Knowledge and practice related to gestational diabetes among primary health care providers in Morocco: Potential for a defragmentation of care?

IMplementation of the Preterm Birth Surveillance PAthway: a RealisT evaluation (The IMPART Study)

BACKGROUND

In the UK, 7.6% of babies are born preterm, which the Department of Health aims to decrease to 6% by 2025. To advance this, NHS England released Saving Babies Lives Care Bundle Version 2 Element 5, recommending the Preterm Birth Pathway for women at risk of preterm birth. The success of this new pathway depends on its implementation. The IMPART (IMplementation of the Preterm Birth Surveillance PAthway: a RealisT evaluation) study aimed to research how, why, for whom, to what extent and in what contexts the prediction and prevention aspects of Preterm Birth Surveillance Pathway is implemented through a realist evaluation. Realist implementation studies are growing in popularity.

METHODS

Initial programme theories were developed through a realist informed literature scope, interviews with developers of the NHS England guidance, and a national questionnaire of current practice. Implementation theory was utilised in developing the programme theories. Data (interviews and observations with staff and women) were undertaken in 3 case sites in England to 'test' the programme theories. Substantive theory was utilised during data analysis to interpret and refine the theories on how implementation could be improved.

RESULTS

Three explanatory areas were developed: risk assessing and referral; the preterm birth surveillance clinic; and women centred care. Explanatory area 1 dealt with the problems in correct risk assessment and referral to a preterm clinic. Explanatory area 2 focused on how once a correct referral has been made to a preterm clinic, knowledgeable and supported clinicians can deliver a well-functioning clinic. Explanatory area 3 concentrated on how the pathway delivers appropriate care to women.

CONCLUSIONS

The IMPART study provides several areas where implementation could be improved. These include educating clinicians on knowledge of risk factors and the purpose of the preterm clinic, having a multidisciplinary preterm team (including a preterm midwife) with specialist preterm knowledge and skills (including transvaginal cervical scanning skills), and sites actively working with their local network. This multidisciplinary preterm team are placed to deliver continuity of care for women at high-risk of preterm birth, being attentive to their history but also ensuring they are not defined by their risk status.

TRIAL REGISTRATION

ISRCTN57127874.

Screening and nursing management of gestational diabetes in Ghana: Evidence-based recommendations

Objective

To describe the development of evidence-based recommendations for screening and nursing management of gestational diabetes mellitus (GDM) in Ghana and present the recommendations.

Design

A qualitative study.

Setting

Military Health Institutions in Ghana.

Measurements

Data from qualitative interviews with 7 women with GDM and 8 midwives, and an integrative literature review including available clinical practice guidelines on screening and nursing management of GDM, was used to develop the recommendations. The National Institute for Health and Care Excellence' steps guided the recommendations' development. Methodological quality of the recommendations was assessed based on an adapted version of the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Six experts reviewed the recommendations and an infographic in support of the recommendations.

Findings

Two main recommendations and an infographic were developed, including: 1. Early screening and diagnosis of GDM, and 2. Involvement of women with GDM and their significant others during pregnancy, intrapartum and postpartum management, in a culturally and socio-economically appropriate manner.

Key conclusions

The recommendations and infographic, once reviewed and pilot tested, may assist midwives managing GDM in Ghana, with support of health institution management.

Implications for practice

The study highlights the need for recommendations which can be used by midwives to manage GDM in Ghana. The recommendations are the first to be contextualized for the Ghanaian setting.

Practices, attitudes and knowledge of midwives and nurses regarding gestational diabetes and pregnancy-induced hypertension

Midwives (M) and obstetric nurses (ON) play a critical role in providing healthcare for pregnant patients at all stages of pregnancy, and ongoing training and education are essential to ensure the best outcomes. This longitudinal quantitative research study aimed to assess the impact of an educational program on the knowledge, attitudes, and practices of 125 midwives and obstetric nurses regarding care for patients with gestational diabetes and pregnancy-induced hypertension. The original questionnaire consisted of 56 items grouped into 3 subscales assessing knowledge (15 items), attitudes (18 items), and practices (23 items). The questionnaire was administered at three distinct intervals during the educational program: pre-test, post-test, and follow-up at three months. The data were analyzed using ANOVA and Pearson correlation coefficients to determine the significance of the differences between the 3 moments of the administration of the questionnaire. There was a significant increase in the level of knowledge, attitudes, and practices of midwives and obstetric nurses following the training module, which was sustained at 3 months after completion compared to pre-training. The comparative analysis of the total scores for every 3 sets of items revealed the positive impact of the educational program on the level of knowledge, attitudes, and practices of midwives and obstetric nurses.

Midwifery awareness of diabetes in pregnancy screening guidelines in Aotearoa New Zealand

OBJECTIVE

Effective and timely management of gestational diabetes mellitus (GDM) requires early detection. However, screening rates have been shown to be relatively low in New Zealand, despite the introduction of national screening guidelines in 2014 which indicate that all pregnant women should be screened. Thus, the aim of this study was to explore the awareness of the New Zealand Ministry of Health Diabetes in Pregnancy screening guidelines by New Zealand midwives.

