A qualitative evaluation of provider decision-making and patient experiences with 1-step and 2-step gestational diabetes (GDM) screening

Background Gestational diabetes mellitus (GDM) affects approximately 14% of pregnancies worldwide and is associated with substantial long-term risks, including type 2 diabetes and cardiovascular disease. Although the 1-step oral glucose tolerance test (OGTT) is more sensitive and recommended by several international organizations, the two-step approach remains standard in the United States. Concerns about fasting burden, patient anxiety, and time commitment have limited adoption of the one-step test, despite its potential to improve early diagnosis, particularly in high-risk populations such as Asian and Hispanic women. Methods We conducted a qualitative study to evaluate barriers and facilitators of 1-step testing at urban clinics affiliated with New York Presbyterian-Queens between June 2023 and January 2026. Pregnant Asian and Hispanic women without prior diabetes who underwent either 1-step or 2-step GDM screening ( n = 17) and obstetric providers ( N = 10) were recruited using purposive sampling. Semi-structured interviews explored experiences with screening, perceptions of testing modalities, and barriers to 1-step implementation. Interviews were transcribed and analyzed using thematic analysis with inductive coding. Results Two major themes were constructed. First, commonly cited barriers to 1-step testing were less significant than anticipated: most women found fasting manageable, accepted the time commitment, and valued diagnosis despite potential anxiety, emphasizing the importance of knowledge for protecting maternal and infant health. Second, provider test selection was primarily driven by institutional norms and established protocols rather than patient preference or perceived clinical superiority. Many clinicians defaulted to the 2-step approach due to training, system constraints, and reluctance to deviate from standard practice. Conclusion Patient-level barriers to 1-step GDM screening may be overestimated, while institutional inertia plays a central role in limiting its adoption. Transitioning to more sensitive screening approaches will require system-level changes, including updated guidelines and infrastructure, to improve early detection and reduce long-term metabolic risk, particularly among high-risk populations.