"Mission impossible"? Midwives' experiences counseling pregnant women with gestational diabetes mellitus

A Social-Ecological Model Exploring Gestational Diabetes Mellitus Screening Practices Among Antenatal Health Care Providers

Gestational diabetes mellitus (GDM) is associated with adverse health outcomes for the pregnant individual and their baby. Screening approaches for GDM have undergone several iterations, introducing variability in practice among healthcare providers. As such, our study aimed to explore the views of antenatal providers regarding their practices of, and counseling experiences on the topic of, GDM screening in Ontario. We conducted a qualitative, grounded theory study. The study population included antenatal providers (midwives, family physicians, and obstetricians) practicing in Hamilton, Ottawa, or Sudbury, Ontario. Semi-structured telephone interviews were conducted and transcribed verbatim. Transcripts were analyzed using inductive coding upon which codes, categories, and themes were developed to generate a theory grounded in the data. Twenty-two participants were interviewed. Using the social-ecological theory, we created a model outlining four contextual levels that shaped the experiences of GDM counseling and screening: Intrapersonal factors included beliefs, knowledge, and skills; interpersonal factors characterized the patient-provider interactions; organizational strengths and challenges shaped collaboration and health services infrastructure; and finally, guidelines and policies were identified as systemic barriers to health care access and delivery. A focus on patient-centered care was a guiding principle for all care providers and permeated all four levels of the model. Patient-centered care and close attention to barriers and facilitators across intrapersonal, interpersonal, organizational, and policy domains can minimize the impact of variations in GDM screening guidelines. Among care providers, there is a desire for additional skill development related to GDM counseling, and for national consensus on optimal screening guidelines.

Depression and diet-related distress among Japanese women with gestational diabetes mellitus

Although the association between gestational diabetes mellitus (GDM) and maternal postpartum depression has been reported, the association between these two factors during pregnancy has not been sufficiently examined. We compared pregnant women with and without GDM to clarify the association and examined factors related to depression in pregnant women with GDM. Questionnaires were administered longitudinally to pregnant Japanese women in the third trimester and at 2 and 4 weeks postpartum. One hundred and five and 108 pregnant women with and without GDM, respectively, were included in the study. Of the 105 women with GDM, 20 (19.0%) reported being depressed during pregnancy, which was significantly higher than that among those without GDM (9.3%). Binomial logistic regression analysis revealed that depression was significantly positively associated with diet-related distress and negatively associated with social support among women with GDM. Diet-related distress and social support are important factors in managing depression in pregnant women with GDM.

Midwives' and Diabetes Nurses' Experience of Screening and Care of Women with Gestational Diabetes Mellitus: A Qualitative Interview Study

Background

Gestational diabetes mellitus (GDM) is increasing and is associated with adverse outcomes for both mother and child. The metabolic demands of pregnancy can reveal a predisposition for type 2 diabetes mellitus (T2DM), and women with a history of GDM are more likely to develop T2DM than women with normoglycemic pregnancies.

Aim

The aim of this study was to explore midwives' and diabetes nurses' experience of their role in screening, care, and follow-up of women with gestational diabetes mellitus and, further, to explore their opinions and thoughts about existing routines and guidelines.

Method

Individual interviews were performed with ten diabetes nurses and eight midwives working in primary and special care. Qualitative content analysis was done according to Graneheim and Lundman.

Results

The analysis of the interviews resulted in the overall theme "An act of balance between normalcy and illness, working for motivation with dilemmas throughout the chain of health care." Difficulties in carrying out the important task of handling GDM while at the same time keeping the pregnancy in focus were central. Women were described as highly motivated to maintain a healthy lifestyle during pregnancy with the baby in mind, but it seemed difficult to maintain this after delivery, and compliance with long-term follow-up with the aim of reducing the risk of T2DM was low. The women came to the first follow-up but did not continue with later contact. This was at a time when the women felt healthy and were focusing on the baby and not themselves. A lack of cooperation and easy access to a dietician and physiotherapist were pointed out as well as a wish for resources such as group activities and multiprofessional teams.

