Diagnosis and management practices for gestational diabetes mellitus in Australia: Cross‐sectional survey of the multidisciplinary team

Systematic development and refinement of a user-centered evidence-based digital toolkit for supporting self-care in gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is a pregnancy complication affecting many women, requiring changes in behaviours, which command them to learn self-care practices shortly. Digital interventions have been developed to support women with GDM. However, they have often overlooked women's needs and characteristics and failed to frame self-care theories into their design. To address this issue, we adopted a mixed methods approach to develop and refine a user-centred, evidence-based digital Toolkit for supporting self-care in GDM, providing behavioural and educational content, particularly about nutrition. To inform the development and refinement of the Toolkit, we conducted a literature review, observed sixty-six nutrition appointments, interviewed eleven dietitians and seventeen patients, and held co-creation sessions with two dietitians, all of which were analysed using a deductive Thematic Analysis. To validate the Toolkit, we conducted a survey with seventeen healthcare professionals, which was analysed using descriptive statistics. The final version of the NUTRIA Toolkit consists of four main modules with thirty-eight artefacts, including behavioural tools to assist women in GDM management. Despite some limitations, this study robustly endorsed the development and refinement of a user-centred, evidence-based Toolkit for supporting self-care in GDM, aiming for future feasibility and trial testing.

A Social-Ecological Model Exploring Gestational Diabetes Mellitus Screening Practices Among Antenatal Health Care Providers

Gestational diabetes mellitus (GDM) is associated with adverse health outcomes for the pregnant individual and their baby. Screening approaches for GDM have undergone several iterations, introducing variability in practice among healthcare providers. As such, our study aimed to explore the views of antenatal providers regarding their practices of, and counseling experiences on the topic of, GDM screening in Ontario. We conducted a qualitative, grounded theory study. The study population included antenatal providers (midwives, family physicians, and obstetricians) practicing in Hamilton, Ottawa, or Sudbury, Ontario. Semi-structured telephone interviews were conducted and transcribed verbatim. Transcripts were analyzed using inductive coding upon which codes, categories, and themes were developed to generate a theory grounded in the data. Twenty-two participants were interviewed. Using the social-ecological theory, we created a model outlining four contextual levels that shaped the experiences of GDM counseling and screening: Intrapersonal factors included beliefs, knowledge, and skills; interpersonal factors characterized the patient-provider interactions; organizational strengths and challenges shaped collaboration and health services infrastructure; and finally, guidelines and policies were identified as systemic barriers to health care access and delivery. A focus on patient-centered care was a guiding principle for all care providers and permeated all four levels of the model. Patient-centered care and close attention to barriers and facilitators across intrapersonal, interpersonal, organizational, and policy domains can minimize the impact of variations in GDM screening guidelines. Among care providers, there is a desire for additional skill development related to GDM counseling, and for national consensus on optimal screening guidelines.

Associations between diet quality and dietary patterns and gestational diabetes mellitus in a low-risk cohort of pregnant women in Australia: a cross-sectional study

INTRODUCTION

Evidence of associations between the Mediterranean Diet Score (MDS) and Dietary Approaches to Stop Hypertension (DASH) score and gestational diabetes mellitus (GDM) in pregnant women is limited. This study examined changes in MDS and DASH and dietary patterns in Australian pregnant women between early and late pregnancy and their associations with GDM.

METHODS

The data from n = 284 participants were analysed. Diet quality indices and empirical dietary patterns were determined in early (15 ± 3 weeks gestation) and late pregnancy (35 ± 2 weeks gestation). Paired t-tests were used to examine changes in scores for diet quality indices and dietary patterns from early to late pregnancy. Logistic regression analysis was used to examine associations between GDM, diet quality indices and dietary patterns.

RESULTS

Three major dietary patterns were identified at early pregnancy. The first and second dietary patterns included unhealthier and healthier food groups, respectively, and the third comprised mixed food groups. Although diet quality scores did not change over time, consumption of the first dietary pattern increased (p = 0.01), and consumption of the second dietary pattern decreased by late pregnancy in women without GDM (p < 0.001).

CONCLUSION

No associations between DASH score, MDS and GDM were found; however an inverse association was observed between the first dietary pattern and GDM in late pregnancy (p = 0.023). Longitudinal studies are needed to examine diet quality and dietary patterns at early and late pregnancy to inform the development of tailored dietary advice for GDM.

