Experiences of women, hospital clinicians and general practitioners with gestational diabetes mellitus postnatal follow-up: A mixed methods approach

https://doi.org/10.1016/j.diabres.2018.12.005Get rights and content

Abstract

Problem

Postnatal screening rates to detect type two diabetes following gestational diabetes are low. The quality of communication is an important element to consider in developing targeted strategies that support women in completing recommended follow-up care.

Aims

To explore the communication perspectives, practices and preferences of women, hospital clinicians and general practitioners, to determine strategies that may promote completion of recommended postnatal GDM follow-up, in Queensland Australia.

Method

We used an exploratory, three-phase, mixed-methods approach, interpreted through intergroup communication theory. Phase one: convergent interviews explored perspectives of the communication experience in GDM care among new mothers (n = 13), hospital clinicians (n = 13) and general practitioners (n = 16). Phase two: a retrospective chart audit assessed current practice in postnatal discharge summaries of women (n = 86). Phase three: an online survey identified the preferences of general practitioners and hospital clinicians who provide maternity care in Queensland. Triangulation of the findings from the interviews, audit and surveys was used to clarify results and increase the robustness of the findings.

Results

Three themes: Seeking information, Written hospital discharge summary (discharge summary) and Clarity of follow-up requirements, provide direction for pragmatic strategies to promote follow-up. Practical recommendations include continued discussion about care with women from the point of GDM diagnosis into the postnatal period; discharge summaries that give primacy to diagnosis and ongoing treatment; and provision of explicit directions for recommended testing and timing.

Implications

This research informs seven practical recommendations to help promote completion of recommended postnatal GDM follow-up.

Introduction

In Australia 12% of pregnancies are complicated by gestational diabetes mellitus (GDM) [1]. Risk factors for GDM in pregnancy include a history of elevated blood glucose levels in pregnancy, age >40 years, ethnicity (Asian, Aboriginal Maori, Torres Strait and Pacific Islanders, Middle Eastern, non-white African), family history of diabetes mellitus, pre-pregnancy body mass index (BMI) >30 kg/m2, previous baby >4500 g birth weight, history of polycystic ovary syndrome [2]. GDM affects both maternal and foetal health during the pregnancy and beyond. The diagnosis of GDM has been identified as the single strongest predictor of women developing type two diabetes (T2DM) and also poses a risk for long term cardiovascular morbidity [3]. Worldwide rates of type two diabetes mellitus are rising exponentially, representing a major public health problem affecting developed and developing countries [4], [5]. At a population level, women diagnosed with GDM represent an ideal group for promotion of the benefits of early interventions that are known to delay or prevent progression to T2DM [6], [7].

GDM raises the risk level of the pregnancy, and therefore requires maternal referral to specialist multidisciplinary care, typically located within hospital-based maternity clinics. For women who undertake shared care (where care is shared between the general practitioner or GP and the maternity hospital), the diagnosis of GDM and subsequent referral for specialist management means that the remainder of antenatal care is managed, in most cases, solely by the hospital. This interrupts GP continuity of care during the pregnancy; although GPs resume their role as primary carers following the birth and discharge from hospital.

In Australia, 97% of births and early postnatal care occur in the hospital setting [1]. In Queensland the average postnatal stay is 2.6 days, with an average of 2 days for public patients (including shared care models) to 4 days for private patients in private hospitals [8]. Women and newborns are usually discharged from the hospital to home. Some women return to the maternity hospital for GDM follow-up. However, for most, the GP will conduct routine postnatal checks for mothers and babies at 6–12 weeks. GDM follow-up is recommended at these times, in addition to routine postnatal mother and baby health checks. Transfer of clinical responsibility back to the GP as the primary health provider is communicated via discharge summary, which is created by hospital maternity clinicians when the mother and baby are discharged from hospital.

This discharge summary is the main communication tool between the hospital and GP. The document should include details about the hospital admission, birth, and the health of mother and baby, along with plans for ongoing postnatal care and additional follow-up, such as GDM care [9].

The need for, and benefits of, GDM follow-up are well established and corroborated by local and international guidelines [2], [10]. Postnatal GDM follow-up in Australia is based on Australian Diabetes In Pregnancy criteria, and states that all women diagnosed with GDM, unless clinically contraindicated, should complete a 75 g 2-h OGTT, preferably between 6 and 12 weeks post-partum [2].