DESIGN

A 24-question online survey based upon the New Zealand screening guidelines was distributed via New Zealand midwifery social media groups to explore the awareness of New Zealand midwives with regard to screening for diabetes in pregnancy. Free text comments were also allowed, these were broadly categorized and reviewed.

PARTICIPANTS

174 registered midwives in Aotearoa New Zealand completed the survey.

MEASUREMENTS AND FINDINGS

All participants responded that they routinely offer glycated haemoglobin screening for detection of undiagnosed pre-gestational diabetes, and 92.9% identified that this should occur prior to 20 weeks gestation (as per the national guidelines). However, less than two thirds of midwives thought that all women should be screened for GDM, with 18.2% indicating they would only do this if immediate risk factors were present. There also appeared to be some confusion over the time period for screening for GDM with 22.9% indicating that this should occur later than the guideline-recommended timepoint of 24-28 weeks gestation. Participants who identified as Māori and community-based midwives were most likely to screen for GDM 'only if risk factors were present'. Participants practicing for more than 6 years, those aged 45-54 years, and midwives identifying as Māori were most likely to screen for GDM after 28 weeks (though these did not reach statistical significance).

KEY CONCLUSIONS

The New Zealand Diabetes in Pregnancy screening guidelines do not appear to be well implemented in our sample group, particularly with regard to screening for GDM. This needs to be evaluated in a larger group of midwives, as education around the timeliness and importance of screening for all women may be required.

IMPLICATIONS FOR PRACTICE

A lack of appropriate or timely screening for GDM may mean that women are not being diagnosed or managed appropriately, which in turn may have implications for both mother and child.

Diagnosis of gestational diabetes in Uganda: The reactions of women, family members and health workers

OBJECTIVES

In Uganda, as in many other low- and middle-income countries, screening for gestational diabetes mellitus is suboptimal and is rarely embedded in routine antenatal care. We describe the experiences of women in Uganda who underwent screening for gestational diabetes mellitus and were diagnosed with the condition as they navigate both the reaction of family members and their interaction with health workers.

METHODS

Pregnant women aged 18 years or older and between 24 and 28 weeks of gestation were enrolled from the antenatal clinics at one of the five hospitals between 13 June 2018 and 31 October 2019. Ten women with gestational diabetes mellitus, ten family members and six health workers were purposively selected to take part. Interviews and focus group discussions were used to collect data on the socio-cultural and health system factors that influence timely screening and effective management of gestational diabetes mellitus in Uganda. Data were analysed thematically.

RESULTS

Women generally reflected on the importance of gestational diabetes mellitus screening and felt that an early diagnosis helped them to get timely medical attention, and most reported a positive experience of the care provided by health workers. However, women who were diagnosed with gestational diabetes mellitus reported feeling fearful and anxious, and some were worried that the condition might be life-threatening. Many women reported that they were upset and largely unprepared to receive a gestational diabetes mellitus diagnosis. A gestational diabetes mellitus diagnosis not only stirred intense feelings of fear and anxiety in women but also affected their spouses and other family members. Many male partners were sympathetic and willing to provide support.

CONCLUSION

Our findings highlight the need to understand the perceptions and emotions that accompany a gestational diabetes mellitus diagnosis to best support women and their family members. An improved recognition of these factors can inform the development of effective gestational diabetes mellitus screening and management programmes.

The lived experiences of midwifery care for women with diabetes: An integrative review

BACKGROUND

Midwives provide care to women across the childbearing journey from pre-conception to the post-partum period in various clinical settings. Due to the increasing incidence of diabetic pregnancies, midwives are now in a position to support other health professionals, as part of a team, to reduce the stress and / or demand on the health care services.

OBJECTIVE

This integrative review synthesises original research that explores the experiences and perceptions of midwives in the provision of care for women with diabetes.

DESIGN

Integrative review.

METHODS

Whittemore and Knafl's (2005) systematic approach was used to search for primary literature related to the research question. Studies meeting the following criteria were included: primary qualitative, quantitative and mixed methods research studies published in peer reviewed journals between January 2009 to October 2019. The population of interest being midwives or nurse-midwives and the outcomes of interest included their perceived role in the management of women with diabetes from the pre conceptual to the postpartum period. The methodological quality of the studies was assessed using the appropriate CASP (Critical Appraisal Skills Programmes, 2014) criteria for qualitative and quantitative research studies. A robust search strategy was conducted using the following databases: EBCSO host (all data bases), Embase, Scopus, and Science Direct (see Table 1).

