Moderate Awareness of Gestational Diabetes Mellitus and Its Complications Among Women in the Northern Borders Province, Saudi Arabia: Implications for Educational Interventions

Abstract

Objective: To assess gestational diabetes mellitus (GDM) awareness among women in the Northern Borders Province of Saudi Arabia and identify factors associated with knowledge levels. Methods: A cross-sectional study was conducted among 461 women using a structured, validated online questionnaire assessing demographics, medical history, and knowledge of GDM’s effects on maternal and neonatal outcomes. Associations between demographic factors and GDM awareness were analyzed using chi-square tests. Results: Most participants (98.5%) were Saudi nationals, with a mean age of 34.5 ± 10.0 years; 82.6% had university-level education. Overall, 42.3% demonstrated fair awareness of GDM, 34.3% had good awareness, and 23.4% had poor awareness. Knowledge of GDM’s maternal complications varied: 70% recognized the risk of emergency cesarean section, but only 8.2% were aware of increased preeclampsia risk. For neonatal outcomes, 58.4% identified high birth weight as a risk, while only 31.9% recognized the risk of congenital anomalies. Higher awareness was significantly associated with education level (p = 0.02), pregnancy status (p = 0.001), trimester (p = 0.002), and family history of relevant conditions (p = 0.04). Conclusion: Although many women showed fair-to-good awareness of GDM, notable gaps remain, especially regarding specific complications. Targeted educational interventions, particularly for less-educated and non-pregnant women, are recommended to improve GDM awareness and pregnancy outcomes.

1. Introduction

Gestational diabetes mellitus (GDM) is a prevalent metabolic disorder of pregnancy, characterized by glucose intolerance with onset or first recognition during gestation, typically between 24 and 28 weeks [1,2]. Globally, GDM complicates an estimated 9–14% of pregnancies, representing a significant public health challenge due to its adverse effects on both maternal and fetal outcomes [3]. According to the International Diabetes Federation, approximately 16% of pregnancies in 2019 were affected by some form of hyperglycemia, with GDM accounting for over 85% of these cases [1].

The pathophysiology of GDM is multifactorial, involving a complex interplay between maternal metabolic adaptations and placental hormones such as cortisol, progesterone, prolactin, and human placental lactogen. These hormonal changes induce progressive insulin resistance, a normal physiological adaptation in pregnancy intended to ensure adequate nutrient supply to the fetus [4]. In women with underlying risk factors, such as advanced maternal age, obesity, family history of diabetes, previous GDM, or certain ethnic backgrounds, this insulin resistance may exceed the compensatory capacity of pancreatic beta cells, resulting in hyperglycemia [5].

The global rise in maternal obesity and the trend toward delayed childbearing have contributed to the increasing prevalence of GDM [6]. In Saudi Arabia, the burden of GDM is particularly pronounced, with reported prevalence rates ranging from 15% to as high as 51% in certain regions and age groups, notably peaking among women aged 31–35 years [7,8,9]. This alarming prevalence underscores the urgent need for effective screening, prevention, and management strategies tailored to the Saudi context [2,10].

GDM poses significant short- and long-term risks for both mother and child. Maternal complications include an increased risk of preeclampsia, cesarean delivery, and future development of type 2 diabetes mellitus [3]. For the fetus and neonate, GDM is associated with macrosomia, shoulder dystocia, preterm birth, respiratory distress syndrome, neonatal hypoglycemia, and a heightened risk of metabolic disorders later in life [11]. Early identification and appropriate management of GDM can substantially reduce these adverse outcomes [12,13,14].

Despite the well-established health implications of GDM, awareness and knowledge among women of reproductive age remain inadequate in many settings [15,16]. Studies conducted in various regions of Saudi Arabia consistently report low levels of GDM awareness, with the majority of women demonstrating poor knowledge regarding its risk factors, complications, and management [17,18,19]. For example, a cross-sectional study in Jeddah found that 77.8% of women had poor knowledge of GDM, and only 6.1% demonstrated good knowledge [19]. Similar trends have been observed in other regions, where educational attainment, multiparity, and personal or family history of diabetes were positively associated with higher awareness levels [18]. Notably, social media and informal networks, rather than healthcare professionals, were the most common sources of information [19].

