The current state of Indigenous and Aboriginal women with diabetes in pregnancy: a systematic review

Gestational Diabetes and Breastfeeding Among Women of Different Races/Ethnicities: Evidence from the Pregnancy Risk Assessment Monitoring Surveys

OBJECTIVE

To examine risk factors for gestational diabetes mellitus (GDM) and factors associated with breastfeeding patterns among women with GDM from different racial/ethnic groups.

METHODS

We used data from Phase 8 (2016-2018) of the Pregnancy Risk Assessment Monitoring System. We used logistic regression to estimate factors associated with GDM and with breastfeeding initiation, and conducted survival analysis using Kaplan-Meier curves, and Cox proportional hazards regression to analyze early cessation of breastfeeding.

RESULTS

Among American Indian and Alaska Native (AI/AN) women, higher education reduced odds (aOR = 0.33; 95% CI: 0.19-0.59) and being married increased odds (aOR = 1.35; 95% CI: 1.02-1.79) of GDM. AI/AN women who received WIC benefits had lower odds of initiating breastfeeding (aOR = 0.70; 95% CI: 0.51-0.95). While there was no association between GDM and initiation of breastfeeding, only a third of AI/AN women with GDM were still breastfeeding by 36 weeks postpartum, compared to more than half of non-Hispanic White and Hispanic women.

CONCLUSIONS FOR PRACTICE

Efforts to reduce GDM among those most at risk are needed, especially among racial and ethnic minorities. Increasing support for women with GDM to continue to breastfeed may improve maternal and child health outcomes and reduce health disparities, particularly among AI/AN women.

Indigenous maternal health and health services within Canada: a scoping review

BACKGROUND

Globally, there are disparities in access to maternal health care services and equity in maternal health outcomes between Indigenous and non-Indigenous populations. While the literature is growing, it has not been systematically synthesized. This review addresses this gap by synthesizing the existing literature on the organizational structure of maternity care, accessibility and delivery of services, and clinical disparities impacting Indigenous maternal health within Canada. It also identifies current knowledge gaps in research on these topics.

METHODS

A scoping review was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines and the extension for scoping reviews. The search for relevant papers was performed in PubMed, CINAHL, and SCOPUS electronic databases and included any empirical literature written in English and published during 2006 - 2021. The research team inductively coded 5 articles to develop a coding scheme, which was then applied to the remaining articles.

RESULTS

A total of 89 articles were included in the review, of which 32 were qualitative papers, 40 quantitative, 8 were mixed-methods publications, and 9 were review papers. The analysis of the articles resulted in identifying a range of overarching themes pertaining to the maternal health of Indigenous women within Canada including provision of services, clinical issues, education, health disparities, organization, spatial context, and impact of informal support. The results suggest that physical, psychological, organizational, and systemic barriers inhibit the quality-of-care pregnant Indigenous women receive, and that maternal health services are not consistently provided in a culturally safe manner. Results also suggest that, compared to non-Indigenous pregnant women, Indigenous women are more likely to develop clinical complications during pregnancy, reflecting the structural impacts of colonization that continue to negatively influence Indigenous maternal health and well-being.

CONCLUSIONS

There are many complex barriers that prevent Indigenous women from receiving high quality and culturally appropriate maternal care. Possible areas that could address the service gaps illuminated through this review include the implementation of cultural considerations across health care jurisdictions within Canada.

Rural healthcare delivery and maternal and infant outcomes for diabetes in pregnancy: A systematic review

AIM

The aim of this systematic review was to examine the literature regarding rural healthcare delivery for women with any type of diabetes in pregnancy, and subsequent maternal and infant outcomes.

METHODS

Eight databases were searched in September 2020, including Medline, EMCare, CINAHL, EMBASE, Maternity and Infant Care, Cochrane, Rural and Remote Health and Aboriginal and Torres Strait Islander Health bibliography. Studies from high-income countries in rural, regional or remote areas with interventions conducted during the antenatal period were included. Intervention details were reported using the template for intervention description and replication template. Two reviewers independently assessed for risk of bias using the RoB2 and ROBINS I tools.

RESULTS

Three articles met the inclusion criteria: two conducted in Australia and one in the United States. A multidisciplinary approach was reported in two of the included studies, which were modified specifically for their respective rural settings. All three studies reported rates of caesarean section, birthweight (grams) and gestational age at birth as maternal and infant outcomes. One study was considered at moderate risk of bias, and two studies were at serious risk of bias.

CONCLUSION

There is a significant gap in research relating to healthcare delivery for women with diabetes in pregnancy in rural areas. This lack of research is concerning given that 19% of individuals in high-income countries reside rurally. Further research is required to understand the implications of healthcare delivery models for diabetes in pregnancy in rural areas.

Associations of gestational diabetes and type 2 diabetes during pregnancy with breastfeeding at hospital discharge and up to 6 months: the PANDORA study

AIMS/HYPOTHESIS

Women with gestational diabetes mellitus (GDM) and obesity experience lower rates of breastfeeding. Little is known about breastfeeding among mothers with type 2 diabetes. Australian Indigenous women have a high prevalence of type 2 diabetes in pregnancy. We aimed to evaluate the association of hyperglycaemia, including type 2 diabetes, with breastfeeding outcomes.

METHODS

Indigenous (n = 495) and non-Indigenous (n = 555) participants of the Pregnancy And Neonatal Diabetes Outcomes in Remote Australia (PANDORA) cohort included women without hyperglycaemia in pregnancy (n = 222), with GDM (n = 684) and with type 2 diabetes (n = 144). The associations of hyperglycaemia in pregnancy and breastfeeding at hospital discharge, 6 weeks and 6 months post-partum were evaluated with logistic regression, after adjustment for maternal obesity, ethnicity, maternal and neonatal characteristics.

