Narratives of Gestational Diabetes Provide a Lens to Tailor Postpartum Prevention and Monitoring Counseling

Barriers to and enablers of type 2 diabetes screening among Indian and Chinese women with prior gestational diabetes: A qualitative study applying the Theoretical Domains Framework

PROBLEM

Women with previous gestational diabetes mellitus (GDM) are at increased risk of type 2 diabetes (T2D).

BACKGROUND

In Australia, GDM and T2D prevalence are particularly high among Indian and Chinese women. Attendance for recommended postpartum T2D screening is low. Our aim was to identify modifiable barriers to, and enablers of, postpartum T2D screening among Chinese and Indian women with prior GDM in Australia, compare these to those of women with prior GDM from the general Australian population, and make culturally appropriate recommendations for intervention (messaging) content.

METHODS

Participants were recruited via the National Gestational Diabetes Register and social media platforms. Semi-structured interviews were conducted in March-May 2021. Using an inductive-deductive approach, data were coded to Theoretical Domains Framework (TDF) domains and mapped to the Capability, Opportunity, Motivation-Behaviour (COM-B) model.

FINDINGS

Ten women participated: 6 Chinese born, 4 Indian born, nine of whom had previously screened for T2D. Nine influential TDF domains were identified, suggesting messaging content needs to address: Motivation (fear of T2D, encourage role modelling beliefs), Opportunity (encourage social support taking cultural and family norms into account), Capability (increase awareness of T2D risk, optimise prompts/reminders) CONCLUSIONS: Use of the COM-B and TDF suggests nine modifiable barriers to, and enablers of, postpartum T2D screening among Indian and Chinese-born women in Australia with prior GDM, mostly consistent with those of general Australian GDM populations. Culture-specific needs, such as including family in knowledge and support, and providing specific information regarding genetic- versus behaviour related risks can be accounted for within an inclusive messaging intervention addressing topics applicable to all women.

Women's perspectives to improve prenatal care for gestational diabetes: A systematic review and meta-aggregation of qualitative studies

INTRODUCTION

In numerous qualitative primary studies, women have identified opportunities to improve prenatal gestational diabetes care. The objective of our systematic review and meta-aggregation was to synthesize patient-guided suggestions for improving prenatal gestational diabetes care that are informed by lived experience of women and their support persons.

MATERIAL AND METHODS

This study was registered a priori on PROSPERO (CRD42023394014). Our search strategy was executed in five databases (Medline, PsycInfo, CINAHL, Scopus, and Web of Science). Primary studies that were qualitative, had full texts in English, studied women who have or had gestational diabetes or their support persons, and included experiential accounts on prenatal gestational diabetes care were included. No date restrictions were applied. Studies that were not qualitative, were secondary analyses, included data on only postpartum care, or evaluated an intervention that was not standard care were excluded. Two independent authors used Covidence software to facilitate screening. The outcomes of interest were patient-reported suggestions to improve quality of gestational diabetes care that are informed by women's or their support persons' accounts of the lived experience of gestational diabetes. Meta-aggregation followed by a thematic synthesis approach was used to analyze the qualitative data to identify women's perspectives to improve gestational diabetes care.

RESULTS

After duplicate removal, a total of 4761 studies underwent screening and a total of 80 studies were ultimately included. Patient- and support persons-reported suggestions to improve care include timely and comprehensive education around gestational diabetes with active engagement of family members, personalized and tailored counseling, patient-centered care, incorporation of digital or online adjuncts to care, and increasing support for women.

CONCLUSIONS

Our systematic review and meta-aggregation identifies several actionable and patient-guided suggestions to improve prenatal gestational diabetes care that are important to consider when embarking on clinical quality improvement.

The holistic maternity care needs of women with Gestational Diabetes Mellitus: A systematic review with thematic synthesis

PROBLEM

Models of care for women with gestational diabetes mellitus (GDM) have evolved in an ad hoc way and do not meet women's needs.

BACKGROUND

GDM affects 50,000 Australian women per annum with prevalence quadrupling in the last ten years. Many health services are struggling to provide a quality service. People with diabetes are calling for care that focuses on their wellbeing more broadly.

AIM

To examine the holistic (emotional, social, economic, and spiritual) care needs of women with GDM.

METHODS

Qualitative and mixed-methods studies capturing the healthcare experiences of women with GDM were searched for in CINAHL, Medline, Web of Science and Scopus. English-language studies published between 2011 and 2023 were included. Quality of studies was assessed using Crowe Critical Appraisal Tool and NVIVO was used to identify key themes and synthesise data.

FINDINGS

Twenty-eight studies were included, representing the experiences of 958 women. Five themes reflect women's holistic needs through their journey from initial diagnosis to postpartum: psychological impact, information and education, making change for better health, support, and care transition.

DISCUSSION

The biomedical, fetal-centric model of care neglects the woman's holistic wellbeing resulting in high levels of unmet need. Discontinuity between tertiary and primary services results in a missed opportunity to assist women to make longer term changes that would benefit themselves (and their families) into the future.