Targeted educational interventions have been shown to significantly improve knowledge and attitudes toward GDM [20]. However, there is a paucity of data on GDM awareness in the Northern Borders Province of Saudi Arabia, a region with unique demographic and cultural characteristics [21]. Understanding the current level of awareness and identifying knowledge gaps in this population are essential for designing effective public health strategies.

Given the high prevalence of GDM in Saudi Arabia and the documented variability in awareness across different regions, this study aims to evaluate the awareness of GDM among women in the Northern Borders Province. Specifically, it seeks to (a) assess the current level of knowledge regarding GDM, its risk factors, complications, and management; (b) identify sociodemographic determinants of awareness; and (c) highlight gaps in knowledge that may hinder effective prevention and early detection. The findings will inform the development of regionally tailored educational programs and public health initiatives to enhance GDM prevention, early detection, and management, ultimately improving maternal and neonatal outcomes in this region and beyond.

2. Results

2.1. Participant Characteristics

A total of 461 women residing in the Northern Borders Province of Saudi Arabia participated in the study, yielding a high response rate and ensuring a robust representation of the target population (Figure 1).

The mean age of participants was 34.5 years (SD ± 9.96). Nearly all respondents (98.5%) were Saudi nationals. The majority had attained a university-level education (82.6%), and most were married (80.3%). At the time of data collection, 10.4% of participants were pregnant, with the majority in their first trimester.

Regarding medical and family history, 26.5% reported a family history of diabetes mellitus (DM), 10% of hypertension (HTN), 5.9% of hypothyroidism, 1.3% of heart disease, and 2.4% of GDM. Among participants themselves, the most common chronic conditions were hypothyroidism (5.4%), DM (5.2%), HTN (2.6%), polycystic ovarian syndrome (PCOS, 2.6%), GDM (2.6%), and preeclampsia (PET, 0.7%) (

Table 1. Basic characteristics of the study participants.

Total Participants = 461		No.	%
Age (years)
Age group (years)	Mean ± SD	34.53 ± 9.96
	18 to 25	116	25.2
	26 to 35	135	29.3
	36–49	210	45.5
BMI (kg/m2)	Underweight	11	2.4
	Normal weight	158	34.3
	Overweight	151	32.8
	Obese	140	30.4
Nationality	Non-Saudi	7	1.5
	Saudi	454	98.5
Parity category	Nulligravida	91	19.7
	Multigravida	219	47.5
	Grand gravida	151	32.8
Are you pregnant	No	413	89.6
	Yes	48	10.4
Trimester (If pregnant)	First trimester	23	5.0
	Second trimester	20	4.3
	Third trimester	5	1.1
Medical history	Diabetes mellitus	24	5.2
	Gestational diabetes milletus	12	2.6
	Hypertension	18	3.9
	Hypothyroidism	25	5.4
	Preeclampsia	3	0.7
	Polycystic ovary syndrome	12	2.6
	None	367	79.6
Family history	Diabetes mellitus	122	26.5
	Gestational diabetes milletus	11	2.4
	Heart diseases	6	1.3
	Hypertension	46	10.0
	Hypothyroidism	27	5.9
	None	249	54.0
Education	Preparatory or lower	13	29
	Secondary school	47	10.2
	University	381	82.6
	Postgraduate	20	4.3
Occupation	Employee	221	47.9
	Housewife	155	33.6
	Student	85	18.4
Place of residence	Arar	365	79.2
	Al-Aweqila	21	4.6
	Turiaf	20	4.3
	Rafha	16	3.5
	Other areas of the Northern Borders Province	39	8.5

Data are presented as mean ± standard deviation (SD) for age or as numbers (No.) and percentages (%). BMI: body mass index.

).

