The Care-Control Paradox for women with Gestational Diabetes

How is it that women have limited agency, when making decisions so profoundly personal, directly affecting their own bodies? This question emerged through conversations between Bhanushree Soni, reflecting on her master’s research exploring the experiences and mental health concerns of women living with gestational diabetes mellitus (GDM), and Deepika Saluja, a public health researcher and a new mother whose own experience of GDM revealed how often care and control become intertwined in women’s lives.

A primigravida woman in her mid-thirties is newly diagnosed with GDM. Overnight, her pregnancy becomes governed by numbers and rules: what to eat, when to eat, how often to check her glucose levels, and which readings to worry about. Alongside concerns for her own health, comes an even heavier fear: Will this affect my baby?

Naturally, she turns to her family for support. Yet the care that surrounds her and her pregnancy is often paradoxical. Her plates are now watched closely. Sugary foods are either hidden or repeatedly offered to her in the name of the baby’s needs. Unsolicited advice flows freely from all directions. Slowly, she begins to wonder: “Is my family really helping me manage my condition, or are they making this harder?”

She is a composite figure, but far from an isolated case. Globally, GDM affects nearly one in five women, and an estimated one in four pregnant women in India, making it a major public health concern. For many women from countries like India, where joint family living is a norm, and family members often play a central role in governing pregnancy-related decisions, managing GDM involves far more than following medical advice. It requires negotiating family expectations, cultural beliefs, and competing ideas about what really constitute as good care. Who decides what she should eat? Whose advice carries authority? And where does her own voice fit within these decisions?

This tension reflects what might be termed the care-control paradox of GDM: support intended to protect women, and their babies can, at times, diminish women’s autonomy and inadvertently undermine their ability to manage their condition effectively.

Clinical guidelines frequently emphasise individual behavioural change, focusing on diet, physical activity and timely glucose monitoring. Yet, these behaviours do not occur in isolation, they are negotiated within households shaped by family relationships, cultural norms, and beliefs about pregnancy and nutrition. Many women develop practical ways to balance this. However, it is often disrupted when family dynamics overshadow self-management. In joint family settings, responses to GDM often fall into two extremes.

In some households, food becomes tightly controlled. Portions are monitored, food choices are questioned, and occasional indulgences attract criticism. What starts as concern can quickly evolve into surveillance and shame. At the other extreme, the diagnosis is minimised or dismissed. Elders insist on traditional foods, sugary treats are justified as essential “for the baby’s strength,” and medical advice is seen as unnecessary or overcautious. Clinical recommendations are often countered with anecdotal accounts of previous generations “who ate everything” and experienced healthy pregnancies.

Although these responses appear very different, they share a common consequence – diminished maternal agency. In both situations, decisions are made for them, not with them.

The implications extend beyond just social discomfort. Evidence suggests the bidirectional relationship between GDM and mental health. Stress, anxiety, and low mood can undermine adherence to dietary and self-management recommendations, while the demands for glucose monitoring and concerns about pregnancy outcomes can themselves contribute to psychological distress. Pregnancy can intensify these challenges through physiological changes, heightened emotional vulnerability, and strong societal expectations surrounding maternal responsibility. Amid this, constant monitoring by family members may increase anxiety and promote unhealthy coping mechanisms, including emotional eating. Conversely, a highly restrictive environment may encourage “hidden eating”, i.e. snacking in secret, followed by guilt and shame. In both cases, the outcome can be poor glycaemic control rather than better self-management.

So how do we break this cycle? By broadening what constitutes GDM care.

1. Involve families, while centring women’s agency: GDM awareness and education should extend beyond individual women and meaningfully include partners and key family members during antenatal visits. Healthcare provider-led discussions can help address myths, align expectations, and position families as supporters rather than decision-makers. Empowerment does not mean excluding families; it means redefining their role from control to partnership.
2. Integrating mental health into routine GDM care: Mental health should be recognised as an integral component of GDM management rather than being optional. Antenatal care providers should conduct routine psychosocial screening during visits identify anxiety, distress, isolation or family-related stressors, enabling timely counselling and support before these challenges begin affecting both well-being and clinical outcomes.
3. Sensitise healthcare providers to autonomy, family dynamics, and respectful communication: Healthcare providers being the most trusted source of information during pregnancy, must be leveraged to provide counselling that integrates social realities in GDM management as part of pregnancy care. Training programmes should equip care providers to recognise family influences, engage constructively with caregivers, avoid paternalistic messaging, and support women in shared decision-making. Respectful, woman-centred communication can help ensure that clinical advice strengthens, rather than unintentionally undermines, women's confidence and autonomy in managing GDM. The challenge is not simply to care more, but to care differently.

Too often research and practice remain focused on glucose readings, while overlooking the social conditions that produce them. We measure blood sugar with remarkable precision, yet pay far less attention to the family dynamics, cultural expectations, and emotional burdens that shape women’s ability to manage GDM. If we are serious about improving outcomes, we must move beyond an individualized model of disease management and recognize that self-management is never entirely self-directed. GDM is not managed only in clinics or through laboratory reports. It’s managed at dinner tables, in family conversations, and in quiet moments of uncertainty, negotiation and choice. Until we acknowledge this reality, we risk treating GDM as a metabolic condition alone, when for many women, it is equally a social one.