Gestational diabetes mellitus screening and diagnosis criteria before and during the COVID-19 pandemic: a retrospective pre-post study

OBJECTIVE

To determine whether perinatal outcomes after excluding gestational diabetes mellitus (GDM) on the basis of fasting venous plasma glucose (FVPG) assessment during the coronavirus disease 2019 (COVID-19) pandemic in 2020 were similar to those during the preceding year after excluding GDM using the standard oral glucose tolerance test (OGTT) procedure.

DESIGN

Retrospective pre-post study.

SETTING, PARTICIPANTS

All women who gave birth in Queensland during 1 July - 31 December 2019 and 1 July - 31 December 2020.

MAIN OUTCOME MEASURES

Perinatal (maternal and neonatal) outcomes for pregnant women assessed for GDM, by assessment method (2019: OGTT/glycated haemoglobin [HbA1c ] assessment; 2020: GDM could be excluded by an FVPG value below 4.7 mmol/L).

RESULTS

3968 of 29 113 pregnant women in Queensland during 1 July - 31 December 2019 (13.6%) were diagnosed with GDM, and 4029 of 28 778 during 1 July - 31 December 2020 (14.0%). In 2020, FVPG assessments established GDM in 216 women (1.1%) and excluded it in 1660 (5.8%). The frequencies of most perinatal outcomes were similar for women without GDM in 2019 and those for whom it was excluded in 2020 on the basis of FVPG values; the exception was caesarean delivery, for which the estimated probability increase in 2020 was 3.9 percentage points (95% credibility interval, 2.2-5.6 percentage points), corresponding to an extra 6.5 caesarean deliveries per 1000 births. The probabilities of several outcomes - respiratory distress, neonatal intensive care or special nursery admission, large for gestational age babies - were about one percentage point higher for women without GDM in 2020 (excluding those diagnosed on the basis of FVPG assessment alone) than for women without GDM in 2019.

CONCLUSIONS

Identifying women at low absolute risk of gestational diabetes-related pregnancy complications on the basis of FVPG assessment as an initial step in GDM screening could reduce the burden for pregnant women and save the health system substantial costs.

Associations of a current Australian model of dietetic care for women diagnosed with gestational diabetes and maternal and neonatal health outcomes

BACKGROUND

Gestational diabetes mellitus (GDM) is a significant public health burden in Australia. Subsequent strain on healthcare systems is widespread and current models of care may not be adequate to provide optimal healthcare delivery. This study aimed to assess a current model of dietetic care with maternal and neonatal outcomes.

METHODS

Hospital medical record data from The Women's Hospital, Melbourne, for women with GDM (n = 1,185) (July 2105-May 2017) was retrospectively analysed. Adjusted linear and logistic regression were used to analyse associations between the number of dietitian consultations and maternal and neonatal health outcomes.

RESULTS

Half of all women (50%) received two consultations with a dietitian. 19% of women received three or more consultations and of these women, almost twice as many were managed by medical nutrition therapy (MNT) and pharmacotherapy (66%) compared with MNT alone (34%). Higher odds of any maternal complication among women receiving 3 + consultations compared to those receiving zero (OR = 2.33 [95% CI: 1.23, 4.41], p = 0.009), one (OR = 1.80 [95% CI: 1.09, 2.98], p = 0.02), or two (OR = 1.65 [95% CI: 1.04, 2.60], p = 0.03) consultations were observed. Lower odds of infant admission to the Neonatal Intensive Care Unit (NICU) were observed among women receiving one (OR = 0.38 [95% CI: 0.18, 0.78], p = 0.008), two (OR = 0.37 [95% CI: 15 0.19, 0.71], p = 0.003), or three + consultations (OR = 0.43 [95% CI: 0.21, 0.88], p = 0.02), compared to no consultations.

CONCLUSION

The optimal schedule of dietitian consultations for women with GDM in Australia remains largely unclear. Alternate delivery of education for women with GDM such as telehealth and utilisation of digital platforms may assist relieving pressures on the healthcare system and ensure optimal care for women during pregnancy.

