Gestational diabetes mellitus (GDM) refers to any degree of glucose intolerance with onset or first recognition during pregnancy [1,2]. GDM is a common and consequential health condition during pregnancy, associated with short- and long-term risks for both mother and child. Women diagnosed with GDM face a significant risk of severe health complications such as hyperglycemia, respiratory issues, macrosomia, premature birth, birth injuries, labor dystocia, and even pregnancy-induced hypertension and heart disease [3-6]. Furthermore, their children, in later development, are more likely to experience childhood obesity, early onset of type II diabetes, and an increased risk of cardiovascular disease later in life [7,8]. A cohort study conducted in a diabetes center in Hong Kong revealed that out of 238 women with GDM and postpartum impaired glucose tolerance detected during the postdelivery period, one-fifth (20%) of them developed type II diabetes after an average follow-up period of 4.3 years [9].

GDM currently affects 2% to 10% of pregnant women in the United States, 2% to 6% in Europe, 5% to 8% in Australia, and 10% to 15% in China [10,11]. Asian women, compared to women of many other ethnic backgrounds, are at a higher risk of developing GDM [11,12]. As one of the most common health problems in pregnancy, GDM requires proactive self-management, particularly through lifestyle modifications in diet and exercise, which can reduce complications for both the mother and infant [1,2,7,13].

Self-management refers to an individual’s ability to manage the symptoms, treatments, physical and psychosocial consequences, and lifestyle changes inherent to chronic disease [14,15]. GDM self-management includes self-monitoring of blood glucose, adjusting diet, and increasing physical exercise [7,12].

Self-management skills are also necessary for pregnant women to manage their perception of health conditions that may induce stress, from pregnancy to the postnatal period. Reviews have revealed that self-management resulted in statistically and clinically significant improvements in anthropometric outcomes among women with gestational diabetes [16] and provided them with greater control over their diet and body weight [13]. An interventional study on self-management in chronic disease management demonstrated improved health status, health behavior, and self-efficacy, as well as fewer emergency room visits for participants [17]. Studies report that women diagnosed with GDM face challenges in adapting to their new diagnosis [18-21]. Women often feel frustrated by being diagnosed with the condition and experience a lack of control [21-23].

A study found that categories of factors affecting self-management include personal lifestyle characteristics, health status, resources, environmental characteristics, and the health care system. Factors may interact to affect self-management and may exist on a continuum from facilitator to barrier [24]. Understanding the factors that affect self-management could enhance the evaluation of self-management among pregnant women with gestational diabetes. This understanding could also guide the development of interventions designed to address individual needs and improve health outcomes. These findings suggest that focusing solely on individual responsibility is insufficient; a broader perspective is needed to understand the multilevel system of factors influencing self-management.

This review emphasizes the use of the socioecological model (SEM) as a guiding framework for understanding the factors that influence self-management behaviors in women with gestational diabetes. The SEM, widely accepted and used for understanding the health behaviors of individuals, takes into account the dynamic interplay between individuals and their environments as determinants of health-related behavior [25]. This model recognizes that an individual’s behavior is influenced by multilevel factors [25,26]. Applied to this review, the SEM provides a framework to systematically identify and analyze the obstacles and enablers of GDM self-management across these levels, from personal experience to policy context.

The aim of this systematic review is to comprehensively explore and identify the obstacles and enablers to the self-management of gestational diabetes in pregnant women. It seeks to understand the specific obstacles and enablers at various levels—intrapersonal, interpersonal, organizational, community, and policy—that influence the self-management of this condition. The review will use the SEM to provide a holistic understanding of the factors affecting the self-management of gestational diabetes among pregnant women.

