Views and Experiences of New Zealand Women with Gestational Diabetes in Achieving Glycaemic Control Targets: The Views Study

Diabetes in pregnancy: Women's views of care in a multi-ethnic, low socioeconomic population with midwifery continuity-of-care

BACKGROUND

Diabetes in pregnancy is diagnosed in 6% of pregnancies annually in Aotearoa-New Zealand, disproportionately affecting multi-ethnic, low socio-economic women. Little is known about the care experience of this population within the model of midwifery continuity-of-care, including views of telehealth care.

AIM

Increase understanding of the experience of diabetes in pregnancy care, including telehealth, among multi-ethnic, low socio-economic women receiving midwifery continuity-of-care.

METHODS

Qualitative interview study with primarily indigenous and migrant women who had diabetes in pregnancy and gave birth 6-18 months previously. Interviewers were matched with participants by ethnicity. Transcripts were analysed using Framework analysis.

RESULTS

Participants were 19 women (5 Māori, 5 Pacific Peoples, 5 Asian, 4 European). Data analysis revealed three key themes: 1) 'shock, shame, and adjustment' to the diagnosis 2) 'learning to manage diabetes in pregnancy' and 3) 'preparation for birth and beyond' to the postpartum period.

DISCUSSION

Receiving the diagnosis of diabetes in pregnancy was a shock. Managing diabetes during pregnancy was particularly challenging for indigenous and migrant women, who wished for better access to culturally appropriate dietary and lifestyle information. Women appreciated having options of telehealth and face-to-face consultations. Preparation for birth and postpartum diabetes follow-up were areas requiring significant improvement. Challenges were mitigated through care from a consistent diabetes specialist midwife and community-based midwifery continuity-of-care.

CONCLUSION

Midwives were the backbone of diabetes in pregnancy care for this multi-ethnic, low socio-economic population. Care could be improved with more culturally appropriate diet and lifestyle information, better birth preparation, and expanded postpartum diabetes support.

Telehealth and Technology for Diabetes in Pregnancy Clinics: Staff Perspectives from South Auckland, New Zealand

Providing care for patients with diabetes in pregnancy (DiP) provides unique challenges beyond those faced in standard antenatal care or diabetes outside of pregnancy. Teleclinics (use of telephone, email, or other technologies) as an alternative to in-person clinic appointments have become more widely used for care since the start of the COVID-19 pandemic. To understand how teleclinics might be improved for ongoing use, it is important to understand the experiences and perceptions of the clinicians involved in DiP care. Aim. To understand staff experiences of DiP teleclinics and gain their perspectives on if and how teleclinics and other technologies might be best used in the future. Methods. A qualitative study using semistructured interviews of healthcare providers in a large DiP service. Twenty staff members (midwifery, obstetrics, physician, dietician, and administration) were approached to participate. Fifteen staff across 5 specialties consented to be interviewed. Template analysis of interview transcripts was performed, with a focus on 3 themes: collaboration and working together are important for providing care for DiP, a need for flexibility in scheduling and the ability to individualise the way care is provided, and challenges to adapting to new technology. Results. Potential benefits of teleclinics were acknowledged, but respondents also viewed teleclinics as not suitable for all DiP patients due to different needs and risks. Challenges to using teleclinics include establishing good rapport and the current limited infrastructure and patient resources. Conclusion. Healthcare providers viewed teleclinics as a way of supporting rather than replacing current care. Maintaining flexibility in clinic scheduling to allow incorporation of teleclinics into patient's current schedule of visits ad hoc and providing extra technical and administrative support are important considerations for developing a teleclinic service.

Different intensities of glycaemic control for women with gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) has major short- and long-term implications for both the mother and her baby. GDM is defined as a carbohydrate intolerance resulting in hyperglycaemia or any degree of glucose intolerance with onset or first recognition during pregnancy from 24 weeks' gestation onwards and which resolves following the birth of the baby. Rates for GDM can be as high as 25% depending on the population and diagnostic criteria used, and overall rates are increasing globally. There is wide variation internationally in glycaemic treatment target recommendations for women with GDM that are based on consensus rather than high-quality trials.

OBJECTIVES

To assess the effect of different intensities of glycaemic control in pregnant women with GDM on maternal and infant health outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (26 September 2022), and reference lists of the retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs. Trials were eligible for inclusion if women were diagnosed with GDM during pregnancy and the trial compared tighter and less-tight glycaemic targets during management. We defined tighter glycaemic targets as lower numerical glycaemic concentrations, and less-tight glycaemic targets as higher numerical glycaemic concentrations.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for carrying out data collection, assessing risk of bias, and analysing results. Two review authors independently assessed trial eligibility for inclusion, evaluated risk of bias, and extracted data for the four included studies. We assessed the certainty of evidence for selected outcomes using the GRADE approach. Primary maternal outcomes included hypertensive disorders of pregnancy and subsequent development of type 2 diabetes. Primary infant outcomes included perinatal mortality, large-for-gestational-age, composite of mortality or serious morbidity, and neurosensory disability.