Use and Preferences of Health Apps among Women and Healthcare Professionals Regarding GDM Postpartum Care Related to Diet, Physical Activity, and Weight Management: A Cross-Sectional Survey

Gestational Diabetes Mellitus (GDM) is a common medical complication of pregnancy, which is associated with increased risk of future diabetes. mHealth (mobile health, in this paper applications abbreviated to apps) can facilitate health modifications to decrease future risks. This study aims to understand mHealth app use and preferences among women with past GDM and healthcare professionals (HCP) in Australia. An explorative cross-sectional online survey was disseminated via social media, a national diabetes registry, and professional networks. Descriptive analyses were conducted on valid responses (women with prior GDM: n = 1475; HCP: n = 75). One third (33%) of women with prior GDM have used health apps, and a further 80% of non-app users were open to using a health app if recommended by their HCP. Over half (53%) of HCPs supported health information delivery via mHealth, although only 14% had recommended a health app to women post-GDM, and lack of knowledge about mHealth apps was common. Health app users reported that they preferred tracking features, while non-users desired credible health and dietary information and plans. Expanding mHealth app use could facilitate healthy behaviours, but endorsement by HCPs is important to women and is still currently lacking.

Clinicians' perspectives on gestational diabetes screening during the global COVID-19 pandemic in Australia

AIM

There is no international consensus for the screening and diagnosis of gestational diabetes mellitus (GDM). In March 2020, modified screening and diagnostic recommendations were rapidly implemented in Queensland, Australia, in response to the COVID-19 pandemic. How clinicians perceived and used these changes can provide insights to support high-quality clinical practice and provide lessons for future policy changes. The aim of this study was to understand clinicians' perceptions and use of COVID-19 changes to GDM screening and diagnostic recommendations.

METHODS

Queensland healthcare professionals responsible for diagnosing or caring for women with GDM were recruited for semi-structured telephone interviews. Data analysis of transcribed interviews used inductive reflexive thematic analysis.

RESULTS

Seventeen interviews were conducted with the following participants: six midwives/nurses, three endocrinologists, two general practitioners, two general practitioners/obstetricians, two diabetes educators, one dietitian and one obstetrician. Three themes emerged: communication and implementation, perceptions and value of evidence and diversity in perceptions of GDM screening. Overall, clinicians welcomed the rapid changes during the initial uncertainty of the pandemic, but as COVID-19 became less of a threat to the Queensland healthcare system, some questioned the underlying evidence base. In areas where GDM was more prevalent, clinicians more frequently worried about missed diagnoses, whereas others who felt that overdiagnosis had occurred in the past continued to support the changes.

CONCLUSIONS

These findings highlight the challenges to changing policy when clinicians have diverse (and often strongly held) views.

Medical nutrition therapy for gestational diabetes mellitus in Australia: What has changed in 10 years and how does current practice compare with best practice?

BACKGROUND

The present study aimed to report Australian dietetic practice regarding management of gestational diabetes mellitus (GDM) and to make comparisons with the findings from a 2009 survey of dietitians and with the Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guidelines (NPG).

METHODS

Cross-sectional surveys were conducted in 2019 and 2009 of dietitians providing medical nutrition therapy (MNT) to women with GDM in Australia. The present study compares responses on demographics, dietetic assessment and interventions, and guideline use in 2019 vs. 2009.

RESULTS

In total, 149 dietitians (2019) and 220 (2009) met survey inclusion criteria. In both surveys >60% of respondents reported dietary interventions aiming for >45% energy from carbohydrate, 15%-25% energy from protein and 15%-30% energy from fat. Many variations in MNT found in 2009 continued to be evident in 2019, including the percentage of energy from carbohydrate aimed for (30%-65% in 2019 vs. 20%-75% in 2009) and the wide range in the recommended minimum daily carbohydrate intake (40-220 and 60-300 g). Few dietitians reported aiming for the NPG minimum of 175 g of carbohydrate daily in both surveys (32% in 2019 vs. 26% in 2009). There were, however, some significant increases in MNT consistent with NPG recommendations in 2019 vs. 2009, including the minimum frequency of visits provided (49%, n = 61 vs. 33%, n = 69; p < 0.001) and provision of gestational weight gain advice (59%, n = 95 vs. 40%, n = 195; p < 0.05).

CONCLUSIONS

Although many dietitians continue to provide MNT consistent with existing NPG, there is a need to support greater uptake, especially for recommendations regarding carbohydrate intake.

Effect of Multidisciplinary Team Continuous Nursing on Glucose and Lipid Metabolism, Pregnancy Outcome, and Neonatal Immune Function in Gestational Diabetes Mellitus

Objective

To investigate the effect of multidisciplinary team (MDT) continuous nursing on glucose and lipid metabolism, pregnancy outcome, and neonatal immune function in gestational diabetes mellitus (GDM).