2.2. Knowledge of GDM-Related Maternal Complications

Participants’ awareness of GDM-associated maternal complications was variable (

Table 2. Knowledge of participants regarding GDM-related maternal complications.

Question	Yes	(%)	No	(%)	I Do Not Know	(%)
Do you think GDM increases the risk of instrumental delivery?	234	50.8	36	7.8	191	41.4
Do you think GDM increases the risk of elective C-sections?	234	50.8	36	7.8	191	41.4
Do you think GDM increases the risk of emergency C-sections?	324	70.3	26	5.6	111	24.1
Do you think GDM increases the risk of preterm labor?	318	69.0	32	6.9	111	24.1
Do you think GDM increases the risk of inducing labor?	209	45.3	54	11.7	198	43.0
Do you think GDM increases polyhydramnios?	214	46.4	39	8.5	208	45.1
Do you think GDM increases the risk of oligohydramnios?	129	28.0	93	20.2	239	51.8
Do you think GDM increases the risk of membrane rupture?	136	29.5	72	15.6	253	54.9
Do you think GDM increases the risk of placental abruption?	155	33.6	55	11.9	251	54.4
Do you think GDM increases preterm?	240	52.1	38	8.2	183	39.7
Do you think GDM increases post-partum hemorrhage?	162	35.1	82	17.8	217	47.1

Data are presented as numbers (No.) and percentages (%). GDM: gestational diabetes mellitus.

). Approximately half of the respondents recognized that GDM increases the risk of instrumental delivery (50.8%) and elective cesarean section (50.8%), while 70% identified an increased risk of emergency cesarean section. Awareness of other maternal complications was as follows: preterm labor (69.0%), induction of labor (45.3%), rupture of membranes (29.5%), polyhydramnios (46.4%), and oligohydramnios (28%). Notably, a substantial proportion of participants did not recognize the association between GDM and certain complications, with 11.9% unaware of the risk of placental abruption, 8.2% for preeclampsia, and 17.8% for post-partum hemorrhage.

2.3. Knowledge of GDM-Related Neonatal Complications

Knowledge regarding the impact of GDM on neonatal outcomes was similarly variable (

Table 3. Knowledge of participants regarding GDM-related neonatal complications.

Question	Yes	N %	No.	N %	I Don’t Know	N %
Do you think GDM increases the risk of high birth weight	269	58.4	59	12.8	133	28.9
Do you think GDM increases low birth weight	138	29.9	162	35.1	161	34.9
Do you think GDM increases breech delivery	111	24.1	76	16.5	274	59.4
Do you think GDM increases shoulder dystocia	200	43.4	57	12.4	204	44.3
Do you think GDM increases hypoglycemia	164	35.6	64	13.9	233	50.5
Do you think GDM increases hyperbilirubinemia	184	39.9	62	13.4	215	46.6
Do you think GDM increases congenital anomalies	147	31.9	72	15.6	242	52.5
Do you think GDM increases NICU admission	266	57.7	31	6.7	164	35.6
Do you think GDM increases stillbirth	186	40.3	56	12.1	219	47.5
Do you think GDM increases neonatal death	163	35.4	54	11.7	244	52.9

Data are presented as numbers (No.) and percentages (%). GDM: gestational diabetes mellitus.

). More than half of the participants (58.4%) identified high birth weight (macrosomia) as a complication of GDM, whereas fewer recognized associations with low birth weight (29.9%), breech delivery (24.1%), and shoulder dystocia (43.4%). Awareness of metabolic complications was moderate, with 35.6% and 39.9% identifying neonatal hypoglycemia and hyperbilirubinemia, respectively. Only 31.9%, 40.3%, and 35.4% of respondents recognized the association between GDM and congenital anomalies, stillbirth, and neonatal death, respectively. A majority (57.7%) believed that GDM could result in admission to the neonatal intensive care unit (NICU).

2.4. Overall Awareness Levels

As illustrated in Figure 2, most participants demonstrated a fair level of awareness regarding GDM (42.3%), while 34.3% exhibited good awareness and 23.4% had poor awareness. These findings indicate a moderate overall knowledge level in this population, with substantial room for improvement.