A comprehensive and reproducible search strategy was developed to systematically identify all relevant literature. The search terms were developed through an iterative process involving a review of key papers on GDM self-management to identify relevant terminology, consultation with database thesauri (eg, MeSH in MEDLINE) to incorporate controlled vocabulary, and the combination of 3 core conceptual categories: GDM (eg, “gestational diabetes mellitus”), self-management (eg, “self-care” and “self-monitoring”), and determinants (eg, “barriers,” “facilitators,” and “enablers”). Boolean operators (AND, OR) were used to link these concepts. The final search strategy was peer-reviewed by a university research librarian to enhance its sensitivity and specificity. Electronic databases to be systematically searched included MEDLINE, PsycINFO, CINAHL, PubMed, Cochrane Library, and Web of Science. The keywords that were searched included the following: (“gestational diabetes” OR “gestational diabetes mellitus” OR “diabetes in pregnancy” OR “GDM”) AND (“self-management” OR “self-care” OR “self-regulation” OR “self-monitoring”) AND (“barriers” OR “obstacles” OR “challenges” OR “difficulties” OR “issues” OR “problems” OR “facilitators” OR “motivators” OR “enablers”).

The initial search was conducted in February 2024 and was limited to papers published in English between 2010 and the end of 2023. To ensure the review included the most current evidence, the search was updated in October 2025 to cover publications from January 2024 to October 2025. A citation search of the included studies was also performed to identify additional relevant studies.

This study has been registered with PROSPERO (CRD42023491588) and was conducted in adherence to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Checklist 1).

Studies were included if they met the following criteria: (1) the population comprised pregnant women diagnosed with GDM, excluding studies focused solely on the postpartum period; (2) the study investigated barriers, facilitators, obstacles, enablers, challenges, or motivators related to GDM self-management, which included behaviors such as dietary modification, physical activity, self-monitoring of blood glucose, and medication adherence; (3) the study was conducted in any health care or community setting; and (4) the study design was qualitative, quantitative descriptive, or mixed methods. Review papers, commentaries, conference abstracts, and protocol papers were excluded. Only studies published in English from January 2010 onward were considered, incorporating an initial search up to the end of 2023 and an updated search to October 2025.

A total of 5843 records were identified through the initial database search. After removing 853 duplicates using Covidence (Veritas Health Innovation Ltd), 4990 unique studies underwent title and abstract screening, resulting in 126 reports sought for retrieval. Of these, 119 were successfully retrieved for full-text eligibility assessment. Additionally, 32 records from an updated search (2024‐2025) and 8 records from citation searching were screened, with 11 and 8 proceeding to full-text assessment, respectively. Following full-text review, 25 studies from the database search, 3 from the updated search, and 2 from the citation search met the inclusion criteria, yielding a total of 30 studies in the final synthesis. The study selection process is detailed in the PRISMA flow diagram in Results section. Screening and eligibility assessments were performed independently by 2 reviewers, with discrepancies resolved through discussion and, where necessary, arbitration by a third reviewer.

The initial screening of titles and abstracts was conducted independently by 2 reviewers. The full texts of potentially eligible studies were subsequently assessed for eligibility against the inclusion and exclusion criteria, also independently by both reviewers. Any discrepancies regarding the inclusion or exclusion of studies were resolved through discussion with a third reviewer until a consensus was reached. This same collaborative process was applied during the quality assessment stage.

The methodological quality of each included study was appraised independently by 2 reviewers using the Mixed Methods Appraisal Tool (MMAT; version 2018; McGill University) [27]. Based on the study designs identified in our review, only the MMAT checklists for qualitative, quantitative, descriptive, and mixed methods studies were applied; no randomized controlled trials or nonrandomized quantitative studies were included. The complete quality assessment results are provided in Multimedia Appendix 1.

In this review, the terms “barriers” and “obstacles” are used interchangeably, as are the terms “facilitators” and “enablers,” to reflect the language used across the included literature. Data extraction and synthesis followed a convergent qualitative synthesis design, explicitly guided by the SEM [25] as an analytical framework. The process consisted of 3 stages: extraction, thematic synthesis, and framework analysis.

This study does not involve human participants.

This systematic eligibility review process resulted in a final dataset of 30 studies on self-management of GDM, with 24 being qualitative studies, 4 quantitative studies, and 2 mixed methods studies (Figure 1). The identified studies represent a diverse population from 13 countries. Most were conducted in Oceania (n=13), followed by Asia (n=7), North America (n=5), Europe (n=4), and Africa (n=1). The total number of participants in these studies was 2070, with sample sizes ranging from 9 to 564.