RESULTS

Indigenous women were more likely to predominantly breastfeed at 6 weeks across all levels of hyperglycaemia. Compared with women with no hyperglycaemia in pregnancy, women with type 2 diabetes had lower odds for exclusive breastfeeding at discharge (adjusted OR for exclusive breastfeeding 0.4 [95% CI 0.2, 0.8] p = 0.006). At 6 weeks and 6 months, the relationship between type 2 diabetes and predominant breastfeeding was not statistically significant (6 weeks 0.7 [0.3, 1.6] p = 0.40, 6 months 0.8 [0.4, 1.6] p = 0.60). Women with gestational diabetes were as likely to achieve predominant breastfeeding at 6 weeks and 6 months as women without hyperglycaemia in pregnancy.

CONCLUSIONS/INTERPRETATION

Indigenous women had high rates of breastfeeding. Women with type 2 diabetes had difficulty establishing exclusive breastfeeding at hospital discharge. Further research is needed to assess the impact on long-term breastfeeding outcomes. Graphical abstract.

Improving systems of care during and after a pregnancy complicated by hyperglycaemia: A protocol for a complex health systems intervention

BACKGROUND

Many women with hyperglycaemia in pregnancy do not receive care during and after pregnancy according to standards recommended in international guidelines. The burden of hyperglycaemia in pregnancy falls disproportionately upon Indigenous peoples worldwide, including Aboriginal and Torres Strait Islander women in Australia. The remote and regional Australian context poses additional barriers to delivering healthcare, including high staff turnover and a socially disadvantaged population with a high prevalence of diabetes.

METHODS

A complex health systems intervention to improve care for women during and after a pregnancy complicated by hyperglycaemia will be implemented in remote and regional Australia (the Northern Territory and Far North Queensland). The Theoretical Domains Framework was used during formative work with stakeholders to identify intervention components: (1) increasing workforce capacity, skills and knowledge and improving health literacy of health professionals and women; (2) improving access to healthcare through culturally and clinically appropriate pathways; (3) improving information management and communication; (4) enhancing policies and guidelines; (5) embedding use of a clinical register as a quality improvement tool. The intervention will be evaluated utilising the RE-AIM framework at two timepoints: firstly, a qualitative interim evaluation involving interviews with stakeholders (health professionals, champions and project implementers); and subsequently a mixed-methods final evaluation of outcomes and processes: interviews with stakeholders; survey of health professionals; an audit of electronic health records and clinical register; and a review of operational documents. Outcome measures include changes between pre- and post-intervention in: proportion of high risk women receiving recommended glucose screening in early pregnancy; diabetes-related birth outcomes; proportion of women receiving recommended postpartum care including glucose testing; health practitioner confidence in providing care, knowledge and use of relevant guidelines and referral pathways, and perception of care coordination and communication systems; changes to health systems including referral pathways and clinical guidelines.

DISCUSSION

This study will provide insights into the impact of health systems changes in improving care for women with hyperglycaemia during and after pregnancy in a challenging setting. It will also provide detailed information on process measures in the implementation of such health system changes.

Pregnancy And Neonatal Diabetes Outcomes in Remote Australia: the PANDORA study-an observational birth cohort

BACKGROUND

In Australia's Northern Territory, 33% of babies are born to Indigenous mothers, who experience high rates of hyperglycemia in pregnancy. We aimed to determine the extent to which pregnancy outcomes for Indigenous Australian women are explained by relative frequencies of diabetes type [type 2 diabetes (T2DM) and gestational diabetes (GDM)].

METHODS

This prospective birth cohort study examined participants recruited from a hyperglycemia in pregnancy register. Baseline data collected were antenatal and perinatal clinical information, cord blood and neonatal anthropometry. Of 1135 women (48% Indigenous), 900 had diabetes: 175 T2DM, 86 newly diagnosed diabetes in pregnancy (DIP) and 639 had GDM. A group of 235 women without hyperglycemia in pregnancy was also recruited.

RESULTS

Diabetes type differed for Indigenous and non-Indigenous women (T2DM, 36 vs 5%; DIP, 15 vs 7%; GDM, 49 vs 88%, p < 0.001). Within each diabetes type, Indigenous women were younger and had higher smoking rates. Among women with GDM/DIP, Indigenous women demonstrated poorer birth outcomes than non-Indigenous women: large for gestational age, 19 vs 11%, p = 0·002; neonatal fat 11.3 vs 10.2%, p < 0.001. In the full cohort, on multivariate regression, T2DM and DIP were independently associated (and Indigenous ethnicity was not) with pregnancy outcomes.

CONCLUSIONS

Higher rates of T2DM among Indigenous women predominantly contribute to absolute poorer pregnancy outcomes among Indigenous women with hyperglycemia. As with Indigenous and minority populations globally, prevention or delay of type 2 diabetes in younger women is vital to improve pregnancy outcomes and possibly to improve the long-term health of their offspring.

