Background: Gestational diabetes mellitus (GDM) screening using the oral glucose tolerance test (OGTT) is routinely recommended in Australia. However, researchers have reported that in some populations, as many as 20-50% of women decline OGTT testing. Little is known about how and why women make this decision, and how different maternity care contexts intersect in decision-making.

Aim: To explore and describe women’s experiences of declining OGTT screening for GDM in Australia using multiple qualitative methods.

Methods: We conducted a national cross-sectional online survey of women in Australia who had given birth within the previous two years (n=1,719). Survey respondents who reported declining OGTT were invited to provide free-text explanations; inductive content analysis was undertaken for open-ended responses (n=386). Semi-structured interviews with women who had declined OGTT (n=17) were analysed using reflexive thematic analysis.

Results: In the survey, 563/1,719 (32.8%) women reported not completing an OGTT in their most recent pregnancy. Free-text responses clustered into three categories: decision-making processes (n=697 concepts), personal context (n=311), and health service context (n=25). Within decision-making, women described preferring alternative screening approaches (e.g., fasting glucose, HbA1c, capillary blood glucose monitoring/CGM), questioning the validity of OGTT due to perceived unreliability and arbitrary diagnostic thresholds, and highlighting the time, cost and physical burden of fasting and ingesting a glucose load (particularly with nausea/vomiting). Anticipated downstream consequences of a GDM label—such as increased surveillance, reduced autonomy, and exclusion from preferred models of care—were central to risk–benefit appraisals. Interview themes extended these findings, showing decisions were values-based and shaped by lived experience, maternity care interactions, and active information seeking; supportive relationships enabled negotiated alternatives, whereas perceived pressure and stigma could contribute to disengagement.  

Conclusions: Within the populations of these national studies, declining OGTT was commonly an informed and considered choice rather than non-compliant behaviour. Offering flexible, evidence-informed screening pathways and strengthening respectful, informed decision-making - particularly within continuity models of care – is recommended as a strategy to better engage with women during childbearing.