Methods

A total of 90 patients with gestational diabetes mellitus (GDM) from January 2018 to December 2019 were recruited and assigned to receive routine care (routine group) or MDT continuous care (study group) according to different nursing methods. Outcome measures included glucose and lipid metabolism, pregnancy outcomes, and neonatal immune function.

Results

There were no significant differences in glucose and lipid metabolism indices and self-rating anxiety scale (SAS) scores, before nursing. After nursing, MDT continuous care resulted in significantly lower levels of fasting blood glucose (FBG), 2 h postprandial blood glucose (2hPBG), glycosylated hemoglobin (HbAlc), triglyceride (TG), and homeostasis model insulin resistance index (HOMA-IR) versus routine care. After nursing, the SAS scores in the two groups were significantly decreased, with lower results in the study group. Patients in the study group showed better compliance than those in the routine group. MDT continuous care was associated with a significantly lower incidence of premature rupture of fetal membranes, cesarean section, premature delivery, macrosomia, and hypoglycemia versus routine nursing. There were no significant differences in immunoglobulin (Ig) A and IgM levels. Patients in the study group showed a higher IgG level and lower CD3, CD4, CD8, and CD4/CD8 levels than those in the routine group.

Conclusion

MDT continuous nursing could effectively regulate glucose and lipid metabolism and improve pregnancy outcomes and neonatal immune function in patients with GDM.

The Perspectives of Diabetes Educators and Dietitians on Diet and Lifestyle Management for Gestational Diabetes Mellitus: A Qualitative Study

This study explores the knowledge and practice of diabetes educators and dietitians on diet and lifestyle management in women with gestational diabetes mellitus (GDM). Diabetes educators and dietitians were recruited from three maternity hospitals in Adelaide (Australia), through snowball and purposive sampling. Thirteen semistructured interviews were conducted, audio recorded, transcribed verbatim, and analysed for codes and themes. Four themes emerged: guidelines and resources, dietary intervention, management delivery, and communication. Diabetes educators and dietitians demonstrated consistent knowledge of nutritional management for GDM and uniform delivery methods. However, a lack of culturally diverse resources was highlighted, along with a lack of continuity of care across the multidisciplinary team. Barriers towards uptake of dietary intervention were reflected by diabetes educators and dietitians as women showing signs of guilt and stress and disengaging from the service. Further exploration on the knowledge and practice of diabetes educators and dietitians for GDM to best inform implementation strategies for knowledge translation of nutritional management is needed. The indication of language and cultural barriers and resources highlight an ongoing key priority area to support the care of women of ethnic minorities.

Health professionals' views and experiences around the dietary and lifestyle management of gestational diabetes in New Zealand

AIM

This study aimed to investigate New Zealand health professionals' views and experiences around the dietary and lifestyle management of gestational diabetes.

METHODS

Semi-structured interviews were conducted remotely with health professionals; sessions were recorded and transcribed. Core themes were extracted using inductive thematic analysis using a framework method.

RESULTS

Twenty-seven health professionals were interviewed (13 diabetes dietitians, 8 specialist diabetes midwives, 2 community midwives, 1 antenatal clinic midwife, 1 obstetrician and 2 endocrinologists). Themes were organised into three central domains: (a) Social and cultural barriers, (b) Service provision and (c) Nutrition advice. Enabling themes included professional collaboration, innovation and creating trusting and supportive environments. Key barriers identified included accessibility, cultural barriers, overwhelmed service, fragmentation and conflicting information and nutrition resource gaps.

CONCLUSIONS

Findings highlight foremost a deficit in primary antenatal nutrition advice that may play a significant role in the fragmentation identified. Investment in community-inclusive services providing antenatal nutrition and diabetes education appears critical to overcome barriers associated with misinformation and poor outcomes. Pathways to include nutrition education from various primary care health providers should be investigated to ease the burden from specialist gestational diabetes clinicians and allow effective delegation of dietetic resources. Revision of current nutrition guidelines for the management of gestational diabetes in New Zealand is needed to facilitate consistent messaging and standards of care.

Health-related behaviours and weight status of expectant fathers

OBJECTIVE

Little attention has been given to the health status and lifestyle behaviours of expectant fathers. This study aimed to examine health-related variables in a cohort of expectant fathers to identify potential focus areas for interventions designed to optimise health and wellbeing outcomes in this group.