2.5. Factors Associated with GDM Awareness

Statistical analysis revealed several significant associations between participant characteristics and GDM awareness levels. A significant positive association was found between higher education and greater awareness of GDM (p = 0.02). Also, pregnant women demonstrated significantly higher knowledge of GDM compared to non-pregnant women (p = 0.001). Awareness levels varied significantly by trimester, with higher knowledge observed among women in later trimesters (p = 0.002). A significant association was observed between family history of chronic diseases (notably heart disease, hypothyroidism, and GDM) and higher GDM knowledge (p = 0.04). Otherwise, no significant associations were identified between GDM awareness and nationality, age group, occupation, place of residence, BMI, medical history (excluding GDM), or parity group (Figure 3).

3. Discussion

The present study provides an assessment of women’s knowledge regarding GDM in the Northern Borders Province of Saudi Arabia, offering valuable insight into a region for which data have been notably sparse. Our findings reveal that while a substantial proportion of participants demonstrated fair or good awareness of GDM, significant knowledge gaps persist, particularly regarding the complications and risk factors associated with the condition. These results are consistent with, yet also distinct from, the broader landscape of GDM awareness studies conducted across Saudi Arabia (Table 4).

3.1. Key Findings

Our analysis identified several sociodemographic factors significantly associated with higher GDM knowledge: education level, pregnancy status, trimester, and family history of diabetes. These findings echo the pattern observed in national and international research, reinforcing the notion that education and personal or familial experience with diabetes are critical determinants of health literacy in this domain [17,22,23,24,25].

Interestingly, neither maternal age nor BMI was significantly associated with awareness of GDM in our sample. This observation is consistent with findings from other regional and international studies, where age and BMI were not consistent predictors of GDM knowledge, and instead, factors such as education, current pregnancy, or personal diabetes experience were more influential [19,22]. This lack of association may reflect the current scope of public health messaging, which may not specifically target older or overweight women, or possibly a ceiling effect in knowledge levels within the studied population. Given that older age and higher BMI are clinical risk factors for GDM, these results suggest that public health campaigns may need to be further tailored to raise awareness among high-risk groups explicitly.

Notably, women who were pregnant, especially those in later trimesters and those with a family history of diabetes, were more likely to possess good or fair levels of knowledge of GDM. This is intuitive, as pregnant women are more likely to receive targeted health education during antenatal visits, and those with a family history may have greater exposure to diabetes-related information [26]. However, the persistent lack of awareness among non-pregnant women and those with lower educational attainment is concerning, as it suggests that opportunities for preconception counseling and primary prevention are being missed [27].

The sources of information reported by participants further highlight areas for intervention. Consistent with studies from Riyadh [24], Jeddah [19], and Qassim [17], mass media and informal networks (family and friends) remain the predominant sources of GDM information, whereas healthcare professionals are less frequently cited. This points to a critical gap in the dissemination of accurate, evidence-based information within the healthcare system and underscores the need for structured educational programs delivered by qualified providers [28].

3.2. Comparison with Previous Studies in Saudi Arabia

A review of published studies on GDM awareness among Saudi women reveals considerable regional and methodological heterogeneity, but several consistent themes emerge (Table 4). For example, a large-scale national study by Alharthi et al. involving over 9000 women reported that most participants had only fair knowledge, with significant deficits in understanding GDM diagnosis and complications [22]. In Jeddah, Abualsaud et al. found that 77.8% of women had poor knowledge, and only 6.1% demonstrated good knowledge, with social media being the main information source [19]. Similarly, a recent study in Qassim reported that 72.2% of women had poor knowledge regarding GDM adverse outcomes, and only 10% had good knowledge [17].