Improving Models of Care for Diabetes in Pregnancy: Experience of Current Practice in Far North Queensland, Australia

Aims: To map health practitioners' experiences and describe knowledge regarding screening and management of Diabetes in Pregnancy (DIP) in Far North Queensland, Australia. Methods: Mixed methods including a cross-sectional survey (101 respondents) and 8 focus groups with 61 health practitioners. All participants provided clinical care for women with DIP. Results: A wide range of healthcare professionals participated; 96% worked with Indigenous women, and 63% were from regional or remote work settings. Universal screening for gestational diabetes at 24-28 weeks gestation was reported as routine with 87% using a 75 g Oral Glucose Tolerance Test. Early screening for DIP was reported by 61% although there was large variation in screening methods and who should be screened <24 weeks. Health practitioners were confident providing lifestyle advice (88%), dietary, and blood glucose monitoring education (67%, 81%) but only 50% were confident giving insulin education. Electronic medical records were used by 80% but 55% also used paper records. Dissatisfaction with information from hospitals was reported by 40%. In the focus groups improving communication and information technology systems were identified as key areas. Other barriers described were difficulties in care coordination and access for remote women. Conclusions: Communication, information technology systems, coordination of care, and education for health professionals are key areas that will be addressed by a complex health systems intervention being undertaken by the DIP Partnership in North Queensland.

Diabetes screening in pregnancy failing women in rural Western Australia: An audit of oral glucose tolerance test completion rates

OBJECTIVE

To quantify screening rate for gestational diabetes mellitus and completion of oral glucose tolerance test in rural and remote Western Australia.

DESIGN AND PARTICIPANTS

Retrospective audit of 551 antenatal records from women of 16 years and older without pre-existing diabetes and with singleton pregnancies delivered in 2013.

MAIN OUTCOME MEASURES

Number of women recorded screened for gestational diabetes mellitus in second or third trimester using oral glucose tolerance test or other tests; gestational diabetes mellitus rate.

RESULTS

Only 278 (50.5%) women were screened with oral glucose tolerance test; 113 (20.5%) had no record of any screening related to gestational diabetes mellitus. In a nested mixed-effects logistic regression model, women with a previous gestational diabetes mellitus diagnosis, two or more risk factors (excluding ethnicity) or high-risk gestational diabetes mellitus ethnicity other than Australian Aboriginal were more likely to be screened, while Australian Aboriginal women were less likely to be screened with oral glucose tolerance test. Clinicians reported patient and clinician factors and logistical difficulties as reasons for the oral glucose tolerance test not being completed at their site. Of those screened with oral glucose tolerance test, a high rate of gestational diabetes mellitus was diagnosed (14.7% versus Western Australia state-wide average of 7.4%).

CONCLUSION

Adherence to oral glucose tolerance test screening in rural Western Australia is inadequate for effective screening for gestational diabetes mellitus. Screening was not acceptable or available for a significant proportion of women at risk. Efforts to improve oral glucose tolerance test adherence and exploration of alternative gestational diabetes mellitus screening strategies are required.

Diabetes care in the dispersed population of Greenland. A new model based on continued monitoring, analysis and adjustment of initiatives taken

Diabetes used to be a rare condition among Inuit in Greenland. However, research in recent decades has shown a high prevalence of undiagnosed diabetes. Addressing diabetes in the geographically dispersed population of Greenland presents a challenge to the health care system. In 2008, a new model of diabetes care was introduced in Greenland that included continual monitoring, analysis, and adjustment of initiatives taken. The overall aim of this review was to review the feasibility of the monitoring of an ongoing national diabetes care programme. After ten years of observation it was clear that monitoring of such a programme based on information in electronic medical records in Greenland was feasible. It was found that the majority of the population in Greenland was in contact with the health care system. Increased diagnostic activity resulted in an increased prevalence of diagnosed diabetes. The quality of diabetes care in Greenland and the testing effectiveness of gestational diabetes were improved. Microvascular complications were frequently observed among Greenlandic diabetic patients, except for retinopathy that was as an exception. In summary, this model may improve diabetes care and potentially care for other chronic conditions in Greenland, and may also be helpful in other remote settings where chronic disease care is difficult.Abbreviations: AD: Anno Domini; ADA: American Diabetes Association; BC: Before Christ; BMI: Body Mass Index; BP: Blood Pressure; CWB: Capillary Whole Blood; EMR: Electronic Medical Record; EASD: European Association for Study of Diabetes; GA: Gestational Age; GDM: Gestational Diabetes Mellitus; FIGO: The International Federation of Gynaecology and Obstetrics; HbA1c: Glycosylated haemoglobin; IDF: International Diabetes Federation; LDL: Low density lipoprotein; NDQIA: National Diabetes Quality Improvement Alliancel; NICE: National Institute for Health and Care Excellence; OECD: Organisation for Economic Co-operation and Development; OGTT: Oral Glucose Tolerance Test; QIH: Queen Ingrid Hospital; RCT: Randomised Controlled Tria;l T1D: Type 1 Diabetes; T2D: Type 2 Diabetes; UACR: Urine Albumin Creatinine Ratio; WHO: World Health Organisation.

The experience of gestational diabetes for indigenous Māori women living in rural New Zealand: qualitative research informing the development of decolonising interventions

Background

Although early detection and management of excess rates of gestational diabetes mellitus (GDM) among Indigenous women can substantially reduce maternal and offspring complications, current interventions seem ineffective for Indigenous women. While undertaking a qualitative study in a rural community in Northland, New Zealand about the complexities of living with diabetes, we observed a common emotional discourse about the burden of diabetic pregnancies. Given the significance of GDM and our commitment to give voice to Indigenous Māori women in ways that could potentially inform solutions, we aimed to explore the phenomenon of GDM among Māori women in a rural context marked by high area-deprivation.

