BackgroundDiabetes in pregnancy is common in South Asians, especially those from low-income backgrounds, and leads to short-term morbidity and longer-term metabolic programming in mother and offspring. We sought to understand the multiple influences on behaviour (hence risks to metabolic health) of South Asian mothers and their unborn child, theorise how these influences interact and build over time, and inform the design of culturally congruent, multi-level interventions.MethodsOur sample for this qualitative study was 45 women of Bangladeshi, Indian, Sri Lankan, or Pakistani origin aged 21–45 years with a history of diabetes in pregnancy, recruited from diabetes and antenatal services in two deprived London boroughs. Overall, 17 women shared their experiences of diabetes, pregnancy, and health services in group discussions and 28 women gave individual narrative interviews, facilitated by multilingual researchers, audiotaped, translated, and transcribed. Data were analysed using the constant comparative method, drawing on sociological and narrative theories.ResultsKey storylines (over-arching narratives) recurred across all ethnic groups studied. Short-term storylines depicted the experience of diabetic pregnancy as stressful, difficult to control, and associated with negative symptoms, especially tiredness. Taking exercise and restricting diet often worsened these symptoms and conflicted with advice from relatives and peers. Many women believed that exercise in pregnancy would damage the fetus and drain the mother’s strength, and that eating would be strength-giving for mother and fetus. These short-term storylines were nested within medium-term storylines about family life, especially the cultural, practical, and material constraints of the traditional South Asian wife and mother role and past experiences of illness and healthcare, and within longer-term storylines about genetic, cultural, and material heritage – including migration, acculturation, and family memories of food insecurity. While peer advice was familiar, meaningful, and morally resonant, health education advice from clinicians was usually unfamiliar and devoid of cultural meaning.Conclusions‘Behaviour change’ interventions aimed at preventing and managing diabetes in South Asian women before and during pregnancy are likely to be ineffective if delivered in a socio-cultural vacuum. Individual education should be supplemented with community-level interventions to address the socio-material constraints and cultural frames within which behavioural ‘choices’ are made.

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INTRODUCTION: While elevated second trimester maternal serum alpha fetoprotein (msAFP) has been associated with adverse pregnancy outcomes, the utility of first trimester msAFP (AFP1) in predicting these outcomes is not known. Our objective was to determine the association between AFP1 and ischemic placental disease (a composite of preeclampsia, fetal growth restriction and/or placental abruption). Secondary outcomes included correlation with second trimester msAFP (AFP2), in addition to the association of AFP1 with preterm birth, fetal demise, and spontaneous abortion. METHODS: An IRB-approved multi-site retrospective cohort study was performed including all patients with AFP1 as part of routine first trimester aneuploidy screening over from April 2015-August 2016. Pregnancies with multiple gestations and known structural or chromosomal abnormalities were excluded. Delivery records were reviewed for adverse pregnancy outcomes. Spearman correlation coefficient assessed the relationship between AFP1 and AFP2. Fisher exact test and Odds Ratios were used to determine the association between AFP1 and adverse pregnancy outcomes. RESULTS: Of 968 patients with AFP1, 847 had complete records available for review (87.5%). There was a positive correlation between AFP1 and AFP2 (rho =0.57, P<.001). There was a significant association between elevated AFP1 (> 2.0 MoM) and ischemic placental disease, 18.9% vs 8.2% (OR 2.6, 95% CI 1.4-4.9). Additionally, there was a significant association between high AFP1 and early onset preeclampsia <34 weeks, spontaneous preterm birth and overall preterm birth. CONCLUSION: Elevated first trimester msAFP is associated with ischemic placental disease and preterm birth and may help to identify at risk pregnancies as early as the first trimester of pregnancy.