MAIN RESULTS

This was an update of a previous review completed in 2016. We included four RCTs (reporting on 1731 women) that compared a tighter glycaemic control with less-tight glycaemic control in women diagnosed with GDM. Three studies were parallel RCTs, and one study was a stepped-wedged cluster-RCT. The trials took place in Canada, New Zealand, Russia, and the USA. We judged the overall risk of bias to be unclear. Two trials were only published in abstract form. Tight glycaemic targets used in the trials ranged between ≤ 5.0 and 5.1 mmol/L for fasting plasma glucose and ≤ 6.7 and 7.4 mmol/L postprandial. Less-tight targets for glycaemic control used in the included trials ranged between < 5.3 and 5.8 mmol/L for fasting plasma glucose and < 7.8 and 8.0 mmol/L postprandial. For the maternal outcomes, compared with less-tight glycaemic control, the evidence suggests a possible increase in hypertensive disorders of pregnancy with tighter glycaemic control (risk ratio (RR) 1.16, 95% confidence interval (CI) 0.80 to 1.69, 2 trials, 1491 women; low certainty evidence); however, the 95% CI is compatible with a wide range of effects that encompass both benefit and harm. Tighter glycaemic control likely results in little to no difference in caesarean section rates (RR 0.98, 95% CI 0.82 to 1.17, 3 studies, 1662 women; moderate certainty evidence) or induction of labour rates (RR 0.96, 95% CI 0.78 to 1.18, 1 study, 1096 women; moderate certainty evidence) compared with less-tight control. No data were reported for the outcomes of subsequent development of type 2 diabetes, perineal trauma, return to pre-pregnancy weight, and postnatal depression. For the infant outcomes, it was difficult to determine if there was a difference in perinatal mortality (RR not estimable, 2 studies, 1499 infants; low certainty evidence), and there was likely no difference in being large-for-gestational-age (RR 0.96, 95% CI 0.72 to 1.29, 3 studies, 1556 infants; moderate certainty evidence). The evidence suggests a possible reduction in the composite of mortality or serious morbidity with tighter glycaemic control (RR 0.84, 95% CI 0.55 to 1.29, 3 trials, 1559 infants; low certainty evidence); however, the 95% CI is compatible with a wide range of effects that encompass both benefit and harm. There is probably little difference between groups in infant hypoglycaemia (RR 0.92, 95% CI 0.72 to 1.18, 3 studies, 1556 infants; moderate certainty evidence). Tighter glycaemic control may not reduce adiposity in infants of women with GDM compared with less-tight control (mean difference -0.62%, 95% CI -3.23 to 1.99, 1 study, 60 infants; low certainty evidence), but the wide CI suggests significant uncertainty. We found no data for the long-term outcomes of diabetes or neurosensory disability. Women assigned to tighter glycaemic control experienced an increase in the use of pharmacological therapy compared with women assigned to less-tight glycaemic control (RR 1.37, 95% CI 1.17 to 1.59, 4 trials, 1718 women). Tighter glycaemic control reducedadherence with treatment compared with less-tight glycaemic control (RR 0.41, 95% CI 0.32 to 0.51, 1 trial, 395 women). Overall the certainty of evidence assessed using GRADE ranged from low to moderate, downgraded primarily due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

This review is based on four trials (1731 women) with an overall unclear risk of bias. The trials provided data on most primary outcomes and suggest that tighter glycaemic control may increase the risk of hypertensive disorders of pregnancy. The risk of birth of a large-for-gestational-age infant and perinatal mortality may be similar between groups, and tighter glycaemic targets may result in a possible reduction in composite of death or severe infant morbidity. However, the CIs for these outcomes are wide, suggesting both benefit and harm. There remains limited evidence regarding the benefit of different glycaemic targets for women with GDM to minimise adverse effects on maternal and infant health. Glycaemic target recommendations from international professional organisations vary widely and are currently reliant on consensus given the lack of high-certainty evidence. Further high-quality trials are needed, and these should assess both short- and long-term health outcomes for women and their babies; include women's experiences; and assess health services costs in order to confirm the current findings. Two trials are ongoing.

