Navigating a ‘Perfect Storm’ on the Path to Prevention of Type 2 Diabetes Mellitus After Gestational Diabetes: Lessons from Patient and Provider Narratives
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Objectives Complications of pregnancy such as gestational diabetes mellitus (GDM) forewarn future chronic illness and disability, and demonstrate the need for a life course approach to prevention. Our study had two aims: (1) to elucidate how experiences reported by patients and providers converge to facilitate or impede follow-up care after GDM, and (2) to elicit recommendations for system-level changes to enhance prevention across key care transitions. Methods We conducted in-depth interviews with 30 GDM patients and 29 providers of maternity, specialty and primary care in an urban safety hospital network, and used a three-tiered thematic analysis to interpret their narratives. Results Findings reveal that a ‘perfect storm’ gathers on the path to prevention across stages of care. At diagnosis, patients feel profound anxiety about the debilitating effects of type 2 diabetes mellitus in their communities, providers choose reassurance over risk communication, and both focus primarily on the birth of a healthy baby. Providers report that clinical teams often lack coordination, and confuse patients with a barrage of often-inconsistent advice. In the postpartum period, providers juggle competing clinical priorities and mothers juggle overwhelming demands; for both, the recommended 2-h oral glucose tolerance test is too arduous for women and providers to do as prescribed. Finally, the transition from maternity to primary care is complicated by communication barriers between clinicians and patients, and between maternity and primary care providers. Conclusions for Practice Respondents propose systems innovations to open communication between provider specialties in order to bridge the chasm between reproductive care and life course prevention.
KeywordsPregnancy Gestational diabetes mellitus Diabetes Postpartum Life course Prevention
We are grateful for the generosity of the 30 women interviewed during the months following the birth of their child, the 29 clinicians interviewed, and the team of research assistants who skillfully conducted the in-depth interviews in diverse settings and languages. We specifically wish to acknowledge the interviewing and management contribution made by Dr. Judy N. Margo.
This work was supported in part by NICHD R21-HD75640.
Compliance with Ethical Standards
Conflict of interest
No competing financial interests exist.
- American Congress of Obstetricians and Gynecologists. (2018). ACOG committee opinion number 736. Presidential Task Force on Redefining the Postpartum Visit.Google Scholar
- Collins, J. L., Lehnherr, J., Posner, S. F., & Toomey, K. E. (2009). Ties that bind: Maternal and child health and chronic disease prevention at the Centers for Disease Control and Prevention. Preventing Chronic Disease, 6, 1–6.Google Scholar
- Friedberg, M. W., Schneider, E. C., Rosenthal, M. B., Volpo, K. G., & Werner, R. M. (2014). Association between participation in a multi-payer medical home intervention and changes in quality, utilization, and costs of care. Journal of the American Medical Association, 311, 815–825.CrossRefGoogle Scholar
- Glaser, B., & Strauss, A. (1967). The discovery of grounded theory: Strategies for qualitative research. New York: Aldine DeGruyter.Google Scholar
- Lu, M. C., Kotelchuck, M., Hogan, V., Jones, L., Wright, K., & Halfon, N. (2010). Closing the black-white gap in birth outcomes: A life-course approach. Journal of Racial and Ethnic Health Disparities, 20, 61–76.Google Scholar
- National Committee for Quality Assurance. (2013). Patient-centered medical homes [fact sheet]. Retrieved from https://www.ncqa.org/Portals/0/Newsroom/2013/pcmh%202011%20fact%20sheet.pdf.
- Ratner, R. E., Christophi, C. A., Metzger, B. E., Dabelea, D., Bennett, P. H., Pi-Sunyer, X., et al. (2008). Prevention of diabetes in women with a history of gestational diabetes: Effects of metformin and lifestyle interventions. Journal of Clinical Endocrinology and Metabolism, 93, 4774–4779.CrossRefGoogle Scholar
- Rice, P. L., & Ezzy, D. (1999). Qualitative research methods: A health focus. Oxford: Oxford University Press.Google Scholar
- Thorne, S. (2008). Interpretive description. Walnut Creek: Left Coat Press.Google Scholar
- Van Ryswyk, E. M., Middleton, P., Shute, E., Hague, W. M., & Crowther, C. A. (2015a). Women’s views and knowledge regarding healthcare seeking for gestational diabetes in the postpartum period: A systematic review of qualitative/survey studies. Diabetes Research and Clinical Practice, 110, 109–122.CrossRefGoogle Scholar
- Van Ryswyk, E. M., Middleton, P. F., Hague, W. M., & Crowther, C. A. (2014). Clinicians’ views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Research and Clinical Practice, 106, 401–411.CrossRefGoogle Scholar