METHODS

Partners of pregnant women who accessed antenatal services at a large maternity unit in a Western Australian hospital were recruited as part of the ORIGINS Project. Analyses were conducted on data from 498 expectant fathers who were primarily of mid and high socioeconomic status.

RESULTS

Participants reported relatively low levels of smoking and alcohol consumption and higher physical activity compared to national averages. Weight status was consistent with population norms for adult males: 76% were overweight or obese and 62% had a waist girth ≥94cm.

CONCLUSIONS

Expectant fathers may benefit from health interventions, especially in relation to managing their weight during this phase of their lives and beyond.

IMPLICATIONS FOR PUBLIC HEALTH

Pregnancy represents a valuable opportunity to engage fathers-to-be in health interventions. Given identified links between paternal weight status and offspring outcomes, interventions focusing on achieving and maintaining a healthy weight among expectant fathers could be beneficial for families.

Searching for Utopia, the Challenge of Standardized Medical Nutrition Therapy Prescription in Gestational Diabetes Mellitus Management: A Critical Review

Gestational diabetes mellitus (GDM) is a common pregnancy disorder and the incidence is increasing worldwide. GDM is associated with adverse maternal outcomes which may be reduced with proper management. Lifestyle modification in the form of medical nutrition therapy and physical activity, as well as self-monitoring of blood glucose levels, is the cornerstone of GDM management. Inevitably, the search for the "ultimate" diet prescription has been ongoing. Identifying the amount and type of carbohydrate to maintain blood glucose levels below targets while balancing the nutritional requirements of pregnancy and achieving gestational weight gain within recommendations is challenging. Recent developments in the area of the gut microbiota and its impact on glycemic response add another layer of complexity to the success of medical nutrition therapy. This review critically explores the challenges to dietary prescription for GDM and why utopia may never be found.

A Review of the Current Status of Gestational Diabetes Mellitus in Australia-The Clinical Impact of Changing Population Demographics and Diagnostic Criteria on Prevalence

The current status of gestational diabetes mellitus in Australia reveals an almost quadrupling prevalence over the last decade. A narrative review of the current Australian literature reveals unique challenges faced by Australian maternity clinicians when addressing this substantial disease burden in our diverse population. Rising rates of maternal overweight and obesity, increasing maternal age and the diversity of ethnicity are key epidemiological impactors, overlaid by the 2015 changes in screening and diagnostic parameters. Our vast land mass and the remote location of many at risk women requires innovative and novel ideas for pathways to diagnose and effectively manage women with gestational diabetes mellitus. By modifying and modernizing models of care for women with gestational diabetes mellitus, we have the ability to address accessibility, resource management and our acute response to global events such as the COVID 19 pandemic. With continuing research, education and robust discourse, Australia is well placed to meet current and future challenges in the management of gestational diabetes mellitus.

An implementation science approach for developing and implementing a dietitian-led model of care for gestational diabetes: a pre-post study

Background

There is strong evidence that women with gestational diabetes mellitus (GDM) who receive a minimum of three appointments with a dietitian may require medication less often. The aim of this study was to evaluate the impact of a dietitian-led model of care on clinical outcomes and to understand the utility of the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework as a prospective tool for implementation.

Methods

This was a pre-post intervention study measuring outcomes before-and-after changing a gestational diabetes (GDM) model of care and included women with GDM managed at a large, regional hospital in Queensland, Australia. The i-PARIHS framework was used to develop, implement and evaluate a dietitian-led model of care which increased dietetic input for women with GDM to a minimum of one initial education and two review appointments. The outcomes were adherence to the schedule of appointments, clinician perspective of the implementation process, pharmacotherapy use, gestational age at commencement of pharmacotherapy and birth weight. Pre- and post- comparisons of outcomes were made using t-tests and chi-squared tests.

Results

Adherence to the dietetic schedule of appointments was significantly increased from 29 to 82% (p < 0.001) but pharmacotherapy use also increased by 10% (p = 0.10). There were significantly more women in the post-intervention group who were diagnosed with GDM prior to 24 weeks gestation, a strong independent predictor of pharmacotherapy use. Infant birthweight remained unchanged. The i-PARIHS framework was used as a diagnostic tool and checklist in the model of care development phase; a facilitation tool during the implementation phase; and during the evaluation phase was used as a reflection tool to identify how the i-PARIHS constructs and their interactions that may have impacted on clinical outcomes.