Glycemic control in gestational diabetes and impact on biomarkers in women and infants

BACKGROUND

Gestational diabetes mellitus (GDM) is linked to the dysregulation of inflammatory markers in women with GDM compared to women without. It is unclear whether the intensity of glycemic control influences these biomarkers. We aimed to assess whether different glycemic targets for women with GDM and compliance influence maternal and infant biomarkers.

METHODS

Maternity hospitals caring for women with GDM were randomized in the TARGET Trial to tight or less tight glycemic targets. Maternal blood was collected at study entry, 36 weeks' gestation, and 6 months postpartum, and cord plasma after birth. We assessed compliance to targets and concentrations of maternal serum and infant biomarkers.

RESULTS

Eighty-two women and infants were included in the study. Concentrations of maternal and infant biomarkers did not differ between women assigned to tighter and less tight glycemic targets; however, concentrations were altered in maternal serum leptin and CRP and infant cord C-peptide, leptin, and IGF in women who complied with tighter targets.

CONCLUSIONS

Use of tighter glycemic targets in women with GDM does not change the concentrations of maternal and infant biomarkers compared to less tight targets. However, when compliance is achieved to tighter targets, maternal and infant biomarkers are altered.

IMPACT

The use of tighter glycemic targets in gestational diabetes does not result in changes to maternal or cord plasma biomarkers. However, for women who complied with tighter targets, maternal serum leptin and CRP and infant cord C-peptide, leptin and IGF were altered compared with women who complied with the use of the less tight targets. This article adds to the current evidence base regarding the impact of gestational diabetes on maternal and infant biomarkers. This article highlights the need for further research to assess enablers to meet the tighter target recommendations and to assess the impact on relevant biomarkers.

Disease Perception and Mental Health in Pregnancies with Gestational Diabetes-PsychDiab Pilot Study

(1) Background: The aim of this work is to investigate the extent to which pregnant women's well-being is burdened by the diagnosis of gestational diabetes, as well as their sensitivities and illness perceptions. Since gestational diabetes is associated with mental disorders, we hypothesized that the burden of illness might be related to pre-existing mental distress. (2) Methods: Patients treated for gestational diabetes in our outpatient clinic were retrospectively asked to complete a survey, including the self-designed Psych-Diab-Questionnaire to assess treatment satisfaction, perceived limitations in daily life and the SCL-R-90 questionnaire to assess psychological distress. The association between mental distress and well-being during treatment was analyzed. (3) Results: Of 257 patients invited to participate in the postal survey, 77 (30%) responded. Mental distress was found in 13% (n = 10) without showing other relevant baseline characteristics. Patients with abnormal SCL-R-90 scores showed higher levels of disease burden, were concerned about glucose levels as well as their child's health, and felt less comfortable during pregnancy. (4) Conclusions: Analogous to the postpartum depression screening, screening for mental health problems during pregnancy should be considered to target psychologically distressed patients. Our Psych-Diab-Questionnaire has been shown to be suitable to assess illness perception and well-being.

A scoping review of gestational diabetes mellitus healthcare: experiences of care reported by pregnant women internationally

Background

Gestational diabetes mellitus (GDM) is a condition associated with pregnancy that engenders additional healthcare demand. A growing body of research includes empirical studies focused on pregnant women’s GDM healthcare experiences. The aim of this scoping review is to map findings, highlight gaps and investigate the way research has been conducted into the healthcare experiences of women with GDM.

Methods

A systematic search of primary research using a number of databases was conducted in September 2021. Studies were included if they had an explicit aim of focusing on GDM and included direct reporting of participants’ experiences of healthcare. Key data from each study was extracted into a purposely-designed form and synthesised using descriptive statistics and thematic analysis.

Results

Fifty-seven articles were included in the analysis. The majority of studies used qualitative methodology, and did not have an explicit theoretical orientation. Most studies were conducted in urban areas of high-income countries and recruitment and research was almost fully conducted in clinical and other healthcare settings. Women found inadequate information a key challenge, and support from healthcare providers a critical factor. Experiences of prescribed diet, medication and monitoring greatly varied across settings. Additional costs associated with managing GDM was cited as a problem in some studies. Overall, women reported significant mental distress in relation to their experience of GDM.

Conclusions

This scoping review draws together reported healthcare experiences of pregnant women with GDM from around the world. Commonalities and differences in the global patient experience of GDM healthcare are identified.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04931-5.

Health professionals' views and experiences around the dietary and lifestyle management of gestational diabetes in New Zealand

AIM

This study aimed to investigate New Zealand health professionals' views and experiences around the dietary and lifestyle management of gestational diabetes.