Method

A qualitative and Kaupapa Māori methodology was utilised. A sub-sample of women (n = 10) from a broader study designed to improve type 2 diabetes mellitus (T2DM) who had experienced GDM or pre-existing diabetes during pregnancy and/or had been exposed to diabetes in utero were interviewed. Participants in the broader study were recruited via the local primary care clinic. Experiences of GDM, in relation to their current T2DM, was sought. Narrative data was analysed for themes.

Results

Intergenerational experiences informed perceptions that GDM was an inevitable heritable illness that “just runs in the family.” The cumulative effects of deprivation and living with GDM compounded the complexities of participant’ lives including perceptions of powerlessness and mental health deterioration. Missed opportunities for health services to detect and manage diabetes had ongoing health consequences for the women and their offspring. Positive relationships with healthcare providers facilitated management of GDM and helped women engage with self-management.

Conclusion

Māori women living with T2DM were clear that health providers had failed to intervene in ways that would have potentially slowed or prevented progression of GDM to T2DM. Participants revealed missed opportunities for appropriate diagnostic testing, treatment and health promotion programmes for GDM. Poor collaboration between health services and social services meant psychosocial issues were rarely addressed and the cycle of intergenerational poverty and disadvantage prevailed. These data highlight opportunities for extended case management to include whānau (family) engagement, input from social services, and evidence-based medicine and/or long-term management and prevention of T2DM.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2103-8) contains supplementary material, which is available to authorized users.

Pregnancy risk factors associated with birthweight of infants born to Australian Aboriginal women in an urban setting - a retrospective cohort study

Background

A key focus of the Closing the Gap campaign is to reduce low birthweight in Aboriginal babies. Limited research exists on factors affecting Aboriginal birthweight in urban areas.

Methods

Retrospective cohort analysis of 38,382 births (38,167 non-Aboriginal, 215 Aboriginal) at the Royal Women’s Hospital in Melbourne from January 2010 to December 2015. Aboriginal status was defined by mothers who identified themselves and their baby as Aboriginal or Torres Strait Islander. The aim was to examine the association of maternal health risk behaviours and obstetric complications with birthweight of infants born to Australian Aboriginal women birthing in an urban setting.

Results

Aboriginal babies had a lower mean birthweight than non-Aboriginal babies (mean difference -290 g; 95% confidence interval [CI] -413, − 166 g), but when accounting for gestational age and sex there was little difference (mean difference 5 g; 95% CI -53, 6 g). Aboriginal babies were significantly more likely to be delivered preterm < 37 weeks (23.3% vs 7.9%, odds ratio [OR] 3.58; 95% CI 2.58, 4.95) and be of low birthweight < 2500 g (22.3% vs 6.7%, OR 4.03; 95% CI 2.90, 5.60) or very low birthweight < 1500 g (9.8% vs 1.8%, OR 5.81; 95% CI 3.67, 9.16).

Aboriginal mothers were significantly more likely to be teenage mothers (9.8% vs 1.6%, OR 5.72; 95% CI 3.54, 9.24), smoke cigarettes throughout the pregnancy (53.8% vs 5.6%, OR 17.2; 95% CI 12.8, 23.0), and use drugs (26.5% vs 2.4%, OR 14.3; 95% CI 10.4, 19.6) during pregnancy, all of which were associated with lower birthweight. Aboriginal mothers were also more likely to have a mental health diagnosis (49.5% vs 18.8%, OR 3.77; 95% CI 2.86, 4.97), be overweight (59.9% vs 42.6%, OR 1.88; 95% CI 1.39, 2.56) and have diabetes (15.3% vs 7.3%, OR 2.31; 95% CI 1.59, 3.35) which were all associated with higher birthweight.

Conclusions

Aboriginal babies born in metropolitan Melbourne are more likely to be of low birthweight compared with non-Aboriginal babies, which in turn was related to higher rates of prematurity and not to being small for gestational age.

Glycemic control and healthcare utilization following pregnancy among women with pre-existing diabetes in Navajo Nation

Background

Native American communities experience greater burden of diabetes than the general population, including high rates of Type 2 diabetes among women of childbearing age. Diabetes in pregnancy is associated with risks to both the mother and offspring, and glycemic control surrounding the pregnancy period is of vital importance.

Methods

A retrospective chart review was conducted at a major Navajo Area Indian Health Service (IHS) hospital, tracking women with pre-existing diabetes who became pregnant between 2010 and 2012. Logistic regression was performed to find patient-level predictors of our desired primary outcome—having hemoglobin A1c (HbA1c) consistently < 8% within 2 years after pregnancy. Descriptive statistics were generated for other outcomes, including glycemic control and seeking timely IHS care.

Results

One hundred twenty-two pregnancies and 114 individuals were identified in the dataset. Baseline HbA1c was the only covariate which predicted our primary outcome (OR = 1.821, 95% CI = 1.184–2.801). Examining glycemic control among pregnancies with complete HbA1c data (n = 59), 59% were controlled before, 85% during, and 34% after pregnancy. While nearly all women received care in the immediate postpartum period, only 49% of women visited a primary care provider and 71% had HbA1c testing in the 2 years after pregnancy.

Conclusions

This is the first analysis of outcomes among women with diabetes in pregnancy in Navajo Nation, the largest reservation and tribal health system in the United States. Our findings demonstrate the positive impact of specialized prenatal care in achieving glycemic control during pregnancy, while highlighting the challenges in maintaining glycemic control and continuity of healthcare after pregnancy.