CONCLUSIONS

The provision of holistic models of care for this cohort is pivotal to improving clinical outcomes and the experiences of women with GDM.

Puerperium experience and lifestyle in women with gestational diabetes mellitus and overweight/obesity in China: A qualitative study

Introduction

Women with overweight or obesity and gestational diabetes mellitus (GDM) are at a high risk of developing type 2 diabetes mellitus (T2DM) and other metabolic diseases. Healthy postpartum lifestyles in women with GDM are important for effectively preventing early T2DM occurrence; however, few studies and guidelines focus in China on this issue.

Aims

This qualitative study aimed to understand the puerperium experience and lifestyle of women with overweight/obesity and GDM.

Methods

A face-to-face, in-depth, and semi-structured interview was conducted using a hermeneutical phenomenology method to collect data that were analyzed through thematic analysis.

Results

Out of 61 recruited women with overweight/obesity and history of GDM, 14 women underwent an interview and provided detailed descriptions of their lifestyle experiences during puerperium. The interview data were used to generate four themes—puerperium dietary behavior, weight perception and “confinement” behavior, family support, disease knowledge, and perceived risk—and nine sub-themes.

Conclusion

Unhealthy lifestyles, misconceptions about food, the conflict between physical activity and confinement behavior, a lack of social and family support, and low awareness of disease risk are all common among overweight/obese women with a history of GDM. Thus, we emphasized that healthcare providers should provide continuous preventive care from pregnancy to postpartum and promote long-term health in high-risk populations with a history of GDM associated with overweight/obesity.

Barriers to and enablers of postpartum health behaviours among women from diverse cultural backgrounds with prior gestational diabetes: A systematic review and qualitative synthesis applying the theoretical domains framework

AIMS

Racial and ethnic disparities exist in gestational diabetes prevalence and risk of subsequent type 2 diabetes mellitus (T2DM). Postpartum engagement in healthy behaviours is recommended for prevention and early detection of T2DM, yet uptake is low among women from diverse cultural backgrounds. Greater understanding of factors impacting postpartum health behaviours is needed. Applying the Theoretical Domains Framework (TDF) and Capability, Opportunity, Motivation-Behaviour (COM-B) model, our aim was to synthesise barriers to and enablers of postpartum health behaviours among women from diverse cultural backgrounds with prior GDM and identify relevant intervention components.

METHODS

Databases, reference lists and grey literature were searched from September 2017 to April 2021. Two reviewers screened articles independently against inclusion criteria and extracted data. Using an inductive-deductive model, themes were mapped to the TDF and COM-B model.

RESULTS

After screening 5148 citations and 139 full texts, we included 35 studies (N = 787 participants). The main ethnicities included Asian (43%), Indigenous (15%) and African (11%). Barriers and enablers focused on Capability (e.g. knowledge), Opportunity (e.g. competing demands, social support from family, friends and healthcare professionals, culturally appropriate education and resources) and Motivation (e.g. negative emotions, perceived consequences and necessity of health behaviours, social/cultural identity). Five relevant intervention functions are identified to link the barriers and enablers to evidence-based recommendations for communications to support behaviour change.

CONCLUSIONS

We provide a conceptual model to inform recommendations regarding the development of messaging and interventions to support women from diverse cultural backgrounds in engaging in healthy behaviours to reduce risk of T2DM.

The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care

Purpose of Review

The "fourth trimester" concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women's cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester.

Recent Findings

A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness.

Summary

Development of a comprehensive postpartum care plan with careful consideration of each patient's risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.

Barriers to and enablers of type 2 diabetes screening among women with prior gestational diabetes: A systematic review update and qualitative synthesis applying the Theoretical Domains Framework

AIMS

Women with prior gestational diabetes have nearly 10 times the risk of developing type 2 diabetes. Postpartum screening for type 2 diabetes is recommended for early diagnosis and management, yet uptake is low. This work updates a previous systematic review and advances it through the application of the Theoretical Domains Framework (TDF) to synthesise personal-level factors impacting type 2 diabetes screening and the Capability, Opportunity, Motivation-Behaviour model (COM-B), to develop messaging recommendations for use in clinical practice and screening promotion interventions.

METHODS

We searched seven academic databases from September 2017 (prior review) to April 2021, reference lists and grey literature. Two reviewers independently screened articles against inclusion criteria (qualitative studies exploring factors impacting postpartum diabetes screening, any language) and extracted data. Using an inductive-deductive model, we coded determinants to the TDF and mapped onto the COM-B model.

RESULTS

We identified 38 eligible papers from 34 studies (N = 1291 participants). Most (71%) reported sample sizes of N ≥ 16. The ratio of barriers to enablers was three to one. Eight key TDF domains were identified. Evidence-based recommendations include addressing knowledge, risk perception, fear of diabetes diagnosis, low prioritisation of personal health and fatalism. The risk of bias was low and confidence in findings was moderate to high. A limitation was conceptual overlap between TDF domains, which we addressed via the study procedure.

CONCLUSIONS

The theoretical categorisation of determinants enables the development of messaging and interventions at the personal level, to promote women's uptake of postpartum type 2 diabetes screening.