FINDINGS

A total of 7275 articles were retrieved and ten papers were included in this review (five qualitative and five quantitative) that fulfilled the inclusion criteria. Two overarching themes were identified: professional and personal impacts on midwifery practice. The professional impact theme included three sub themes: organisational issues, professional development and holistic support. The personal impact theme also included three themes: limited diabetes knowledge, limited clinical practice skills and mental attitude.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The findings indicate that midwives need opportunities to learn and develop skills specific to their role so that each individual's needs can be met. These opportunities include provision of education at a university level, offering work based training and increasing the number of post registration courses targeted at midwives who are willing to upskill to provide appropriate care to women with diabetes. Courses are required to address the knowledge, attitudes to diabetes, appropriate assessment skills and innovative communication skills for midwives.

Gestational Diabetes: Exploring the Perceptions, Practices and Barriers of the Community and Healthcare Providers in Rural Bangladesh: A Qualitative Study

BACKGROUND AND OBJECTIVE

Gestational Diabetes Mellitus (GDM) is a prevalent and important disease during pregnancy and has detrimental effects on both the mother and the baby. The current study explored the perception and attitude of the community people about GDM and describes the challenges and gaps in knowledge, availability and accessibility of services for GDM screening and management at a rural community in Bangladesh.

METHODS

We performed a qualitative study including seven Focus Group Discussions (FGDs) and eight Key Informant Interviews (KIIs) from November 2017 to January 2018 at randomly selected areas of Tangail district. A highly trained team including two anthropologists conducted the qualitative studies (FGDs and KIIs) under the guidance of experienced researchers. Thematic analysis was performed.

RESULTS

GDM is not a known term for pregnant women, their husbands, mothers, and mothers-in-law. Most of the participants (78.7%) did not even hear the term. Some of them (25.5%) perceived that GDM will persist for whole life and transmit from husband to wife and mother to baby. Some people (21.3%) thought that GDM entirely depends on the wish of the God. Most of the participants (68.1%) perceived that symptoms of other types of diabetes and GDM are almost the same. Some participants (19.1%) thought that GDM patients need to intake some medicines that might affect the fetus. The majority of the respondents (83%) had no idea when a pregnant woman should test her diabetes during pregnancy. If GDM diagnosed, pregnant women decided to follow the advice of the doctors. The results from KII with health managers found that they lack in-depth knowledge of GDM. There is no structured guideline or protocol at their facilities for GDM management.

CONCLUSION

The existing barriers at the communities for adequate detection and management of GDM are identified properly. The findings of this study will be helpful for the decision-makers in taking necessary actions to control the GDM.

Barriers and facilitators for implementing programmes and services to address hyperglycaemia in pregnancy in low and middle income countries: A systematic review

AIMS

An estimated 87.6% of hyperglycaemia in pregnancy cases are in low and middle income countries (LMICs). The aim of this study is to review the evidence on barriers and facilitators to programmes and services addressing hyperglycaemia in pregnancy in LMICs.

METHODS

A systematic review and narrative synthesis was conducted based on searches in PubMed. A total of 23 qualitative and quantitative studies were included.

RESULTS

Barriers and facilitators exist at the health system level, individual level and social and societal levels and are often interacting. At the health system level they relate to capacity in terms of human and material resources; availability of feasible and appropriate guidelines; organisational management and referral pathways. Individual level barriers and facilitators include knowledge; risk perception; illness beliefs; financial condition; work obligations; concerns for the baby and hardship associated with services. At the social and societal level important factors are: perceptions and norms related to women's roles, mobility and health; the knowledge and support of women's social network; and structural aspects.

CONCLUSIONS

Numerous factors influence programmes and services addressing hyperglycaemia in pregnancy in LMICs. Thus, several components are needed to ensure detection, treatment and follow-up of women with hyperglycaemia in pregnancy.

Barriers of Adherence and Possible Solutions to Nonadherence to Antidiabetic Therapy in Women with Diabetes in Pregnancy: Patients' Perspective

Diabetes in pregnancy contributes to maternal mortality and morbidity though it receives little attention in developing countries. The purpose of the study was to explore the barriers to adherence and possible solutions to nonadherence to antidiabetic therapy in women with diabetes in pregnancy. Antidiabetic therapy referred to diet, physical activity, and medications. Four focus group discussions (FGDs), each with 7 participants, were held at a central hospital in Zimbabwe. Included were women with a diagnosis of diabetes in pregnancy, aged 18 to 49 years, and able to speak Shona or English. Approval was obtained from respective ethical review boards. FGDs followed a semistructured questionnaire. Detailed notes were taken during the interviews which were also being audiotaped. Data were analysed thematically and manually. Themes identified were barriers and possible solutions to nonadherence to therapy. Barriers were poor socioeconomic status, lack of family, peer and community support, effects of pregnancy, complicated therapeutic regimen, pathophysiology of diabetes, cultural and religious beliefs, and poor health care system. Possible solutions were fostering social support, financial support, and improvement of hospital services. Individualised care of women with diabetes is essential, and barriers and possible solutions identified can be utilised to improve care.