Implementation of a diabetes in pregnancy clinical register in a complex setting: Findings from a process evaluation

Background

Rates of diabetes in pregnancy are disproportionately higher among Aboriginal than non-Aboriginal women in Australia. Additional challenges are posed by the context of Aboriginal health including remoteness and disadvantage. A clinical register was established in 2011 to improve care coordination, and as an epidemiological and quality assurance tool. This paper presents results from a process evaluation identifying what worked well, persisting challenges and opportunities for improvement.

Methods

Clinical register data were compared to the Northern Territory Midwives Data Collection. A cross-sectional survey of 113 health professionals across the region was also conducted in 2016 to assess use and value of the register; and five focus groups (49 healthcare professionals) documented improvements to models of care.

Results

From January 2012 to December 2015, 1,410 women were referred to the register, 48% of whom were Aboriginal. In 2014, women on the register represented 75% of those on the Midwives Data Collection for Aboriginal women with gestational diabetes and 100% for Aboriginal women with pre-existing diabetes. Since commencement of the register, an 80% increase in reported prevalence of gestational diabetes among Aboriginal women in the Midwives Data Collection occurred (2011–2013), prior to adoption of new diagnostic criteria (2014). As most women met both diagnostic criteria (81% in 2012 and 74% in 2015) it is unlikely that the changes in criteria contributed to this increase. Over half (57%) of survey respondents reported improvement in knowledge of the epidemiology of diabetes in pregnancy since establishment of the register. However, only 32% of survey respondents thought that the register improved care-coordination. The need for improved integration and awareness to increase use was also highlighted.

Conclusion

Although the register has not been reported to improve care coordination, it has contributed to increased reported prevalence of gestational diabetes among high risk Aboriginal women, in a routinely collected jurisdiction-wide pregnancy dataset. It has therefore contributed to an improved understanding of epidemiology and disease burden and may in future contribute to improved management and outcomes. Regions with similar challenges in context and high risk populations for diabetes in pregnancy may benefit from this experience of implementing a register.

Does Indigenous health research have impact? A systematic review of reviews

Background

Aboriginal and Torres Strait Islander Australians (hereafter respectfully Indigenous Australians) claim that they have been over-researched without corresponding research benefit. This claim raises two questions. The first, which has been covered to some extent in the literature, is about what type(s) of research are likely to achieve benefits for Indigenous people. The second is how researchers report the impact of their research for Indigenous people. This systematic review of Indigenous health reviews addresses the second enquiry.

Methods

Fourteen electronic databases were systematically searched for Indigenous health reviews which met eligibility criteria. Two reviewers assessed their characteristics and methodological rigour using an a priori protocol. Three research hypotheses were stated and tested: (1) reviews address Indigenous health priority needs; (2) reviews adopt best practice guidelines on research conduct and reporting in respect to methodological transparency and rigour, as well as acceptability and appropriateness of research implementation to Indigenous people; and (3) reviews explicitly report the incremental impacts of the included studies and translation of research. We argue that if review authors explicitly address each of these three hypotheses, then the impact of research for Indigenous peoples’ health would be explicated.

Results

Seventy-six reviews were included; comprising 55 journal articles and 21 Australian Government commissioned evidence review reports. While reviews are gaining prominence and recognition in Indigenous health research and increasing in number, breadth and complexity, there is little reporting of the impact of health research for Indigenous people. This finding raises questions about the relevance of these reviews for Indigenous people, their impact on policy and practice and how reviews have been commissioned, reported and evaluated.

Conclusions

The findings of our study serve two main purposes. First, we have identified knowledge and methodological gaps in documenting Indigenous health research impact that can be addressed by researchers and policy makers. Second, the findings provide the justification for developing a framework allowing researchers and funding bodies to structure future Indigenous health research to improve the reporting and assessment of impact over time.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-017-0548-4) contains supplementary material, which is available to authorized users.

Call to action: A new path for improving diabetes care for Indigenous peoples, a global review

Diabetes has reached epidemic proportions in Indigenous populations around the globe, and there is an urgent need to improve the health and health equity of Indigenous peoples with diabetes through timely and appropriate diabetes prevention and management strategies. This review describes the evolution of the diabetes epidemic in Indigenous populations and associated risk factors, highlighting gestational diabetes and intergenerational risk, lifestyle risk factors and social determinants as having particular importance and impact on Indigenous peoples. This review further describes the impact of chronic disease and diabetes on Indigenous peoples and communities, specifically diabetes-related comorbidities and complications. This review provides continued evidence that dramatic changes are necessary to reduce diabetes-related inequities in Indigenous populations, with a call to action to support programmatic primary healthcare transformation capable of empowering Indigenous peoples and communities and improving chronic disease prevention and management. Promising strategies for transforming health services and care for Indigenous peoples include quality improvement initiatives, facilitating diabetes and chronic disease registry and surveillance systems to identify care gaps, and prioritizing evaluation to build the evidence-base necessary to guide future health policy and planning locally and on a global scale.

Obesity, Diabetes, and Birth Outcomes Among American Indians and Alaska Natives

Objectives To examine the relationships between prepregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), and prepregnancy body mass index, with several adverse birth outcomes: preterm delivery (PTB), low birthweight (LBW), and macrosomia, comparing American Indians and Alaska Natives (AI/AN) with other race/ethnic groups. Methods The sample includes 5,193,386 singleton US first births from 2009-2013. Logistic regression is used to calculate adjusted odds ratios controlling for calendar year, maternal age, education, marital status, Kotelchuck prenatal care index, and child's sex. Results AI/AN have higher rates of diabetes than all other groups, and higher rates of overweight and obesity than whites or Hispanics. Neither overweight nor obesity predict PTB for AI/AN, in contrast to other groups, while diabetes predicts increased odds of PTB for all groups. Being overweight predicts reduced odds of LBW for all groups, but obesity is not predictive of LBW for AI/AN. Diabetes status also does not predict LBW for AI/AN; for other groups, LBW is more likely for women with DM or GDM. Overweight, obesity, DM, and GDM all predict higher odds of macrosomia for all race/ethnic groups. Conclusions for Practice Controlling diabetes in pregnancy, as well as prepregnancy weight gain, may help decrease preterm birth and macrosomia among AI/AN.