A framework for understanding how midwives perceive and provide care management for pregnancies complicated by gestational diabetes or hypertensive disorders of pregnancy

BACKGROUND

Both gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) are common, and each are associated with adverse maternal and perinatal outcomes. Midwives may be the first point of care when these conditions arise. This study evaluated the experiences of midwives when providing care to women and people with pregnancies complicated by GDM or HDP.

METHODS

A mixed methods study was completed in Ontario, Canada, using a sequential, explanatory approach. A total of 144 online surveys were completed by midwives, followed by 20 semi-structured interviews that were audio recorded and transcribed verbatim. Survey data were analysed using descriptive statistics. Thematic analysis was used to generate codes from the interview data, which were mapped to the Theoretical Domains Framework (TDF), to elucidate factors that might influence management.

RESULTS

Most of the midwives' clinical behaviours relating to GDM or HDP were in keeping with guidelines and regulatory standards set by existing provincial standards. Six theoretical domains from the TDF appeared to influence midwives'care pathway: "Internal influences" included knowledge, skills and beliefs about capabilities; while "external influences" included social/professional role and identity, environmental context, and social influences. Interprofessional collaboration emerged as a significant factor on both the internal and external levels of influence.

CONCLUSIONS

We identified barriers and facilitators that may improve the experiences of midwives and clients when GDM or HDP newly arises in a pregnancy, necessitating further consultation or management by another health care provider.

Womeńs experiences with managing advice on gestational diabetes - a qualitative interview study

OBJECTIVE

This study aims to gain insight into womeńs experiences with gestational diabetes and their strategies to cope with advice for changing lifestyle. Further, health care professionalś approach to women with gestational diabetes is discussed.

METHODS

Semi-structured interviews with nine women with gestational diabetes were conducted at a university hospital, adopting a phenomenological approach.

RESULTS

Three themes were created: 1) Experience of control, 2) personal strategies, and 3) unintended consequences. Women experienced that the monitoring at the outpatient clinic was associated with surveillance and safety and adopted different strategies to cope with gestational diabetes. Some women experienced feeling different and labelled due to the monitoring and their eating habits. Some women expressed concern for the baby and the risk of getting diabetes after birth. Womeńs experiences and how they transfer and cope with information about gestational diabetes at an outpatient obstetric clinic are brought forward, and it became evident that individual needs in gestational diabetes care are not being met in all situations.

CONCLUSION

Women experienced surveillance and safety while being monitored at the outpatient clinic. At the same time, self-monitoring seemed to stimulate feelings of concern about otherś reactions to the condition. In addition, we found that womeńs strategies for behaviour change included limited food intake, controlling food purchases, and being physically active. Concerning the management of gestational diabetes, some women felt that the information was not sufficiently adapted to their individual needs, thus health professionalś approach to gestational diabetes should be based on the womeńs perspective.

New Zealand women's experiences of managing gestational diabetes through diet: a qualitative study

Background

For women with gestational diabetes mellitus (GDM) poor dietary choices can have deleterious consequences for both themselves and their baby. Diet is a well-recognised primary strategy for the management of GDM. Women who develop GDM may receive dietary recommendations from a range of sources that may be inconsistent and are often faced with needing to make several dietary adaptations in a short period of time to achieve glycaemic control. The aim of this study was to explore how women diagnosed with GDM perceive dietary recommendations and how this information influences their dietary decisions during pregnancy and beyond.

Methods

Women diagnosed with GDM before 30 weeks’ gestation were purposively recruited from two GDM clinics in Auckland, New Zealand. Data were generated using semi-structured interviews and thematic analysed to identify themes describing women’s perceptions and experiences of dietary recommendations for the management of GDM.

Results

Eighteen women from a diverse range of sociodemographic backgrounds participated in the study. Three interconnected themes described women’s perceptions of dietary recommendations and experiences in managing their GDM through diet: managing GDM is a balancing act; using the numbers as evidence, and the GDM timeframe. The primary objective of dietary advice was perceived to be to control blood glucose levels and this was central to each theme. Women faced a number of challenges in adhering to dietary recommendations. Their relationships with healthcare professionals played a significant role in their perception of advice and motivation to adhere to recommendations. Many women perceived the need to follow dietary recommendations to be temporary, with few planning to continue dietary adaptations long-term.

