Lost opportunities to prevent early onset type 2 diabetes mellitus after a pregnancy complicated by gestational diabetes

Abstract

ObjectivesGestational diabetes mellitus (GDM) greatly increases the risk of developing diabetes in the decade after delivery, but few women receive appropriately timed postpartum glucose testing (PPGT) or a referral to primary care (PC) for continued monitoring. This qualitative study was designed to identify barriers and facilitators to testing and referral from patient and providers' perspectives.MethodsWe interviewed patients and clinicians in depth about knowledge, values, priorities, challenges, and recommendations for increasing PPGT rates and PC linkage. Interviews were coded with NVIVO data analysis software, and analyzed using an implementation science framework.ResultsWomen reported motivation to address GDM for the health of the fetus. Most women did not anticipate future diabetes for themselves, and focused on delivery outcomes rather than future health risks. Patients sought and received reassurance from clinicians, and were unlikely to discuss early onset following GDM or preventive measures. PPGT barriers described by patients included provider not mentioning the test or setting it up, transportation difficulties, work responsibilities, fatigue, concerns about fasting while breastfeeding, and timing of the test after discharge from obstetrics, and no referral to PC for follow-up. Practitioners described limited communication among multiple care providers during pregnancy and delivery, systems issues, and separation of obstetrics from PC.ConclusionsPatients' barriers to PPGT included low motivation for self-care, structural obstacles, and competing priorities. Providers reported the need to balance risk with reassurance, and identified systems failures related to test timing, limitations of electronic medical record systems (EMR), lack of referrals to PC, and inadequate communication between specialties. Prevention of early onset has great potential for medical cost savings and improvements in quality of life.

What is the postpartum experience of Danish women following gestational diabetes? A qualitative exploration

“…Neufeld has similarly documented how women with GDM perceive their treatment as strict and controlling, and have challenges with food cravings . The finding that women with GDM exhibit a high degree of motivation to change their lifestyle based on concerns for their baby has likewise been reported in other studies . As evidence suggests that a mother's lifestyle influences her offspring during childhood , the question thus becomes how to channel and sustain this motivation to ensure the health of both the mother and the child in the years following a GDM pregnancy.…”

Women's views on screening for Type 2 diabetes after gestational diabetes: a systematic review, qualitative synthesis and recommendations for increasing uptake

“…Some respondents indicated that they did not understand how the test worked, meaning one participant ate breakfast so had to come back another time , and another questioned the procedure saying, ‘… How can you give somebody sugar to drink and then you're going to have to test it? They're definitely going to find the sugar’ . Several suggested using more pleasant tests .…”

“…Finally, the need to work presented a further barrier to attendance because women were not able to take time away for the test: ‘I couldn't leave work because they could take it away and I knew the situation I was in, I needed to work’ , and it presented another demand on their time: ‘… I've been running around trying to get stuff done before I go back to work’ (screened) .…”

“…In particular, understanding the significance of diabetes was a motivator to attend, ‘… so I am afraid of diabetes … That's why I'm screening’ (screened) . This could be reinforced through knowing friends and family with diabetes, or their own experience: one participant considered the implications of a diagnosis very seriously, saying ‘… I would have to ask for counselling or something to help me cope with that …’ . Additionally, plans for future pregnancies motivated some to be tested ‘… to avoid any complications that might jeopardize her ability to do this successfully’ .…”

Type 2 diabetes mellitus (T2DM) onset and "remission".

“…Previous studies have identified several risk factors associated with the onset of T2DM such as physical inactivity, alcohol and tobacco consumption, diet, family history of diabetes, aging, obesity, prior history of gestational diabetes, impaired glucose tolerance, race/ethnicity, (6)(7)(8)(9)(10)(11)(56)(57)(58), high blood pressure (12), appendicectomy (13), hypothyroidism (14), depression and anxiety (59). Pharmacological factors such as the use of statins also increases the risk of T2DM by 10-12% (60), statins have a dose dependent class effect on new-onset T2DM, i.e., the risk of developing T2DM increases with the increase in statin dose (61).…”