Obstetric and Perinatal Morbidity in Northern Tasmanian Aboriginal Population: A Retrospective Cohort Study

INTRODUCTION

Aboriginal and Torres Strait Islander women are at increased risk of maternal morbidity and mortality as compared to non-Aboriginals. Similarly, aboriginal babies are at increased risk of low birth weight and infant mortality.

AIM

To investigate the independent association of aboriginality with Tasmanian maternal and neonatal morbidity.

MATERIALS AND METHODS

A retrospective analysis of all the births (gestation more than 20 weeks) from June 2013 to May 2014 was conducted at the Launceston General Hospital, Tasmania. The study compared 66 Aboriginal (4.2% of the total births) to 1477 non-aboriginal births for maternal and neonatal morbidity. Comparisons were made using logistic regression. The outcome measures were maternal and neonatal morbidity.

RESULTS

Significantly higher number of aboriginal women (49% vs 19%; OR 4.15 90%CI 2.52- 6.85) smoked and used illicit drugs (15% vs 2%; OR 9.24; 95%CI 4.28-19.96) than the non-aboriginal women (both p<0.001). Maternal morbidity was not significantly different between aboriginal compared to non-aboriginal women (OR 0.64; 95%CI 0.36-1.14; p=0.13; adjusted OR 1.00; 95%CI 0.52-1.93; p=0.99). Factors positively associated with maternal morbidity included: age (OR 1.28; 95%CI 1.13-1.46; p<0.01) and BMI (OR 1.50; 95%CI 1.33-1.70; p<0.01). The unadjusted OR of neonatal morbidity for aboriginality was 1.98 (95%CI 1.17-3.34; p=0.01) and adjusted was 1.45 (95%CI 0.77-2.72; p=0.25). Factors positively associated with neonatal morbidity included smoking (OR 2.24; 95%CI 1.59-3.14; p<0.01), illicit drug use 95%CI 1.49-(OR 3.26; 95%CI 1.49-7.13; p <0.01), hypertension (OR 2.49; 95%CI 1.61-3.84; p<0.01) and diabetes (OR 1.92; 95%CI 1.33-2.78; p<0.01).

CONCLUSION

The composite Aboriginal maternal morbidity does not differ, however the increased rates of smoking and illicit drug use are largely responsible for neonatal morbidity. Along with strengthening strategies to decrease medical comorbidities in aboriginals, we recommend intensifying smoking and illicit drug cessation programs.

Trends in Indigenous and non-Indigenous caesarean section births in the Northern Territory of Australia, 1986-2012: a total population-based study

OBJECTIVE

To examine trends in caesarean section deliveries and factors associated with these trends for Indigenous and non-Indigenous mothers.

DESIGN

Total population-based study.

SETTING

Northern Territory of Australia, 1986-2012.

POPULATION

Pregnancies among Northern Territory residents, limited to singleton live births with cephalic presentations delivered at 37-42 weeks' gestation (n = 78 561).

METHODS

Descriptive analyses of demographic and obstetric risk factors. Poisson regression with robust variance to estimate the likelihood of caesarean delivery with and without labour compared with vaginal delivery, over time and between Indigenous and non-Indigenous mothers, adjusting for risk factors.

MAIN OUTCOME MEASURES

Trends in caesarean sections and risk of caesarean delivery compared with vaginal delivery.

RESULTS

The total rate of caesarean deliveries in the Northern Territory increased between 1986 and 2012. From the year 2000, the rise was driven by increases in caesareans with labour among nulliparous mothers and no labour caesareans among multiparous mothers. Increases in demographic and obstetric risk factors explained the rise in caesareans with labour among nulliparous Indigenous mothers, whereas other unmeasured variables contributed to the rise among non-Indigenous mothers. Increases in previous caesarean delivery contributed to the rise in all caesareans among multiparous mothers. Following adjustment, the risk of Indigenous nulliparous mothers having a caesarean with labour was 47% greater than for non-Indigenous nulliparous mothers [adjusted risk ratio 1.47 (95% CI 1.34-1.60)].

CONCLUSIONS

Increases in demographic and obstetric risk factors partially explained the increase in caesarean rates in the Northern Territory and the contribution of these factors differed between Indigenous and non-Indigenous mothers.

TWEETABLE ABSTRACT

Caesarean section rates increased between 1986 and 2012 in the Northern Territory of Australia.

Solving the mystery: the true prevalence of gestational diabetes in indigenous women

This commentary briefly reviews what is currently known about estimating the prevalence of gestational diabetes in indigenous women. It offers insights into numerous factors likely playing a role in its observed variability. It also highlights important key concepts to consider in the overall evaluation and management of gestational diabetes in this particular population.

The prevalence of gestational diabetes mellitus among Aboriginal and Torres Strait Islander women in Australia: a systematic review and meta-analysis

INTRODUCTION

Gestational diabetes mellitus (GDM) is an important and increasing health problem. This study aims to investigate and explain the marked variation in reported GDM prevalence among Australian Indigenous women.