The majority of the studies recruited participants through the traditional method of direct contact with pregnant women during clinic visits (n=20). However, newer recruitment methods were also introduced, such as email (n=4), phone (n=3), mobile applications (n=1), and social media (n=2).

In the self-management of GDM, diet modification was the most commonly adopted approach according to 27 studies, followed by exercise (n=23), blood glucose monitoring (n=20), and insulin self-administration (n=3). The characteristics of the selected studies are summarized and listed in Table 1.

The results, detailed in Multimedia Appendix 1, demonstrate high methodological quality overall. Of the 30 appraised studies, the majority were qualitative (n=24), with quantitative descriptive (n=4) and mixed methods (n=2) studies. The vast majority of criteria were rated “Yes.” A small number of “Cannot tell” ratings were present, primarily for criterion 1.5 (qualitative) and criterion 4.4 (quantitative descriptive). No study received more than 2 such ratings, supporting the robustness of the evidence base.

The functional support network provided by a woman’s immediate social circle was a pivotal factor influencing GDM self-management. A significant obstacle was the absence of this support from family and partners, which left women without the necessary encouragement and practical help [20,28,35,39,45,47-49,53]. This challenge was often exacerbated when family or friends provided unhealthy food, creating interpersonal conflict and directly undermining dietary adherence [55]. A related obstacle was the lack of shared responsibility for family and work commitments, which placed the burden of managing GDM solely on the woman amidst her existing duties [28,32,37,39,45,49,54]. Quantitatively, 38.3% (23/60) of women identified being offered unhealthy food by family or colleagues as a barrier [40], while family and child care responsibilities were also frequently cited (32.9%‐40.9%) [34].

Conversely, a robust functional support network served as a powerful enabler. This included emotional and appraisal support—such as encouragement, empathy, and shared accountability—which helped women cope with the stress of their diagnosis and maintain motivation [28-30,32,35-38,40,45,48-50,53-55]. Husband encouragement was a key motivator, reported by 22.6% to 28.7% of women [34]. Tangible, indirect logistical aid was equally critical, with collaborative healthy meal preparation by family members being a key factor in successfully managing dietary changes [28-30,32,35-38,40,45,48-50,53].

At the organizational level, the structure and delivery of health care services significantly influence self-management. The analysis identified 3 key factors: the quality and applicability of health care, its accessibility and continuity, and workplace demands.

At the community level, broader societal and environmental factors play a significant role. The analysis identified 2 key factors: the food environment and cultural norms, as well as the digital information and peer support landscape.

At the policy level, systemic and regulatory factors were found to significantly influence the resources available for GDM self-management. The analysis identified 2 key factors: regulatory and infrastructural systems, and economic support systems.

This systematic review, using the SEM, reveals that adherence to GDM self-management is not primarily an issue of individual willpower but a complex systemic challenge. Factors enabling or hindering women exist and interact across all 5 levels of the SEM—from personal emotions to national policy. The key contribution of this synthesis is, therefore, not merely the identification of these multilevel determinants but the critical insight into how they interlock to create a context that can either overwhelm or empower women. Moving beyond a simple listing of barriers and facilitators, the following discussion integrates these findings to critically inform the development of effective, holistic support strategies, with particular attention to the role of digital health solutions.

Our findings align with and extend existing literature on chronic disease self-management, which emphasizes the limitations of an individual-focused approach [24]. The significant burdens reported at the intrapersonal level—emotional distress, knowledge deficits, and logistical constraints—are consistent across studies of GDM [29,33]. However, this review underscores that these personal challenges are frequently exacerbated by challenges at other levels. For instance, intrapersonal anxiety and confusion are often directly amplified by organizational factors such as conflicting information from providers or a lack of continuity of care [28,37]. Similarly, the interpersonal obstacle of unsupportive family environments is linked to community-level cultural norms about food and pregnancy [54,55]. This pattern confirms the core SEM tenet that individual behavior is embedded within and shaped by broader systems, a perspective sometimes underemphasized in GDM management research, which focuses predominantly on educational interventions. The interconnected nature of these challenges calls for equally interconnected solutions.

