Women with pre-existing diabetes and their experiences of maternity care services

What are the childbearing experiences of women with type 1 diabetes? A scoping review of qualitative literature

PROBLEM

Type 1 diabetes is associated with the risk of adverse outcomes for mother and baby.

BACKGROUND

How pregnant people adapt to the challenges of type 1 diabetes and engage with healthcare professionals can affect how likely they will be to maintain good glycaemic control. Therefore, it is important to understand the childbearing and care experiences of women with type 1 diabetes.

AIM

To examine contemporary literature describing the childbearing experiences of women with type 1 diabetes over the last decade.

METHOD

The review follows 5 stages of Arksey and O'Malley's scoping review framework. Four databases were searched for English language publications 2012-2023 using indexed terms and Boolean operators. 64 studies were retrieved, 10 included in the review. Braun and Clarke's thematic synthesis process was used to collate findings.

FINDINGS

Five key themes emerged: 1. Glycaemic control dominates the childbearing journey, 2. Emphasis on risk, 3. Importance of social and peer support, 4. Care organisation, systems, and communication, 5. The impact of technology on the childbearing experience.

CONCLUSION

Based on lived experiences, women with type 1 diabetes value being treated as partners in their care by health professionals providing medical and midwifery services. Peer and social support from family, friends and the diabetes community can bring comfort and reassurance in a perceived 'medicalised' childbearing journey. Further research is needed on the impact of the use of type 1 diabetes technologies on childbearing experiences and how peer support can be incorporated into current care provision.

Self-management of type 2 diabetes mellitus in pregnancy and breastfeeding experiences among women in Thailand: Study protocol

Women with type 2 diabetes mellitus are at a higher risk of pregnancy complications. Although traditional beliefs and practices influence diabetes management and breastfeeding, recommendations integrating Thai cultural beliefs in maternal care are lacking. The purpose of this study is to describe diabetes self-management in pregnancy and breastfeeding experiences in women with preexisting type 2 diabetes mellitus from Thailand. A convergent parallel mixed-methods study will be conducted. Data will be collected from 20 pregnant women with preexisting type 2 diabetes mellitus in Thailand who are either primigravida or multigravida, aged 20-44 years old, speak the Thai language, and provide consent. The National Institute on Minority Health and Health Disparities Framework's sociocultural and behavioral domains guides the research aims. Data will be collected two times. The first time is during pregnancy (T1); study participants will complete questionnaires and engage in an interview about diabetes self-management, breastfeeding confidence, and breastfeeding intention. The second time is at 4-6 weeks postpartum (T2); study participants will be interviewed about their breastfeeding experiences. We will review and extract maternal health outcomes including body mass index, gestational weight gain, and glycated hemoglobin for T1 as well as fasting plasma glucose for T2. Qualitative data will be analyzed using directed content analysis. Quantitative data will be analyzed using descriptive statistics. Data sources will be triangulated with relative convergence in the results. This proposed study is significant because the findings will be used as a preliminary guide to developing a culturally tailored approach to enhance health outcomes of Thai women with diabetes in pregnancy and postpartum periods.

Self-management education among women with pre-existing diabetes in pregnancy: A scoping review

BACKGROUND

Education is a cornerstone of self-management for adults with diabetes. Self-management is particularly important during pregnancy for women with type 1 and type 2 diabetes, as perinatal outcomes are affected by maternal glycemic control. To our knowledge, literature describing the provision of diabetes education and support during pregnancy for women with type 1 and type 2 diabetes has not been synthesized, nor examined within its context as a complex intervention.

OBJECTIVES AND DESIGN

This scoping review aims to synthesize the evidence regarding prenatal diabetes education and support for women with type 1 and type 2 diabetes and to apply the Medical Research Council framework for complex interventions where appropriate.

DATA SOURCES AND METHODS

We searched EMBASE, CINAHL, and MEDLINE from inception to February 2019 for primary studies focused on prenatal diabetes education among women with type 1 and type 2 diabetes. Two independent reviewers screened eligible studies against inclusion criteria. A narrative synthesis of the included studies was conducted.

RESULTS

Of 511 identified citations, 30 studies were included in the final review. Approximately 44% of the pooled sample were women with type 1 diabetes, 46% had gestational diabetes mellitus, and 10% had type 2 diabetes. Education focused on self-monitoring of blood glucose, attaining glycemic targets, and following a healthy diet. Many studies included educational elements that went beyond traditional didactic teaching and promoted self-management skills and self-management support. The majority of education was delivered via one-on-one outpatient appointments every one to three weeks. About half of the reviewed studies used a multidisciplinary team approach, with most including a combination of physicians, nurses, dietitians, and midwives. Application of the Medical Research Council framework revealed that most studies were limited in methods (i.e., randomization) and few examined process evaluation or intervention cost-effectiveness.