MATERIALS AND METHODS

We searched five databases to August 2013 for studies of GDM prevalence; two people independently assessed search results, extracted data, and appraised risk of bias. Meta-analysis was conducted, and between-study heterogeneity examined using subgroup analyses. Within-study findings were synthesized narratively.

RESULTS

The pooled GDM prevalence from 23 of the 25 total studies (5.74%, 4.78-6.71) was similar to that reported in national studies, but heterogeneity was substantial (I(2)  = 97%), making conclusions from between-study comparisons difficult. The greatest reductions in heterogeneity were seen within subgroups using localized diagnostic criteria (I(2)  = 43%, 3 studies), universal screening (I(2)  = 58%) and some jurisdictions, probably reflecting proxy measures of increased consistency in diagnostic and screening methods. Insufficient data were available to assess the effect of factors such as rurality, diagnostic criteria, study design and data sources on prevalence. Synthesis of within-study findings showed: higher age-adjusted prevalences of GDM in Indigenous versus non-Indigenous women; Indigenous women have greater increases in prevalence with maternal age; and non-Indigenous women appear to have a steeper increase in GDM prevalence over time. Prevalence increased almost fourfold in two studies following introduction of universal screening when compared with selective risk-based screening, although numbers were small.

DISCUSSION/CONCLUSIONS

The published GDM prevalence among Indigenous women varies markedly, probably due to variation in diagnostic and screening practices.

Risk factors for gestational diabetes mellitus: ethnic disparities

OBJECTIVE

Gestational diabetes mellitus (GDM) increases the risk of poor maternal and infant health outcomes; therefore, the objective of this study was to compare the ethnic disparities and identify the risk factors for GDM.

DESIGN

We performed a cross-sectional analysis using patient records from a hospital located in the Puli area of Central Taiwan.

SETTING

A teaching hospital located in a rural mountainous area of Central Taiwan.

PARTICIPANTS

Between 2002 and 2012, the hospital admitted 154 patients (107 non-aborigines, 30 aborigines, and 17 non-Taiwanese) who exhibited glucose intolerance during their pregnancy.

MAIN OUTCOME MEASURES

GDM was confirmed using the oral-glucose-tolerance-test administered in dose of either 100 g or 75 g. The incidence and risk factors for GDM in the aboriginal and non-aboriginal women was compared.

RESULTS

We excluded the patients who had overt diabetes or were non-Taiwanese. Thus, 132 patients (28 aboriginal and 104 non-aboriginal women; mean age 30 years) were enrolled in the final study. A total of 51 patients (15 aboriginal, 36 non-aboriginal women) had GDM, which was more prevalent among the aboriginal mothers (53.6% versus 34.6%). The risk factors for GDM among the aboriginal women were persistent glycosuria and prior macrosomia.

CONCLUSION

The Taiwanese aboriginal women exhibited higher incidence of GDM; thus, we recommend that early screening and health education for pregnant aboriginal women be provided.

The worldwide epidemic of female obesity

The rapidly rising number of individuals who are overweight and obese has been called a worldwide epidemic of obesity with >35% of adults today considered to be overweight or obese. Women are more likely to be overweight and obese than their male counterparts, which has far-reaching effects on reproductive health and specifically pregnancy, with obese women facing an increased risk of gestational diabetes, preeclampsia, operative delivery, fetal macrosomia, and neonatal morbidity. The etiology of obesity is highly complex encompassing genetic, environmental, physiologic, cultural, political, and socioeconomic factors, making it challenging to develop effective interventions on both a local and global scale. This article describes the extent and the cost of the obesity epidemic, which, although historically seen as a disease of high-income countries, is now clearly a global epidemic that impacts low- and middle-income countries and indigenous groups who bear an ever-increasing burden of this disease.

Improving health service delivery for women with diabetes in pregnancy in remote Australia: survey of care in the Northern Territory Diabetes in Pregnancy Partnership

BACKGROUND

In the Northern Territory (NT), 38% of 3500 births each year are to Indigenous women, 80% of whom live in regional and remote areas. Compared with the general Australian population, rates of pre-existing type 2 diabetes in pregnancy are 10-fold higher and rates of gestational diabetes are 1.5-fold higher among Indigenous women. Current practices in screening for diabetes in pregnancy in remote Australia are not known.

AIMS

To assess current health service delivery for NT women with diabetes in pregnancy (DIP) by surveying healthcare professionals' views and practices in DIP screening and management.

MATERIALS AND METHODS

A cross-sectional survey of NT healthcare professionals providing clinical care for women with DIP was conducted based on pre-identified themes of communication, care-coordination, education, orientation and guidelines, logistics and access, and information technology.

RESULTS

Of the 116 responders to the survey, 78% were primary healthcare professionals, 32% midwives and 25% general practitioners. High staff turnover was evident: of Central Australian professionals, only 33% (urban) and 18% (regional/remote) had been in their current position over 5 years. DIP screening was conducted at first antenatal visit by 66% and at 24-28-week gestation by 81%. Only 50% of respondents agreed that most women at their health service received appropriate care for DIP, and 41% of primary care practitioners were neutral or not confident in their skills to manage DIP.

CONCLUSIONS

It is promising that many healthcare professionals report following new guidelines in conducting early pregnancy screening for DIP in high risk women. Several challenges were identified in healthcare delivery to a high risk population in remote Australia.

Patient and caregiver perspectives of health provision practices for First Nations and Métis women with gestational diabetes mellitus accessing care in Winnipeg, Manitoba

BACKGROUND

More North American Indigenous women are diagnosed with gestational diabetes mellitus (GDM) than the general population. Despite the number of health problems associated with GDM, few studies have been conducted that explore Indigenous women's understandings of GDM in an effort to develop appropriate and effective health strategies.