By contrast, Wafa et al. in Tabuk observed a higher level of awareness, with 76.1% of women demonstrating good knowledge and a majority displaying positive attitudes towards GDM management [23]. This discrepancy may reflect differences in sampling, local health education initiatives, or healthcare infrastructure. In Almadinah Almunawarah, Khayat et al. found that more than half of women had poor knowledge, and rural residence was a strong predictor of inadequate awareness [25]. However, it is worth noting that the measurement of “knowledge” and its categorization was not standardized across all included studies. While some studies used validated questionnaires with explicit scoring systems and defined cut-offs for categorizing knowledge levels, others assessed awareness using alternative methods, varying numbers of questions, or context-specific definitions. As a result, reported proportions of knowledge categories (good/fair/poor) must be interpreted with caution; apparent differences may reflect variations in measurement instruments, scoring thresholds, or the scope of knowledge assessed, as well as population differences.

The above findings collectively suggest that, while some reports indicate a high level of awareness, the overall landscape is characterized by insufficient knowledge, particularly in rural areas and among less-educated women. This is further corroborated by the current data from the Northern Borders Province, where the proportion of women with good knowledge remains modest despite relatively high educational attainment among participants.

Table 4. Summary of some related studies across Saudi Arabia.

First Author (Year)	Region	Study Type	Sample Size	Main Outcome (Knowledge Assessment)
Alharthi (2018) [22]	National (Multiple)	Cross-sectional	9002	Most had fair knowledge, poor awareness of GDM diagnosis (15.9%).
Alnaeem (2019) [29]	Dhahran	Cross-sectional	405	There was a lack of GDM awareness among pregnant women, with limited knowledge of risk factors and inadequate self-care and management.
Abualsaud (2022) [19]	Jeddah	Cross-sectional	385	Nearly 77.8% had poor knowledge; 6.1% had good knowledge; main source: social media.
Khayat (2022) [25]	Almadinah	Cross-sectional	333	Nearly 53.5% have poor knowledge; 7.8% have good knowledge; rural women are at higher risk.
Wafa (2023) [23]	Tabuk	Cross-sectional	539	Nearly 76.1% had good knowledge; 70.9% understood the definition of GDM
Hakeem (2023) [30]	Jeddah	Cross-sectional	489	Of the participants, 53.6% exhibited comprehensive knowledge of GDM, 35.2% possessed moderate knowledge, and 11.2% displayed minimal knowledge. Elevated awareness levels were significantly correlated with higher education, increased gravidity, and prior knowledge of GDM.
Arafah (2024) [24]	Riyadh	Cross-sectional	405	More than 40% of the participants had poor knowledge about GDM complications, diagnosis, and management. Women with a lack of exercise, those having a history of GDM and primigravida, and those with a low education level were more likely to have poor knowledge about GDM.
Almazyad (2024) [17]	Qassim	Cross-sectional	270	Approximately 72.2% had poor knowledge, while 10% had good knowledge.
Present study (2025)	Northern Borders	Cross-sectional	461	Nearly 34.3% have good, 42.3% have fair, and 23.4% have poor knowledge; education and pregnancy status were associated with the knowledge levels.

Table 4. Summary of some related studies across Saudi Arabia.

First Author (Year)	Region	Study Type	Sample Size	Main Outcome (Knowledge Assessment)
Alharthi (2018) [22]	National (Multiple)	Cross-sectional	9002	Most had fair knowledge, poor awareness of GDM diagnosis (15.9%).
Alnaeem (2019) [29]	Dhahran	Cross-sectional	405	There was a lack of GDM awareness among pregnant women, with limited knowledge of risk factors and inadequate self-care and management.
Abualsaud (2022) [19]	Jeddah	Cross-sectional	385	Nearly 77.8% had poor knowledge; 6.1% had good knowledge; main source: social media.
Khayat (2022) [25]	Almadinah	Cross-sectional	333	Nearly 53.5% have poor knowledge; 7.8% have good knowledge; rural women are at higher risk.
Wafa (2023) [23]	Tabuk	Cross-sectional	539	Nearly 76.1% had good knowledge; 70.9% understood the definition of GDM
Hakeem (2023) [30]	Jeddah	Cross-sectional	489	Of the participants, 53.6% exhibited comprehensive knowledge of GDM, 35.2% possessed moderate knowledge, and 11.2% displayed minimal knowledge. Elevated awareness levels were significantly correlated with higher education, increased gravidity, and prior knowledge of GDM.
Arafah (2024) [24]	Riyadh	Cross-sectional	405	More than 40% of the participants had poor knowledge about GDM complications, diagnosis, and management. Women with a lack of exercise, those having a history of GDM and primigravida, and those with a low education level were more likely to have poor knowledge about GDM.
Almazyad (2024) [17]	Qassim	Cross-sectional	270	Approximately 72.2% had poor knowledge, while 10% had good knowledge.
Present study (2025)	Northern Borders	Cross-sectional	461	Nearly 34.3% have good, 42.3% have fair, and 23.4% have poor knowledge; education and pregnancy status were associated with the knowledge levels.