CONCLUSION

We identified a lack of studies centred on educational interventions for women with type 2 diabetes in pregnancy. As pregnancy for women with type 2 diabetes involves significant changes, including the transition from oral hypoglycemics to insulin therapy, often without exposure to diabetes-specific preconception care and counselling, future research may focus on optimizing preconception and prenatal education and support for this high-risk group. This is particularly relevant as the prevalence of type 2 diabetes is increasing worldwide. Future research ought to also design, implement and evaluate interventions in accordance with the Medical Research Council framework for complex interventions.

The lived experiences of healthcare during pregnancy, birth, and three months after in women with type 1 diabetes mellitus

Being pregnant, giving birth, and becoming a mother the first months after birth, is for women with type 1 diabetes mellitus (T1DM) a period of difficult challenges. In order to identify their need of support from healthcare, the aim of this study was to describe healthcare during pregnancy, labour, birth, and up to 12 weeks after birth as experienced by Swedish women with T1DM. We used a phenomenological reflective lifeworld research approach, and made 1-2 individual interviews with ten women in late pregnancy and/or 2-3 months after. Transcribed interviews were analysed through focusing on the meanings of the study phenomenon. The results revealed how the diabetes disease, as well as the risks and responsibility that comes with it, become more visible during the period in question, due to a constant monitoring, performed by the woman herself as well as by the healthcare professionals. The essential meaning of the phenomenon is a need to share the burden of risks and responsibilities with healthcare professionals. The complex situation that these women are in, both as experts on their illness and care and in need of care, requires a care that make women feel capable and responsible, but at the same time offers support and relieve them of their responsibility when needed.

Lived experiences of women with co-existing BMI≥30 and Gestational Diabetes Mellitus

OBJECTIVE

to explore the lived experiences of women with co-existing maternal obesity (BMI ≥ 30) and Gestational Diabetes Mellitus (GDM) during pregnancy and the post-birth period (<3 months post-birth).

DESIGN

A qualitative, sociological design was utilised. Data were collected using a series of sequential in-depth narrative interviews during pregnancy and post-birth and fieldnotes. Cross sectional thematic analysis of the data set was undertaken, alongside the construction/analysis of in-depth biographical longitudinal case profiles of individual participants.

SETTING

Participants were recruited from diabetic antenatal clinics at two NHS hospital trusts in the South West of England.

PARTICIPANTS

27 women with co-existing BMI ≥ 30 and GDM. Participants were predominantly of low socio-economic status (SES).

FINDINGS

Women were experiencing a number of social and economic stressors that compromised their ability to manage pregnancies complicated by maternal obesity and GDM, and make lifestyle changes.Women perceived themselves to be stigmatised by healthcare professionals and the general public due to their obese and gestational diabetic status.

KEY CONCLUSIONS

Women of low SES with maternal obesity and GDM perceived healthcare professionals' recommendations with respect to lifestyle change as unrealistic given their constrained social/material circumstances. Frequent references to weight/lifestyle change by different HCPs were seen as stigmatising and may be counterproductive.

IMPLICATIONS FOR PRACTICE

Women would like more collaborative care which acknowledges/addresses their personal and financial circumstances. Multidisciplinary teams should give consideration to how, by whom, and the frequency with which issues of weight/lifestyle change are being discussed in order to avoid women feeling stigmatised.

A lot of hard work, but doable: Pregnancy experiences of women with type-1 diabetes

Despite many medical advances, pregnant women with type-1 diabetes are still considered to be at high risk. Previous research suggests that physicians' focus on strict glycemic control and negative outcomes can result in fear and uncertainty about undertaking pregnancy. The present study was designed to gain insight into the lived pregnancy experiences of women with type-1 diabetes and to solicit their thoughts on what health care providers could do to assist them to have a healthy pregnancy. Ten U.S. women with type-1 diabetes who were currently pregnant and/or had previously given birth participated in structured interviews. They described the hard work required to attain the strict glycemic control necessary during pregnancy to maintain their health and that of their fetus. However, they found diabetes and pregnancy to be a more positive and successful experience than they had anticipated. The results suggest that early diabetes education, pregnancy planning, and social support are important, yet often overlooked, factors that increase the likelihood of physically and emotionally successful pregnancy experiences for women with type-1 diabetes.