Conclusions

The value of empathetic, individually tailored advice was highlighted in this study. A greater emphasis on establishing healthy dietary habits not just during pregnancy but for the long-term health of both mother and baby is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04297-0.

Healthcare Professionals' Perspectives on the Cross-Sectoral Treatment Pathway for Women with Gestational Diabetes during and after Pregnancy-A Qualitative Study

Gestational diabetes mellitus (GDM) increases the risk of adverse outcomes during and after pregnancy, including a long-term risk of type 2 diabetes. Women with GDM are treated by numerous healthcare professionals during pregnancy and describe a lack of preventive care after pregnancy. We aim to investigate healthcare professionals’ perspectives on the cross-sectoral treatment pathway for women with GDM—during and after pregnancy. A qualitative study was conducted using systematic text condensation. Nine healthcare professionals (two general practitioners, four midwives, two obstetricians and one diabetes nurse) were interviewed and eight health visitors participated in two focus group discussions., Three major themes emerged: (1) “professional identities”, which were identified across healthcare professionals and shaped care practices; (2) ”unclear guidelines on type 2 diabetes prevention after GDM”, which contributed to uncertainty about tasks and responsibilities during and after pregnancy; and (3) “cross-sectoral collaboration”, which relied heavily on knowledge transfers between hospitals, general practice and the local municipality. The findings implicate that clear, transparent guidelines for all sectors should be prioritized to strengthen cross-sectoral care to women with GDM during and after pregnancy. As a result, strong cross-sectoral care throughout the GDM care pathway may improve maternal health by supporting healthy behaviors, facilitate weight loss and reduce the risk of subsequent GDM and early onset diabetes.

Qualitative study on public health nurses' experience and assessment of nutritional and physical activity counseling of women with gestational diabetes

INTRODUCTION

The number of pregnant women with gestational diabetes mellitus (GDM) has increased worldwide. GDM is a known risk factor for pregnant mothers and their fetuses that may increase various complications and health concerns. Nutrition and physical activity (PA) counseling during pregnancy can be crucial in supporting pregnant women to adopt healthier lifestyle practices and reducing these risks. This study describes public health nurses’ (PHNs) experiences of nutrition and PA counseling and their assessments on how to develop the counseling for pregnant women with GDM.

METHODS

This is a descriptive qualitative study containing theme-interviews of 11 PHNs working in an antenatal maternity care setting. The data were analyzed using inductive content analysis.

RESULTS

Five main themes were identified related to PHNs’ experiences and assessment of nutrition and PA counseling for pregnant women with GDM: competency of nutrition and PA counseling, challenges of counseling, positive experiences of counseling, printed material, and counseling practices. PHNs considered nutrition and PA counseling both challenging and rewarding. There was lack of knowledge and skills to provide proper counseling and adequate material to support versatile counseling.

CONCLUSIONS

Material related to nutrition and PA counseling should be updated and standardized. PHNs need further training to improve knowledge in the area of diet and exercise.

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.

Perspectives on Barriers and Facilitators in Caring for Women with Gestational Diabetes in Rural Appalachia

PURPOSE

The purpose of this study was to explore perspectives of healthcare providers in rural Appalachia who care for pregnant women with gestational diabetes, including management facilitators and barriers.

STUDY DESIGN AND METHODS

Qualitative study with interviews and thematic analysis. Thematic analysis was conducted using the sort and sift method after inductive content analysis with open coding, identifying categories, and abstraction.

RESULTS

Twenty-one advanced practice nurses and 10 physicians participated in the study. Three themes were identified: rural healthcare challenges including limited resources and lack of adherence to recommendations, cultural influences including normalization of diabetes and food culture, and collaborative care including accessible resources and patient motivation.

CLINICAL IMPLICATIONS

The themes provide insight into the perceived barriers and facilitators of healthcare providers caring for women with gestational diabetes in rural Appalachia. Consistent, evidence-based communication with cultural consideration supports effective education and care of women with gestational diabetes. Healthcare providers' knowledge of local resources, accessible electronic medical records, and communication among the various team members enhance collaboration in diabetic management in the rural setting.