3.3. Clinical Implications and Future Perspectives

The persistence of knowledge gaps regarding GDM among Saudi women has significant public health implications. Given the high prevalence of GDM in Saudi Arabia and its well-documented impact on maternal and neonatal outcomes, improving awareness is a critical step towards early detection, effective management, and prevention of complications [31]. Our findings reinforce the urgent need for (1) targeted educational interventions, which include programs that prioritize women with lower educational attainment, non-pregnant women, and those residing in rural or underserved areas; (2) integration of GDM education into routine care within antenatal clinics and primary healthcare centers, utilizing culturally appropriate materials and interactive methods; (3) leveraging healthcare providers as primary sources of GDM education, counterbalancing the influence of potentially unreliable information from mass media and social networks; and (4) running community-based campaigns, including the use of social media, which can help raise baseline awareness and correct misconceptions.

Building on these findings, we are currently developing a multifaceted educational program for the Northern Borders Province. Planned interventions include community-based group education sessions, distribution of culturally tailored written and visual materials during antenatal clinic visits, targeted digital and social media campaigns, and the implementation of peer educator models within local networks. These methods are designed to reach both high-risk groups and the wider community and will be evaluated for effectiveness using pre- and post-intervention assessments of GDM knowledge. Ongoing collaboration with healthcare providers and community stakeholders is intended to ensure sustainability and maximize public health impact.

Future research should investigate the effectiveness of targeted educational interventions in enhancing GDM knowledge and outcomes, particularly among rural and low-literacy populations. Qualitative studies could provide deeper insight into the barriers and facilitators of GDM awareness, informing the design of tailored health promotion strategies.

3.4. Reflections on Scope, Risks, and Educational Targeting

There is ongoing debate regarding whether comprehensive awareness of GDM should be promoted among all women or primarily those at highest risk. While universal awareness can facilitate earlier engagement with antenatal care and potentially reduce adverse outcomes, it may unintentionally cause distress or stigmatization if not appropriately framed. To minimize these risks, educational efforts should be as follows:

(1) Culturally sensitive and reassuring, emphasizing both the preventability and treatability of GDM; (2) prioritized for at-risk women (e.g., those with a history of GDM, obesity, or older maternal age), with tailored depth and detail; (3) balanced to prevent unnecessary anxiety or feelings of blame.

Not all GDM complications hold equal clinical weight, and educational content should focus especially on those that are most common and severe.

3.5. Strengths and Limitations

A major strength of this study is its focus on a previously understudied region, contributing new data to the national discourse on GDM awareness. The use of a validated questionnaire and a relatively large sample size enhances the reliability of our findings. However, the cross-sectional design precludes causal inference, and the reliance on self-reported data may introduce recall or social desirability bias. Additionally, the study sample, although robust, was skewed towards women with higher educational attainment, which may have overestimated the true level of GDM awareness in the general population.

Importantly, our questionnaire did not include specific items assessing the sources from which participants acquired their knowledge of GDM, such as healthcare professionals, the internet, social media, or childbirth classes. As a result, we were unable to analyze or report the distribution of information sources among study respondents. This is a limitation for interpreting the effectiveness and reach of existing educational channels in the region. We recommend that future research should include such items to better inform the design of targeted interventions.

