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Poor risk management observed in women after gestational diabetes
Competing priorities and a low motivation for self-care often prevent women with gestational diabetes from undergoing continued postpartum monitoring for development of type 2 diabetes, including postpartum glucose testing, according to recent study findings.
In a qualitative study conducted in 2012 and 2013, Judith A. Bernstein, PhD, professor of community health sciences at Boston University School of Public Health, and colleagues interviewed 25 clinicians who managed gestational diabetes during or after pregnancy and 27 patients. Patients enrolled in the study during the third trimester of pregnancy after a diagnosis of gestational diabetes; a 1-hour interview took place at 10 to 14 weeks postpartum in their homes. Questions to clinicians and patients asked about knowledge, values and priorities, sources of information, challenges and recommendations for a single change that could be instituted to increase rates of testing and linkage. All interviews were recorded and transcribed; researchers developed a coding scheme and test for inter-rater reliability based on the first five transcripts, and then applied the coding scheme to the text and grouped material by four domains: intervention, individual characteristics, inner context and outer context.
Researchers found that women were highly motivated to address their gestational diabetes diagnosis for the sake of their child, but less so for themselves.
“Most were aware of possible consequences of [gestational diabetes] for the child and seriousness of a diagnosis of diabetes if they actually had diabetes, but most were certain that there would be no future problems after delivery, in part because physicians were reassuring about their ability to provide good care,” the researchers wrote. “While some women wanted the truth about their diagnosis (‘Please don’t sugar coat’), some were afraid to hear what was said and thought pregnancy was ‘not a time to hear more problems.’”
Many patients reported not understanding the significance of postpartum testing and referral for continued monitoring after the postpartum period, the researchers noted, adding that the test was problematic for many patients because the effort involved (showing up early in the morning, fasting) was “not congruent with having a new baby in the house.” In addition, providers recognized that communication of a gestational diabetes diagnosis and any testing that occurred before a postpartum primary care visit “fell into the chasm between specialties.”
In interviews, some patients “appeared bewildered” by the task of finding a primary care provider who would accept their insurance, whereas several practitioners said they often did not follow up with patients to find out if they were receiving continuing care postpartum.
Practitioners suggested several innovations that could be implemented to increase testing rates and improve chances for successful transition to primary care.
“Several interviewees stressed the need to change ‘meaningful use’ discharge instructions to include an appointment for glucose testing at 12 weeks and the name of a [primary care] source,” the researchers wrote. “It was also suggested that the most effective way to foster compliance with [postpartum glucose test] would be to move the test from the laboratory to home, with a visiting nurse administering the 2-hour glucose tolerance test in the home to address transportation and childcare issues.”
Several practitioners proposed a new category of outreach workers to act as gestational diabetes navigators, to contribute to continuity of care. – by Regina Schaffer
Disclosure: The researchers report no relevant financial disclosures.