 2 diabetes as one of the most common risk factors for GDM.³⁶

Furthermore, this study found a significant association between a history of abortion and GDM, with aOR = 2.19 (95% CI: 1.25–3.85; p < 0.0089). Similarly, there was a significant association between a history of prematurity and GDM, with an aOR = 3.47 (95% CI: 1.37–8.79; p < 0.0113) (Table 4). These findings align with a study conducted in Jordan, which also reported significant associations between both a history of abortion and prematurity with GDM.³⁵ This study showed an association between a history of macrosomia and GDM compared to pregnant women without GDM, with aOR= 8.92 (95% CI: 2.54–31.36 vs. aOR = 0.11 [95% CI: 0.03–0.39; p = 0.0002]).

According to the regression model, obstetric history reveals notable variations. Preterm birth shows β = –1.080 (OR = 0.34; p = 0.044), corresponding to a 66% risk reduction. Macrosomia demonstrates β = –1.433 (OR = 0.24; p = 0.052), equivalent to a 76% reduction, although this association approaches but does not reach conventional statistical significance. History of abortion shows a non-significant β (–0.105; p = 0.765), indicating no clear association with gestational diabetes in this study.