Regarding our knowledge scoring, the thresholds were chosen based on methodologies from prior studies in Saudi Arabia and internationally, aiming for practical comparability. However, we recognize this approach’s limitations, as it does not weigh the relative importance of each knowledge item. Further research could explore more nuanced scoring systems that reflect the clinical impact of specific knowledge gaps.

Although multivariate logistic regression analysis is often desirable for identifying independent predictors, our dataset contained several important covariates with relatively small group sizes, making such modeling statistically inappropriate due to a high risk of overfitting and unstable estimates. We therefore limited our analysis to univariate associations to maintain the validity of our findings.

3.6. Study Implementation Challenges

Conducting this research in the Northern Borders Province presented several notable challenges. The geographic spread and sparse population of the region limited opportunities for in-person recruitment and made face-to-face data collection impractical, necessitating reliance on online survey dissemination. This approach, while logistically feasible, may have constrained participation among women with limited internet access or lower digital literacy, especially in remote or rural communities. Additionally, cultural norms and sensitivities around health topics, particularly those related to pregnancy and diabetes, may have led to hesitancy or reluctance to participate, potentially introducing selection bias. The online, self-administered survey design further depended on voluntary participation and self-selection, making it difficult to verify eligibility, track response rates, or identify reasons for non-participation. Taken together, these factors could affect the representativeness and generalizability of our sample, underscoring the need for multi-modal recruitment and culturally tailored engagement strategies in future studies involving similar populations.

4. Materials and Methods

4.1. Study Design and Setting

A community-based, descriptive cross-sectional study was conducted in the Northern Borders Province of Saudi Arabia from 1 February to 31 March 2023. The Northern Borders Province is a geographically and culturally distinct region, and this study targeted its entire female population of reproductive age to ensure comprehensive representation.

4.2. Study Population and Eligibility Criteria

Women were eligible if they resided in the Northern Borders Province, were aged ≥18 years, and could read and comprehend Arabic. The online survey was provided solely in Arabic, and the introductory link explicitly requested that only those able to understand Arabic proceed. Due to the nature of online research, cognitive and language exclusions were managed via self-selection, with participants confirming their eligibility and comprehension before giving e-consent and beginning the survey. The full Arabic questionnaire and English translation are provided as Supplementary File S1.

4.3. Sample Size Determination

The sample size was calculated using the Raosoft online sample size calculator (http://www.raosoft.com/samplesize.html) (accessed 15 June 2023) based on the following parameters: confidence level: 95%, margin of error: 5%, population size, estimated based on regional census data, anticipated response distribution: 50% (maximizing sample size), additional 5% added to account for potential non-response or incomplete data. The minimum calculated sample size was 370.

4.4. Sampling Technique

A non-probability convenience sampling method was employed, leveraging social media platforms, community groups, and local health centers to disseminate the survey link. Efforts were made to reach diverse subgroups within the region to maximize representativeness.

4.5. Data Collection Tool

4.5.1. Questionnaire Development and Validation

A structured, self-administered electronic questionnaire was developed using Google Forms. The questionnaire was initially adapted in content and structure from a previously reported instrument used in Najran, Saudi Arabia [32]. Given the lack of reported validation in the source study, all subsequent validation steps were independently undertaken and are described below.

4.5.2. Content and Face Validity

• The draft questionnaire was reviewed by a panel of three subject-matter experts (obstetrician, endocrinologist, epidemiologist) to ensure content validity, clarity, and cultural appropriateness. Based on expert feedback, and in response to concerns about participant comprehension, medical terms such as “polyhydramnios,” “oligohydramnios,” “dystocia,” “hyperbilirubinemia,” and “congenital anomalies” were replaced with simpler, locally familiar phrases (e.g., “too much or too little amniotic fluid,” “difficult labor,” “yellowing of the baby’s skin,” “birth defects”).
• A pilot test was conducted with 20 women from the target population, who were subsequently excluded from the main study.
• The questionnaire was distributed in Arabic, the native language of the study population. Technical medical terms identified by experts and highlighted by pilot testers were translated using lay terminology or brief explanations widely recognized by Saudi women in clinical settings. Comprehension of all questionnaire items by the Arabic-speaking population was confirmed during the pilot phase. Supplementary File S1 includes both the Arabic questionnaire as administered to participants and the English translation used for reporting purposes.