Conclusions

The i-PARIHS framework was found to be useful in the development, implementation and evaluation of a dietitian-led model of care which saw almost 90% of women with GDM meet the minimum schedule of dietetic appointments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03352-6.

Effects of Changing Diagnostic Criteria for Gestational Diabetes Mellitus in Queensland, Australia

OBJECTIVE

To evaluate the effects of updated gestational diabetes mellitus (GDM) screening and diagnostic criteria on selected perinatal outcomes in Queensland, Australia.

METHODS

This was a pre-post comparison study using perinatal data the year before (2014) and after (2016) the screening and diagnostic criteria for GDM was changed in Queensland, Australia. In 2015, Queensland adopted the one-step screening and diagnostic criteria based on the International Association of the Diabetes and Pregnancy Study Groups' recommendations. The data from 62,517 women in 2014 and 61,600 women in 2016 who gave birth from 24 weeks of gestation were analyzed in three groups in each year: women with GDM; women without diagnosed GDM; and total population. The outcome measures were gestational hypertension, cesarean birth, gestational age at delivery, birth weight, preterm delivery, large-for-gestational age (LGA) neonates, small-for-gestational-age (SGA) neonates, neonatal hypoglycemia, and respiratory distress.

RESULTS

The diagnosis of GDM increased from 8.7% (n=5,462) to 11.9% (n=7,317). After changing the diagnostic criteria, the changes to outcomes, odds ratios (OR), and adjusted odds ratios (aOR) (95% CI) for outcomes with statistically significant differences for the total population were: gestational hypertension 4.6% vs 5.0%, OR 1.09 (1.03-1.15), aOR 1.07 (1.02-1.13); preterm birth 7.6% vs 8.0%, OR 1.05 (1.01-1.09), aOR 1.06 (1.02-1.10); neonatal hypoglycemia 5.3% vs 6.8%, OR 1.31 (1.25-1.37), aOR 1.32 (1.25-1.38); and respiratory distress 6.2% vs 6.0%, OR 0.96 (0.91-1.00), aOR 0.94 (0.89-0.99). There was no change to cesarean births or LGA or SGA neonates for women with or without diagnosed GDM or the total population.

CONCLUSION

Except for a very small decrease in respiratory distress, changing the diagnostic criteria has resulted in more GDM diagnoses with no observed changes to measured perinatal outcomes for women with and without diagnosed GDM.

The lived experiences of midwifery care for women with diabetes: An integrative review

BACKGROUND

Midwives provide care to women across the childbearing journey from pre-conception to the post-partum period in various clinical settings. Due to the increasing incidence of diabetic pregnancies, midwives are now in a position to support other health professionals, as part of a team, to reduce the stress and / or demand on the health care services.

OBJECTIVE

This integrative review synthesises original research that explores the experiences and perceptions of midwives in the provision of care for women with diabetes.

DESIGN

Integrative review.

METHODS

Whittemore and Knafl's (2005) systematic approach was used to search for primary literature related to the research question. Studies meeting the following criteria were included: primary qualitative, quantitative and mixed methods research studies published in peer reviewed journals between January 2009 to October 2019. The population of interest being midwives or nurse-midwives and the outcomes of interest included their perceived role in the management of women with diabetes from the pre conceptual to the postpartum period. The methodological quality of the studies was assessed using the appropriate CASP (Critical Appraisal Skills Programmes, 2014) criteria for qualitative and quantitative research studies. A robust search strategy was conducted using the following databases: EBCSO host (all data bases), Embase, Scopus, and Science Direct (see Table 1).

FINDINGS

A total of 7275 articles were retrieved and ten papers were included in this review (five qualitative and five quantitative) that fulfilled the inclusion criteria. Two overarching themes were identified: professional and personal impacts on midwifery practice. The professional impact theme included three sub themes: organisational issues, professional development and holistic support. The personal impact theme also included three themes: limited diabetes knowledge, limited clinical practice skills and mental attitude.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The findings indicate that midwives need opportunities to learn and develop skills specific to their role so that each individual's needs can be met. These opportunities include provision of education at a university level, offering work based training and increasing the number of post registration courses targeted at midwives who are willing to upskill to provide appropriate care to women with diabetes. Courses are required to address the knowledge, attitudes to diabetes, appropriate assessment skills and innovative communication skills for midwives.