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

BACKGROUND

Women with gestational diabetes mellitus (GDM) receive acute but short-term care during pregnancy. There is less direct support during the postpartum period; women are offered general advice on how to follow a healthy lifestyle to avoid developing future type 2 diabetes. Observational studies suggest that a substantial proportion of women with prior GDM do not sustain recommended lifestyle changes postpartum. In a qualitative study, we examined how Danish women diagnosed with GDM experience the transition from a GDM-affected pregnancy to the postpartum period.

METHODS

Semistructured interviews with six women diagnosed with GDM. Data were analysed using qualitative content analysis.

RESULTS

A GDM diagnosis was accompanied by worries about the health of the woman's baby. This was also the driving force behind the women's motivation to engage in lifestyle changes during pregnancy. The outpatient treatment was perceived to be strict and associated with various challenges, including cravings and discomfort. After the delivery, taking care of the baby became the women's dominant focus. Social and emotional support from partners were needed to maintain motivation and prioritise a healthy lifestyle. The women's experience of the health system varied. However, in the postpartum period all the women experienced limited interaction and initiative from their healthcare providers in supporting them to engage in a healthy lifestyle.

CONCLUSIONS

This study identified barriers and facilitators to sustaining a healthy lifestyle postpartum. Efforts at multiple levels - including the individual, family and health system - are needed to facilitate and support a healthy lifestyle among women with prior GDM.

German gynecologists' experience with a universal screening for gestational diabetes mellitus in daily practice: A qualitative study

OBJECTIVE

In March 2012, a universal screening for gestational diabetes mellitus (GDM) was implemented in Germany. Despite international recommendations, a two-step approach was introduced [step 1: 50-g glucose challenge test (GCT); if GCT is suspicious, step 2 follows: 75-g oral glucose tolerance test with (OGTT)]. This qualitative study aimed at examining how gynecologists administer the screening for GDM in daily practice, whether they perceive any difficulties, and whether they have suggestions for improvement.

MATERIAL AND METHODS

Seventeen resident gynecologists were interviewed face-to-face in semi-structured interviews. The interviews were recorded, transcribed verbatim, coded, and analyzed using qualitative content techniques.

RESULTS

We revealed differences in the screening administration. Three gynecologists directly offered the second step of the two-step screening (OGTT) instead of completing the first step before offering the second step. These gynecologists only conducted GCT if the woman (with statutory health insurance) was not willing to pay for OGTT. Critique concerns the late introduction of billing codes, lack of information from official institutions, unavailability of readymade syrup with 50-g glucose, and lack of information material for pregnant women.

CONCLUSION

Our results reflect that not all gynecologists appear to conduct the screening conforming to the maternity directive. However, this has to be validated in larger quantitative surveys. That some gynecologists directly conducted OGTT may fuel the discussion regarding the screening procedure. The two-step approach was already highly controversial at the time of introducing the screening because national and international organizations recommend a one-step approach. Therefore, our results are also relevant for other countries who have implemented a two-step screening and for countries planning to implement a screening.

Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: a systematic review of qualitative/survey studies

AIM

To examine clinician views and knowledge regarding postpartum healthcare provision for women who have experienced gestational diabetes (GDM).

METHODS

Systematic review that searched PubMed, Web of Science, EMBASE and CINAHL. Qualitative studies and surveys, with clinicians as participants, which reported pre-specified outcomes, including barriers and facilitators to postpartum care for GDM, were included. Two authors independently assessed quality and undertook thematic synthesis.

RESULTS

Eleven surveys and two interview studies were included (4435 clinicians). Key themes included adequacy of knowledge of risk of type 2 diabetes mellitus (T2DM), gaps between knowledge and practice relating to postpartum screening, and differing perceptions of the value of postpartum screening. Clinicians perceived that women faced obstacles to accessing healthcare, and a need for improved GDM education. Studies reported shortfalls in systems to ensure postpartum screening occurs, and a need to improve communication and collaboration relating to care of women who have experienced GDM. The surveys were often limited in their depth and ability to identify remedial strategies.

CONCLUSIONS

Barriers to provision of care for women who have had GDM, such as lack of communication of the diagnosis, need to be addressed, and further interview studies exploring clinician views on screening for T2DM are required.