METHODS

A qualitative investigation was conducted to describe the experiences of First Nations and Métis women with GDM. Unstructured interviews and focus groups initially took place with 25 advisors such as maternal care providers and community representatives. Semi-structured explanatory model interviews were subsequently carried out with 29 First Nations and Métis women in Winnipeg, Manitoba, Canada.

RESULTS

Divisions in health services, communication and cultural barriers exist, and limit prenatal care access as well as the consistent interpretation of diabetes education messages.

CONCLUSIONS

Collectively the results suggest living with GDM can be overwhelming and underscore the need for health care providers to encourage self-efficacy towards effective management practices in the context of cultural safety.

Macrosomia in non-gestational diabetes pregnancy: glucose tolerance test characteristics and feto-maternal complications in tropical Asia Pacific Australia

OBJECTIVE

To look into the glucose tolerance test characteristics and determine complications in non-gestational diabetes pregnant subjects.

METHODS

From 2006 to 2009 all non-gestational diabetes mellitus (non-GDM) pregnant women who delivered macrosomia at the North Australia's Townsville Hospital were retrospectively reviewed by extracting data from clinical record. Glucose tolerance tests results were analysed in the light of an earlier diagnosis of non-GDM.

RESULTS

Ninety-one non-GDM mothers with macrosomia were studied and compared with 41 normoglycemic subjects without macrosomia. Of the subjects with non-GDM macrosomia, 45 (49.4%) had normal 50 g glucose challenge test (GCT) without further testing, another 8 (8.8%) had abnormal GCT but normal 75 g oral glucose tolerance test (OGTT). A total of 4 (4.4%) subjects had normal GCT and OGTT. Interestingly, 14 out of 16 (87.5%) subjects who were tested with OGTT owing to past history of macrosomia had normal results but delivered macrosomic babies. Only 12 subjects had both GCT and OGTT, the rest of the cohort had either of the two tests. Subjects with non-GDM macrosomia had higher frequency of neonatal hypoglycaemia 34% as compared to 10% in non-macrosomic babies (P=0.003). Other feto-maternal complications were similar in both groups.

CONCLUSIONS

No significant pattern of glucose tolerance characteristics was identified in non-GDM mothers with macrosomic babies. In spite of being normoglycemic significant neonatal hypoglycaemia was recorded in non-GDM macrosomic babies. Further prospective studies on a larger population are needed to verify our findings.

Maternal health issues and cardio-metabolic outcomes in the offspring: a focus on Indigenous populations

Non-communicable diseases (NCDs) including diabetes, obesity and cardiovascular disease are the leading causes of death worldwide. Indigenous populations are disproportionally affected. In an effort to halt the increasing disease burden, the mechanisms underlying the increasing rate of NCDs are an important area of study. Recent evidence has focused on the perinatal period as an influential period impacting the future cardio-metabolic health of the offspring. This concept has been defined as metabolic foetal programming and supports the importance of the developmental origins of health and disease in research and clinical practice, specifically in prevention efforts to protect future generations from NCDs. An understanding of the underlying mechanisms involved is not clear as of yet. However, an understanding of these mechanisms is imperative in order to plan effective intervention strategies. As much of the discussion below is gleaned from large epidemiological studies and animal studies, further research with prospective cohorts is necessary.

Ethics and Community Involvement in Syntheses Concerning American Indian, Alaska Native, or Native Hawaiian Health: A Systematic Review

BACKGROUND

The objective of the research was to review reporting of ethical concerns and community involvement in peer-reviewed systematic reviews or meta-analyses concerning American Indian, Alaska Native, or Native Hawaiian (AI/AN/NH) health.

METHODS

Text words and indexed vocabulary terms were used to query PubMed, Embase, Cochrane Library, and the Native Health Database for systematic reviews or meta-analyses concerning AI/AN/NH health published in peer-reviewed journals, followed by a search through reference lists. Each article was abstracted by two independent reviewers; results were discussed until consensus was reached.

RESULTS

We identified 107 papers published from 1986-2012 that were primarily about AI/AN/NH health or presented findings separately for AI/AN/NH communities. Two reported seeking indigenous reviewer feedback; none reported seeking input from tribes and communities. Approximately 7% reported on institutional review board (IRB) approval of included studies, 5% reported on tribal approval, and 4% referenced the sovereignty of AI/AN tribes. Approximately 63% used evidence from more than one AI/AN/NH population study, and 28% discussed potential benefits to communities from the synthesis research.

CONCLUSIONS

Reporting of ethics and community involvement are not prominent. Systematic reviews and meta-analyses making community-level inferences may pose risks to communities. Future systematic reviews and meta-analyses should consider ethical and participatory dimensions of research.

Race/Ethnicity, Obesity, and Related Cardio-Metabolic Risk Factors: A Life-Course Perspective

The adoption of health behaviors characterized by minimal energy expenditure and overconsumption of energy has led to cardiometabolic risk factors in pregnancy, childhood, and youth, all of which increase the prevalence of cardiovascular disease in adulthood. The propensity to develop abdominal obesity and cardiometabolic risk factors appears to disproportionally affect non-white ethnic groups. While the majority of observational research has been conducted in populations of European origin, studies in non-white ethnic groups across the life-course are underway and there is evidence that unique ethnic-specific differences exist. This review will focus on the life-course determinants of obesity and its related cardio-metabolic risk factors among diverse ethnic groups including people of Afro-Caribbean origin, South Asian, East Asian, and indigenous ancestry.