Well-Being and Diabetes Management in Early Pregnant Women with Type 1 Diabetes Mellitus

This paper explores well-being and diabetes management in women with type 1 diabetes mellitus (DM) in early pregnancy and investigates associations among perceived well-being, diabetes management, and maternal characteristics. Questionnaires were answered by 168 Swedish women. Correlation analyses were conducted with Spearman's correlation coefficient (rs). The women reported relatively high scores of self-efficacy in diabetes management (SWE-DES-10: 3.91 (0.51)) and self-perceived health (excellent (6.5%), very good (42.3%), good (38.7%), fair (11.3%) and poor (1.2%)). Moderate scores were reported for general well-being (WBQ-12: 22.6 (5.7)) and sense of coherence (SOC-13: 68.9 (9.7), moderate/low scores for hypoglycemia fear (SWE-HFS 26.6 (11.8)) and low scores of diabetes-distress (SWE-PAID-20 27.1 (15.9)). A higher capability of self-efficacy in diabetes management showed positive correlations with self-perceived health (rs = -0.41, p < 0.0001) and well-being (rs = 0.34, p < 0.0001) as well as negative correlations with diabetes distress (rs = -0.51, p < 0.0001) and hypoglycemia worries (rs = -0.27, p = 0.0009). Women with HbA1c levels of ≤48 mmL/mol scored higher in the subscales "goal achievement" in SWE-DES (p = 0.0028) and "comprehensibility" in SOC (p = 0.016). Well-being and diabetes management could be supported by strengthening the women's capability to achieve glycemic goals and their comprehensibility in relation to the treatment. Further studies are needed to test this.

[Utilization of tacit knowledge by maternal healthcare providers: a systematic mapping of the literature]

INTRODUCTION

The search for efficient answers to strengthen maternal health care has included various sources of evidence for decision making. In this article, we present a systematic mapping of the scientific literature on the use of tacit knowledge in relation to maternal healthcare.

METHODS

A systematic mapping was conducted of scientific articles published in Spanish and English between 1971 and 2014 following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

Of 793 articles, 30 met the inclusion criteria; 60% were from high-income countries and 66.7% were focused on health professionals. We identified a predominance of qualitative methodologies (62%). Four categories regarding the use of tacit knowledge were generated: proposals to improve the organization of the maternal care system (30%) and to improve the care provided to women during the continuum of pregnancy, childbirth and postpartum (26.7%), determination of health workers' perception and skill levels (26.7%) and the interactions between tacit and explicit knowledge in clinical decision making (16.7%).

CONCLUSIONS

This mapping shows that tacit knowledge is an emerging, innovative and versatile research approach used primarily in high-income countries and that includes interesting possibilities for its use as evidence to improve maternal healthcare, particularly in middle- and low-income countries, where it needs to be strengthened.

Psychosocial issues of women with type 1 diabetes transitioning to motherhood: a structured literature review

BACKGROUND

Life transitions often involve complex decisions, challenges and changes that affect diabetes management. Transition to motherhood is a major life event accompanied by increased risk that the pregnancy will lead to or accelerate existing diabetes-related complications, as well as risk of adverse pregnancy outcomes, all of which inevitably increase anxiety. The frequency of hyperglycaemia and hypoglycaemia often increases during pregnancy, which causes concern for the health and physical well-being of the mother and unborn child. This review aimed to examine the experiences of women with T1DM focusing on the pregnancy and postnatal phases of their transition to motherhood.

METHODS

The structured literature review comprised a comprehensive search strategy identifying primary studies published in English between 1990-2012. Standard literature databases were searched along with the contents of diabetes-specific journals. Reference lists of included studies were checked. Search terms included: 'diabetes', 'type 1', 'pregnancy', 'motherhood', 'transition', 'social support', 'quality of life' and 'psychological well-being'.

RESULT

Of 112 abstracts returned, 62 articles were reviewed in full-text, and 16 met the inclusion criteria. There was a high level of diversity among these studies but three common key themes were identified. They related to physical (maternal and fetal) well-being, psychological well-being and social environment. The results were synthesized narratively.

CONCLUSION

Women with type 1 diabetes experience a variety of psychosocial issues in their transition to motherhood: increased levels of anxiety, diabetes-related distress, guilt, a sense of disconnectedness from health professionals, and a focus on medicalisation of pregnancy rather than the positive transition to motherhood. A trusting relationship with health professionals, sharing experiences with other women with diabetes, active social support, shared decision and responsibilities for diabetes management assisted the women to make a positive transition. Health professionals can promote a positive transition to motherhood by proactively supporting women with T1DM in informed decision-making, by facilitating communication within the healthcare team and co-ordinating care for women with type 1 diabetes transitioning to motherhood.