"An on-going individual adjustment": a qualitative study of midwives' experiences counselling pregnant women on physical activity in Sweden

Background

In Sweden, midwives play prominent supportive role in antenatal care by counselling and promoting healthy lifestyles. This study aimed to explore how Swedish midwives experience the counselling of pregnant women on physical activity, specifically focusing on facilitators and barriers during pregnancy. Also, addressing whether the midwives perceive that their own lifestyle and body shape may influence the content of the counselling they provide.

Methods

Eight focus group discussions (FGD) were conducted with 41 midwives working in antenatal care clinics in different parts of Sweden between September 2013 and January 2014. Purposive sampling was applied to ensure a variation in age, work experience, and geographical location. The FGD were digitally recorded, transcribed verbatim, and analyzed using manifest and latent content analysis.

Results

The main theme– “An on-going individual adjustment” was built on three categories: “Counselling as a challenge”; “Counselling as walking the thin ice” and “Counselling as an opportunity” reflecting the midwives on-going need to adjust their counselling depending on each woman’s specific situation. Furthermore, counselling pregnant women on physical activity was experienced as complex and ambiguous, presenting challenges as well as opportunities. When midwives challenged barriers to physical activity, they risked being rejected by the pregnant women. Despite risking rejection, the midwives tried to promote increased physical activity based on their assessment of individual needs of the pregnant woman. Some participants felt that their own lifestyle and body shape might negatively influence the counselling; however, the majority of participants did not agree with this perspective.

Conclusions

Counselling on physical activity during pregnancy may be a challenging task for midwives, characterized by on-going adjustments based on a pregnant woman’s individual needs. Midwives strive to find individual solutions to encourage physical activity. However, to improve their counselling, midwives may benefit from further training, also organizational and financial barriers need to be addressed. Such efforts might result in improved opportunities to further support pregnant women’s motivation for performance of physical activity.

Midwives' strategies in challenging dietary and weight counselling situations

OBJECTIVE

By enhancing maternal nutritional status, midwives can help women lower the risks of pregnancy complications and adverse birth outcomes as well as improve maternal health during pregnancy and in the long run. Dietary counselling is, on the other hand, not reported to be effective. Poor communication and conflicting messages are identified as possible barriers to adherence with recommendations. Midwives' experiences of providing dietary advice and counselling during pregnancy are sparsely reported. The aim of this study was therefore to explore midwives' strategies when faced with challenging dietary counselling situations.

METHODS

Seventeen midwives from different parts of Sweden and working within antenatal health care were interviewed by telephone. The interviews were analysed using qualitative content analysis.

RESULTS

Challenges were commonly experienced when counselling women who were overweight, obese, had eating disorders or were from different cultures. The midwives talked in terms of "the problematic women" when addressing counselling problems. Strategies used in challenging counselling situations were Getting acquainted; Trying to support and motivate; Pressure to choose "correctly"; Controlling and mastering; and Resigning responsibility.

CONCLUSIONS

The results indicate that Swedish midwives' counselling strategies are quite ambiguous and need to be questioned and that counselling of vulnerable groups of women should be highlighted. We could identify a need for education of practicing midwives to develop person-centred counselling skills.

A Cross-sectional Study of Midwives' Perspectives Towards their Professional Educational Needs

BACKGROUND

Midwives are one of the most important health care providers and meeting their professional educational needs can be effective in maternal and child health promotion.

AIM

The aim of this study was to investigate the midwives' perspectives towards their educational needs.

METHODS

In this cross-sectional study which was conducted in 2012 in Sari, North of Iran, 223 midwives during a convenience sampling method expressed their educational needs. The instrument of the data collection was a self-administered 64-question researcher- made questionnaire about the participants' educational needs in 10 fields related to midwifery profession.

RESULTS

The mean age and employment record of the participants were 33.87±10.49 and 10.09±8.14 years respectively, and the majority (65.02%) of them was employed in the health care centers. Findings showed that the highest score of midwives' educational need was related to need to education about labor and delivery care (75.14±21.13%) which was followed by the need to education about pre marriage counseling (74.04±19.95%) and pre conception counseling (71.33±21.89%).