4.5.3. Reliability Assessment

The internal consistency of the knowledge section was evaluated by calculating Cronbach’s alpha, which yielded a value of 0.82, indicating good reliability.

4.5.4. Questionnaire Structure

The final questionnaire consisted of 35 items, organized into three sections:

• Sociodemographic Data: age, marital status, education, occupation, income, parity, gravidity, and family history of diabetes.
• Awareness and Sources of Information: questions assessing knowledge of GDM risk factors, screening, sources of information, and perceived impact on maternal health.
• Knowledge of GDM Complications: items evaluating understanding of GDM-related complications in mothers and newborns.

4.5.5. Outcome Measures

Primary Outcome: Level of knowledge regarding GDM, defined by the proportion of correct responses to knowledge-based questions.

Scoring System: Good knowledge: ≥75% correct answers, fair knowledge: 50–74% correct answers, and poor knowledge: <50% correct answers. The cut-offs values were adapted from previously published survey studies in the region, facilitating cross-study comparability [18,19]. These thresholds, though widely used, are inherently arbitrary and should be interpreted as pragmatic, rather than absolute, indicators of knowledge adequacy.

4.6. Data Collection Procedure

The electronic survey link was distributed via WhatsApp, Facebook, and local community organizations. Participation was voluntary and anonymous. Informed consent was obtained electronically prior to survey initiation. Data collection was monitored to prevent duplicate responses (by restricting one response per device).

4.7. Consideration of Societal Structure

In conducting this study, we carefully considered the unique socioeconomic landscape of Saudi Arabia, where it is well documented that a large proportion of adults, and particularly women, hold university degrees despite elevated rates of unemployment or underemployment. Recent national and regional data, including our own prior research in the Northern Borders Province, confirm that over 70% of women in this age group have completed higher education [33,34,35]. Our recruitment strategy sought to ensure representation from across employment and income groups, but the high educational attainment observed among respondents is consistent with the broader demographic profile of the region and does not reflect a methodological or sampling bias [33]. To support this, we incorporated occupational and income questions in our survey to contextualize participants’ backgrounds and facilitate analysis of how these factors relate to GDM awareness.

4.8. Statistical Analysis

Data were exported from Google Forms to Microsoft Excel and subsequently imported into IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA) for analysis. Descriptive Statistics: Categorical variables were summarized as frequencies and percentages. Continuous variables were checked for normality and summarized as means ± standard deviations. Inferential statistics included the chi-square (χ²) test to examine associations between categorical variables (e.g., knowledge level and sociodemographic factors). For continuous variables, categorization was performed where necessary prior to analysis. Multivariate logistic regression analysis was conducted to identify independent predictors of good knowledge, adjusting for potential confounders (e.g., age, education, parity, family history). A two-tailed p-value < 0.05 was considered statistically significant.

4.9. Ethical Considerations

The study protocol was reviewed and approved by the Local Committee of Bioethics of Northern Border University, approval number (59/44/H) on 5 July 2023. Participation was voluntary, and informed consent was obtained from all participants. All data were collected anonymously and stored securely, accessible only to the research team. The study was conducted in accordance with the principles of the Declaration of Helsinki.

4.10. Quality Control

The survey was pilot-tested for clarity and technical functionality prior to full deployment. Data were checked for completeness and consistency prior to analysis. Incomplete responses were excluded from the final dataset.

5. Conclusions

In summary, our study highlights the persistent gaps in GDM awareness among Saudi women, aligning with national trends while also underscoring unique regional characteristics. Addressing these gaps through targeted, multi-faceted educational strategies is essential for improving the health outcomes of mothers and their children across the region.