GDM postnatal follow-up screening is supported by clinicians, as it facilitates early management strategies to delay or manage T2DM [11]. Nevertheless, completion of GDM specific postnatal screening is low, highly variable, and has long been considered a “missed opportunity” to assess the return to non-pregnant glucose regulation as well as health promoting strategies for women following GDM [12]. Despite this consensus, postnatal GDM follow-up completion rates remain low [13]. Interventions including patient and clinician reminders have met with limited success [14]. The reasons why women do not complete screening are not well understood [5]; but the quality of health communication is implicated as an important feature in the promotion and completion of recommended GDM care.

Nevertheless, the literature shows a dearth of research about the role of communication in completion of postnatal GDM care. Research about GDM follow-up has focused on non-modifiable factors (age, ethnicity, parity, education level); this approach has provided few clinically useful strategies [5]. To explore the knowledge gap around communication and completion of recommended postnatal GDM care, a different approach is necessary. We selected an intergroup communication framework for this study.

Intergroup communication theoretical frameworks have been applied to other maternity services and health care, including patients and clinicians, [15], [16] but to the best of our knowledge our research is the first to examine patients’ and clinicians’ perspectives of GDM care in this way [17], [18]. This research employs an intergroup theory, Communication Accommodation Theory (CAT) [19].

Section snippets

Methods

A mixed-methods approach [20] was used, consisting of three sequential phases, with each set of results and methods informing subsequent phases. Table 1 summarises research questions, sample recruitment, data collection and analytic approaches.

We triangulated data sources and methods in order to affirm the validity of each of the phase results [21]. Triangulation also enabled us to identify pragmatic strategies that may support the completion of GDM postnatal follow-up.

Phases two and three are

Convergent interviews: perspectives of women and clinicians

Phase one involved 37 interviews, women diagnosed with GDM (n = 13), and clinicians (hospital clinicians and general practitioners) (n = 24) who provide care to women with GDM. Women’s ages ranged 17–32 years of age; nine women identified as Caucasian and four as Asian. Two had completed secondary education to Year 12 and all other women had completed tertiary education.

A precis of phase one findings is presented below to provide context and link with later phases. The studies of women’s [17]

Triangulation of the three phases and discussion

Triangulation of the qualitative and quantitative phases was undertaken to increase the methodological rigor and confirm the findings across the phases. Three major themes were identified: (1) seeking information, (2) discharge summary, and (3) clarity of follow-up requirements. These are described and interpreted below.

Theme One: Seeking information appeared initially in interviews with women and GPs, then again in audit and survey results. GPs and women reported their communication and

Conclusion

This research clearly identifies the importance of understanding intergroup communication in order to improve the quality of care that women receive for GDM follow-up in the postnatal period. It has informed the development of practical recommendations that may improve rates of follow-up whereby effective communication between clinicians and women with GDM is vital to support completion of recommended postnatal GDM care.

Statement of significance:

Problem: Completion of postnatal gestational

Acknowledgements

We would like to express our gratitude to the researchers, women, clinicians and others who have generously given their time to participate in and support these studies.

Funding

This research is part of Catherine Kilgour's PhD candidature, made possible with funding from an Australian Postgraduate Award.

Conflicts of interest

No conflict of interest to declare.

References (30)

  • I.P. Mathieu et al.

    Disparities in postpartum follow-up in women with gestational diabetes mellitus

    Clin Diabet

    (2014)
  • Queensland Health

    Queensland perinatal statistics 2016

    (2018)
  • Australian Commission on Safety and Quality in Healthcare

    Safety and quality evaluation of electronic discharge summary systems

    (2011)
  • American Diabetes Association

    Position statement 13. management of diabetes in pregnancy: standards of medical care in diabetes

    Diabet Care

    (2018)
  • B. Hemmingsen et al.

    Diet, physical activity or both for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus

    Cochrane Database Syst Rev

    (2017)
  • Cited by (7)

    • The stigma associated with gestational diabetes mellitus: A scoping review

      2022, eClinicalMedicine
      Citation Excerpt :

      In fact, internalised stigma was identified as the most reported form of stigma experience in the literature. 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.20,22–29,31–37,39,41,44–57 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

    • Diagnosing and providing initial management for patients with Gestational Diabetes: What is the General Practitioner's experience?

      2020, Diabetes Research and Clinical Practice
      Citation Excerpt :

      It may not be clear who is responsible for follow up and exactly what is required [11,40]. In an audit of discharge summaries for women with GDM, undertaken in the same area as this study, no summaries provided detailed advice on follow up testing, and the overall quality was assessed as rarely adequate for clinical handover to the GPs delivering postnatal care [41]. Clear instructions are vital.

    View all citing articles on Scopus
    View full text