METHODS

Semi-structured interviews were conducted remotely with health professionals; sessions were recorded and transcribed. Core themes were extracted using inductive thematic analysis using a framework method.

RESULTS

Twenty-seven health professionals were interviewed (13 diabetes dietitians, 8 specialist diabetes midwives, 2 community midwives, 1 antenatal clinic midwife, 1 obstetrician and 2 endocrinologists). Themes were organised into three central domains: (a) Social and cultural barriers, (b) Service provision and (c) Nutrition advice. Enabling themes included professional collaboration, innovation and creating trusting and supportive environments. Key barriers identified included accessibility, cultural barriers, overwhelmed service, fragmentation and conflicting information and nutrition resource gaps.

CONCLUSIONS

Findings highlight foremost a deficit in primary antenatal nutrition advice that may play a significant role in the fragmentation identified. Investment in community-inclusive services providing antenatal nutrition and diabetes education appears critical to overcome barriers associated with misinformation and poor outcomes. Pathways to include nutrition education from various primary care health providers should be investigated to ease the burden from specialist gestational diabetes clinicians and allow effective delegation of dietetic resources. Revision of current nutrition guidelines for the management of gestational diabetes in New Zealand is needed to facilitate consistent messaging and standards of care.

The psychosocial challenges associated with gestational diabetes mellitus: A systematic review of qualitative studies

BACKGROUND

Gestational diabetes is a disease with complex management that requires multidisciplinary collaboration. To achieve treatment goals, in addition to using medications and paying attention to exercise and diet, it is also important to take into account the mental health and psychosocial aspects of diabetes management. This study aimed to highlight these challenges associated with gestational diabetes.

METHOD

This qualitative systematic review involved a search of the following databases: CINAHL, EMBASE, MEDLINE, and PsycINFO. Title, abstract, and full-text screening was done using Covidence software, and quality assessment of the included papers was conducted using the Critical Appraisal Skills Programme Checklist. Enhancing transparency in reporting the synthesis of the qualitative research statement (ENTREQ) was used in the design of this paper. Data synthesis was done using meta-aggregation method.

RESULTS

Out of the 2440 articles searched, 24 were qualitatively analyzed. The CASP score of the included papers was optimal. The 514 findings extracted from the 24 studies were aggregated into five broad conceptual categories: psychological challenges, socio-cultural challenges, information-communication challenges, challenges associated with a lifestyle change, and challenges related to health care.

CONCLUSION

Recognizing the psychosocial challenges associated with gestational diabetes and developing support packages tailored to psychosocial needs can help improve the management of these patients.

Protocol for a qualitative study exploring the perception of need, importance and acceptability of a digital diabetes prevention intervention for women with gestational diabetes mellitus during and after pregnancy in Malaysia (Explore-MYGODDESS)

INTRODUCTION

Women who develop gestational diabetes mellitus (GDM) have an increased risk of developing type 2 diabetes, and to reduce this risk the women have to adopt healthy behaviour changes. Although previous studies have explored the challenges and facilitators to initiate behaviour change among women with GDM, there is limited data from Malaysian women. Thus, this study will explore the factors affecting the uptake of healthy behaviour changes and the use of digital technology among women and their healthcare providers (HCPs) to support healthy behaviour changes in women with GDM.

METHODS AND ANALYSIS

The study will be modelled according to the Capability, Opportunity, Motivation and Behaviour and Behaviour Change Wheel techniques, and use the DoTTI framework to identify needs, solutions and testing of a preliminary mobile app, respectively. In phase 1 (design and development), a focus group discussion (FGDs) of 5-8 individuals will be conducted with an estimated 60 women with GDM and 40 HCPs (doctors, dietitians and nurses). Synthesised data from the FGDs will then be combined with content from an expert committee to inform the development of the mobile app. In phase 2 (testing of early iterations), a preview of the mobile app will undergo alpha testing among the team members and the app developers, and beta testing among 30 women with GDM or with a history of GDM, and 15 HCPs using semi-structured interviews. The outcome will enable us to optimise an intervention using the mobile app as a diabetes prevention intervention which will then be evaluated in a randomised controlled trial.

ETHICS AND DISSEMINATION

The project has been approved by the Malaysia Research Ethics Committee. Informed consent will be obtained from all participants. Outcomes will be presented at both local and international conferences and submitted for publications in peer-reviewed journals.

