Gestational diabetes mellitus follow-up in Norwegian primary health care: a qualitative study

Abstract

BackgroundWomen with gestational diabetes mellitus (GDM) have a tenfold increased risk of developing diabetes, and a high risk of recurrent GDM. Endorsing the life-course approach aiming to prevent disease and promote health across generations, the Norwegian GDM guideline recommends follow-up in primary care after delivery, with information on the increased risks, lifestyle counselling, and annual diabetes screening. Few reports exist on Norwegian women’s experiences of GDM follow-up. AimTo elucidate women’s experiences with follow-up of GDM in pregnancy and after delivery, and to explore their attitudes to diabetes risk and motivation for lifestyle changes. Design & settingQualitative study in primary care in the region of Stavanger, Norway. MethodSemi-structured in-depth interviews were conducted 24–30 months after delivery with 14 women aged 28–44 years, with a history of GDM. Data were analysed thematically. ResultsMost women were satisfied with the follow-up during pregnancy; however, only two women were followed-up according to the guideline after delivery. In most encounters with GPs after delivery, GDM was not mentioned. To continue the healthy lifestyle adopted in pregnancy, awareness of future risk was a motivational factor, and the women asked for tailored information on individual risk and improved support. The main themes emerging from the analysis were as follows: stigma and shame; uncertainty; gaining control and finding balance; and a need for support to sustain change. ConclusionWomen experienced a lack of support for GDM in Norwegian primary care after delivery. To maintain a healthy lifestyle, women suggested being given tailored information and improved support.

The stigma associated with gestational diabetes mellitus: A scoping review

“…22 , 56 Feelings of failure have been reported, especially in relation to ‘failing’ the glucose tolerance test and being diagnosed with GDM, but also in terms of feeling like they failed the unborn child if insulin treatment was required. 20 , 26 , 28 , 33 , 37 , 39 , 41 , 53 In a cohort study, Levy-Schiff and colleagues also found that women with GDM report a higher degree of negative pregnancy-related emotions, such as disappointment, guilt, and worry, than women with no known diabetes during pregnancy. 54 …”

“…Women diagnosed with GDM have described experiencing discrimination from varying sources, including healthcare personnel, spouses and relatives as well as from the local community and society in general. 18 , 19 , 20 , 21 , 23 , 24 , 25 , 26 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 From healthcare personnel, women diagnosed with GDM report feeling judged; being told ‘horror stories’ about their unborn child's health; being made fun of for weight gain; not being given a choice regarding treatment; feeling threatened, shamed or ‘chastised’ for not meeting glucose targets; being mistrusted regarding whether they follow the diet; and being treated like ‘irresponsible children’. 18 , 19 , 20 , 21 , 23 , 24 , 25 , 26 , 29 , 30 , 33 , 34 , 35 , 38 , 39 , 42 Studies have also documented that the women were being accused by their spouses of laziness, and women with GDM have reported feeling like they were under surveillance and scrutiny from their spouse during day-to-day activities, which may be accompanied by being nagged at and judged for what they ate.…”

“… 30 , 31 , 33 , 34 The heightened attention to the women's diet was also reported from people in general. 41 Discrimination from other family members and relatives is particularly evident in studies conducted in smaller communities in rural China and India as well as in Native American populations where women with GDM experienced that especially their mother-in-law blamed them for the diagnosis; accused them of having unhealthy babies due to GDM; were sarcastic in their remarks; assumed the women would have diabetes for the rest of their lives; or even accused them of having kept diabetes a secret before marriage. 32 , 40 , 43 Finally, women diagnosed with GDM may also experience discrimination from society and their local communities.…”

“…Thus, numerous studies have documented that women diagnosed with GDM report feeling responsible for their diagnosis and experiencing feelings of guilt, self-blame, failure, embarrassment, sadness, shame and negative self-talk. 20 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 39 , 41 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 In some studies, these reactions and perceptions were reported to decrease as the women familiarise themselves with the diagnosis and succeed in managing their GDM. 32 However, in some cases, the feelings were also presented as lasting and impactful.…”

“…Consequences ascribed to GDM-specific stigma by the women include avoidance of screening/testing, both during and after pregnancy; not reporting on blood glucose readings; disordered eating; not wanting more children; stress; social isolation; loneliness and not prioritising own health after pregnancy. 18 , 19 , 20 , 21 , 25 , 26 , 27 , 28 , 31 , 33 , 34 , 37 , 38 , 39 , 40 , 41 , 45 , 49 , 57 , 58 , 59 , 60 , 61 Women diagnosed with GDM have reported negative interactions with healthcare personnel, guilt, fear, and not wanting to identify with diabetes as reasons for not going to scheduled appointments with a doctor, for misreporting in their daily glucose readings and for not attending oral glucose tolerance tests postpartum. 21 , 29 , 34 , 37 Not attending screening for GDM has further been raised as a possible strategy for pregnant women to not be diagnosed with GDM in the first place and thus avoid stigmatisation.…”