A critical synthesis of the results points to 2 dominant, cross-level themes: fragmentation of support and information inequity. Fragmentation occurs when care is discontinuous (organizational), social support is absent (interpersonal), and policies fail to coordinate services (policy), leaving women to manage alone. This isolation intensifies intrapersonal stress. Information inequity arises when accessible, trustworthy guidance is scarce. It manifests as a lack of knowledge (intrapersonal), confusing clinical advice (organizational), and an online landscape rife with misinformation (community). These themes are synergistic, creating a vicious cycle that traps women. For example, a woman may receive vague dietary advice from a busy clinic (organizational), seek clarity online only to encounter conflicting information (community), feel increased anxiety and guilt (intrapersonal), and lack a supportive partner to help her navigate these challenges (interpersonal). Effective interventions must, therefore, be designed to bridge these fragments and curate reliable information flows. The relevance of the SEM for understanding GDM-related behaviors is further supported by recent systematic reviews applying the SEM to postpartum physical activity, which similarly identified critical barriers and facilitators at social, organizational, and community levels beyond the individual [57,58].

Consequently, to disrupt these cycles, support strategies must be multipronged and explicitly designed to counteract these systemic failures. Digital health platforms are uniquely positioned to integrate solutions across SEM levels, but their design must be informed by this nuanced understanding. For example, to combat information inequity, a platform must provide centralized, evidence-based, and culturally tailored education (addressing intrapersonal and organizational failures) while incorporating algorithmically vetted content and professional moderation to create a trusted digital community (addressing community-level risks). To address fragmentation of support, features could include shared care plans visible to both patients and providers to improve continuity (organizational), tools to involve and educate family members (interpersonal), and integrated telehealth functions that bypass geographical and time barriers (organizational or community). Crucially, for such tools to be equitable, sustainable, and trustworthy, policy-level advocacy for reimbursement, funding, and robust data security and privacy protection frameworks is essential [43].

These design principles require special consideration for high-risk or underserved populations identified in this review. A critical finding is that challenges related to understanding information should not be reductively classified merely as “language barriers.” For women with limited health literacy—who struggle to comprehend complex medical information even in their primary language—and for working professionals, the health care system’s responsibility extends beyond translation. Providers must prioritize simplifying information, using clear communication, and ensuring cultural relevance to actively improve health literacy. For employed women, such as nurses [54], asynchronous, flexible digital features that accommodate shifting schedules are critical. A one-size-fits-all tool risks perpetuating the very inequities it seeks to solve.

This review has several limitations. Although the methodological quality of the included studies, assessed using the MMAT, was generally high (Multimedia Appendix 1), the preponderance of qualitative studies and those from high-income countries may affect the transferability of findings. The predominance of qualitative studies enriches the understanding of lived experience but limits quantitative generalizability. Furthermore, most included studies were from English-speaking and high-income countries, which may not capture the full spectrum of contextual barriers in low-resource settings and may affect the transferability of findings. Finally, while the SEM provided a valuable organizing framework, the classification of some factors (eg, personal logistics) into a single level is inherently somewhat reductive, as influences often span multiple levels.

Supporting GDM self-management, therefore, demands a systemic view. Achieving meaningful improvement will depend on integrating strategies that simultaneously empower the individual, engage her support network, streamline and humanize health care delivery, foster supportive communities, and advocate for enabling policies. Future intervention research, particularly in digital health, must therefore evaluate not just patient-level outcomes but also how effectively solutions address these interconnected, multilevel determinants to achieve truly comprehensive care.

The findings of this review underscore the necessity for comprehensive, multilevel strategies to enhance adherence to GDM self-management. These implications target various stakeholders across the socioecological spectrum.

In conclusion, this systematic review demonstrates that successful self-management of GDM requires an integrated, multilevel approach informed by the SEM. Moving beyond a focus on individual responsibility, effective support must simultaneously address intrapersonal, interpersonal, organizational, community, and policy factors. By designing interventions and systems that acknowledge and bridge these interconnected levels, health care providers, policymakers, and communities can significantly improve adherence to self-management, ultimately leading to better health outcomes for mothers and their children.