Sociodemographic Factors Associated with Adherence to Dietary Guidelines in Women with Gestational Diabetes: A Cohort Study

Dietary advice is the cornerstone of care for women with gestational diabetes mellitus (GDM). However, adherence to this advice is variable. We aimed to identify the proportion of women with GDM who adhere to the New Zealand nutrition guideline recommendations and assess the sociodemographic factors linked to dietary adherence. We assessed dietary intake at 36 weeks’ gestation in a cohort of 313 women with GDM and compared this with the dietary recommendations for the management of GDM. Associations between maternal characteristics and dietary adherence were assessed using ANOVA, chi square, logistic regression, and linear regression tests. Women with GDM had an average adherence score of 6.17 out of 10 to dietary recommendations, but no one adhered to all the recommendations. Adherence to recommendations was lowest for saturated fat, and wholegrain breads and cereals. While 85% visited a dietitian, only 28% of women achieved their recommended weight gain. Maternal factors associated with lower dietary adherence were primiparity, no previous history of GDM, being underweight, and smoking. Adherence to the dietary recommendations by women with GDM in New Zealand for the management could be improved. Further research is needed to identify ways for women with GDM to improve their dietary adherence.

Comparing the Efficacies of Telemedicine and Standard Prenatal Care on Blood Glucose Control in Women With Gestational Diabetes Mellitus: Randomized Controlled Trial

BACKGROUND

Gestational diabetes mellitus (GDM) can usually be well controlled by health education and lifestyle management, resulting in better pregnancy outcomes. However, standard clinical prenatal care, which consists of clinic visits every 2 weeks, may not provide sufficient management for women with GDM. Telemedicine demonstrates a potential to fill this gap.

OBJECTIVE

The objective of this study was to investigate whether health education and lifestyle management delivered through a WeChat group chat was more effective in controlling blood glucose (BG) than standard clinical prenatal care among women with GDM.

METHODS

In this multicenter randomized controlled trial, women with GDM diagnosed by an oral glucose tolerance test between 23 and 30 (+6) gestational weeks were randomized to a WeChat group chat-based BG management group or a routine clinical prenatal care group. The primary outcome was the change in the glycemic qualification rate during the follow-up period in both groups. The secondary outcomes were pregnancy outcomes.

RESULTS

A total of 309 women with GDM participated in the trial, with 162 women randomized to the control group and 147 to the intervention group. No significant differences in baseline characteristics were found between the control and intervention groups. Participants were further divided into 4 groups according to gestational weeks at enrollment for further analysis. The glycemic qualification rate of the intervention group was higher than that of the control group at nearly all time points in Groups 1 to 3, among which 3 time points reached statistical significance: Group 1 at T3 (54.8% vs 83.3%) and Group 2 at T3 (62.5% vs 80.0%) and T7 (75.0% vs 100%). The glycemic qualification rate gradually increased as gestational weeks progressed in both groups, regardless of the intervention method. None of the pregnancy outcomes measured, including delivery mode, premature rupture of the membranes, preterm birth, infant's birth weight, and postpartum hemorrhage, were significantly different between the control and intervention groups.

CONCLUSIONS

This multicenter randomized controlled trial that assessed women with noninsulin-dependent GDM demonstrated that additional instant messaging platforms, such as WeChat, used for health education and lifestyle intervention in China tend to be more effective for BG control than standard clinical prenatal care alone.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03748576; https://clinicaltrials.gov/ct2/show/NCT03748576.

Gestational diabetes mellitus yesterday, today and tomorrow: A 13 year italian cohort study

AIMS

To describe all cases of gestational diabetes mellitus (GDM) managed at the Italian Hospital of San Daniele del Friuli from 2006 to 2018, after the establishment of a dedicated multidisciplinary team.

METHODS

Data on mothers, pregnancies, and newborns have been recorded since the team establishment. The associations of maternal, pregnancy, and delivery characteristics with complications of pregnancy and delivery and adverse birth outcomes were assessed.

RESULTS

894 cases of GDM were observed, representing 6.8% of all deliveries. More than 20% of women were non-Italian, 5.3% had a previous macrosomic child, 12.5% previous diabetes or GDM, 27.3% family history of diabetes. On average, women had 4 visits at the clinic; mean glycated hemoglobin was 5.3%; starting body mass index (BMI) 26.2 and weight gain 10.3 kg. Cesarean sections were 21.8%. Pre-eclampsia was the most common pregnancy complication (4.7%). 6.0% of newborns were macrosomic and there were 3 fetal deaths. Only 26.3% of women had a post-partum oral glucose tolerance test. Initial BMI, weight gain, nationality, family history of diabetes or previous diabetes-related pregnancy complications were associated with pregnancy complications or adverse outcomes.

CONCLUSIONS

We identified factors to be targeted for preventing GDM complications. Further efforts should be directed at post-partum.