Gestational Diabetes: Exploring the Perceptions, Practices and Barriers of the Community and Healthcare Providers in Rural Bangladesh: A Qualitative Study

BACKGROUND AND OBJECTIVE

Gestational Diabetes Mellitus (GDM) is a prevalent and important disease during pregnancy and has detrimental effects on both the mother and the baby. The current study explored the perception and attitude of the community people about GDM and describes the challenges and gaps in knowledge, availability and accessibility of services for GDM screening and management at a rural community in Bangladesh.

METHODS

We performed a qualitative study including seven Focus Group Discussions (FGDs) and eight Key Informant Interviews (KIIs) from November 2017 to January 2018 at randomly selected areas of Tangail district. A highly trained team including two anthropologists conducted the qualitative studies (FGDs and KIIs) under the guidance of experienced researchers. Thematic analysis was performed.

RESULTS

GDM is not a known term for pregnant women, their husbands, mothers, and mothers-in-law. Most of the participants (78.7%) did not even hear the term. Some of them (25.5%) perceived that GDM will persist for whole life and transmit from husband to wife and mother to baby. Some people (21.3%) thought that GDM entirely depends on the wish of the God. Most of the participants (68.1%) perceived that symptoms of other types of diabetes and GDM are almost the same. Some participants (19.1%) thought that GDM patients need to intake some medicines that might affect the fetus. The majority of the respondents (83%) had no idea when a pregnant woman should test her diabetes during pregnancy. If GDM diagnosed, pregnant women decided to follow the advice of the doctors. The results from KII with health managers found that they lack in-depth knowledge of GDM. There is no structured guideline or protocol at their facilities for GDM management.

CONCLUSION

The existing barriers at the communities for adequate detection and management of GDM are identified properly. The findings of this study will be helpful for the decision-makers in taking necessary actions to control the GDM.

Staff resourcing, guideline implementation and models of care for gestational diabetes mellitus management

BACKGROUND

In 2014, updated screening and diagnostic criteria for gestational diabetes (GDM) were introduced across Australia. Many states including Queensland introduced clinical guidelines to include these changes and other recommendations for GDM management. While it is understood that GDM diagnosis has increased, it is unknown whether resources or service delivery have changed, or whether health services have implemented the guidelines.

AIMS

To understand the staff resourcing, models of care, level of guideline implementation and barriers and enablers to implementing the guideline across Queensland Health GDM services.

MATERIALS AND METHODS

A 22-item electronic survey containing multiple choice and open-ended questions was disseminated to healthcare professionals involved in GDM care across 14 Hospital and Health Services (HHS) in Queensland between August and October 2017.

RESULTS

Fifty-three surveys were included for analysis. Between 2014 and 2016, Queensland GDM diagnosis increased by an average of 33%, yet only eight out of 14 HHS reported increases to staff resourcing. Full implementation of the GDM guideline was reported by 41% of metropolitan compared with 29% for regional and 25% for rural/remote services. Guideline recommendations were inconsistently delivered for physical activity advice, minimum schedule of dietetics appointments and psychosocial support. The most common barrier to guideline implementation was staff resourcing (85%), whereas enablers included staff/teamwork (42%), staff resourcing (21%), local protocols (21%) and staff education/knowledge (15%).

CONCLUSIONS

Increased staff funding as well as an implementation science-driven process for guideline implementation is required to ensure that the increasing number of women with GDM can receive evidence-based care.

microRNA-96 protects pancreatic β-cell function by targeting PAK1 in gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is a disease condition in which a woman develops high blood sugar levels during pregnancy, which might be induced by multiple factors. Among those relative factors, microRNA (miRNA) is well-known to be involved in GDM development. In this study, we investigated the role of miRNA in GDM by analyzing miRNA expression profiling in placenta tissues from healthy or GDM pregnancies. We found that miR-96 was the most down-regulated miRNA in GDM samples. Furthermore, miRNA target gene prediction revealed that p21-activated kinase 1 (PAK1) is a potential target of miR-96. Functional assays showed that miR-96 enhanced β-cell function, whereas PAK1 inhibited β-cell function and cell viability. Our findings demonstrate that miR-96 plays a critical role in GDM development by regulating PAK1 expression, insulin secretion, and β-cell function. © 2018 BioFactors, 44(6):539-547, 2018.