CONCLUSIONS

Owing to the emergence of new dimensions of tasks in midwifery practice and due to developing some changes in the educational needs of midwives, it's necessary to implement an updated educational package in order to deliver the recommended standards of care and to increase midwives' participation in continuing education programs.

A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services

OBJECTIVE

to synthesise qualitative research on task-shifting to and from midwives to identify barriers and facilitators to successful implementation.

DESIGN

systematic review of qualitative evidence using a 4-stage narrative synthesis approach. We searched the CINAHL, Medline and the Social Science Citation Index databases. Study quality was assessed and evidence was synthesised using a theory-informed comparative case-study approach.

SETTING

midwifery services in any setting in low-, middle-, and high-income countries.

PARTICIPANTS

midwives, nurses, doctors, patients, community members, policymakers, programme managers, community health workers, doulas, traditional birth attendants and other stakeholders.

INTERVENTIONS

task shifting to and from midwives.

FINDINGS

thirty-seven studies were included. Findings were organised under three broad themes: (1) challenges in defining and defending the midwifery model of care during task shifting, (2) training, supervision and support challenges in midwifery task shifting, and (3) teamwork and task shifting.

KEY CONCLUSIONS

this is the first review to report implementation factors associated with midwifery task shifting and optimisation. Though task shifting may serve as a powerful means to address the crisis in human resources for maternal and newborn health, it is also a complex intervention that generally requires careful planning, implementation and ongoing supervision and support to ensure optimal and safe impact. The unique character and history of the midwifery model of care often makes these challenges even greater.

IMPLICATIONS FOR PRACTICE

evidence from the review fed into the World Health Organisation's 'Recommendations for Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions through Task Shifting' guideline. It is appropriate to consider task shifting interventions to ensure wider access to safe midwifery care globally. Legal protections and liabilities and the regulatory framework for task shifting should be designed to accommodate new task shifted practices.

Experts' encounters in antenatal diabetes care: a descriptive study of verbal communication in midwife-led consultations

Aim. We regard consultations as cocreated communicatively by the parties involved. In this paper on verbal communication in midwife-led consultations, we consequently focus on the actual conversation taking place between the midwife and the pregnant woman with diabetes, especially on those sequences where the pregnant woman initiated a topic of concern in the conversation. Methods. This paper was undertaken in four hospital outpatient clinics in Norway. Ten antenatal consultations between midwives and pregnant women were audiotaped, transcribed to text, and analyzed using theme-oriented discourse analysis. Two communicative patterns were revealed: an expert's frame and a shared experts' frame. Within each frame, different communicative variations are presented. The topics women initiated in the conversations were (i) delivery, time and mode; (ii) previous birth experience; (iii) labor pain; and (iv) breast feeding, diabetes management, and fetal weight. Conclusion. Different ways of communicating seem to create different opportunities for the parties to share each other's perspectives. Adequate responses and a listening attitude as well as an ambiguous way of talking seem to open up for the pregnant women's perspectives. Further studies are needed to investigate the obstacles to, and premises for, providing midwifery care in a specialist outpatient setting.

Health care professionals meeting with individuals with Type 2 diabetes and obesity: Balancing coaching and caution

The burden of diabetes and obesity is increasing worldwide, indicating a need to find the best standard for diabetes care. The aim of this study was to generate a theory grounded in empirical data derived from a deeper understanding of health care professionals' main concerns when they consult with individuals with diabetes and obesity and how they handle these concerns. Tape-recorded interviews were conducted with seven groups and three individual members of a diabetes team in an area of western Sweden. The grounded theory (GT) method was used to analyse the transcribed interviews. A core category, labelled Balancing coaching and caution and three categories (Coaching and supporting, Ambivalence and uncertainty, and Adjusting intentions) emerged. The core category and the three categories formed a substantive theory that explained and illuminated how health care professionals manage their main concern; their ambition to give professional individualised care; and find the right strategy for each individual with diabetes and obesity. The theory generated by this study can improve our understanding of how a lack of workable strategies limits caregivers' abilities to reach their goals. It also helps identify the factors that contribute to the complexity of meetings between caregivers and individuals with diabetes.