Maternal and Child Health Journal

, Volume 23, Issue 5, pp 603–612 | Cite as

Navigating a ‘Perfect Storm’ on the Path to Prevention of Type 2 Diabetes Mellitus After Gestational Diabetes: Lessons from Patient and Provider Narratives

  • Lois McCloskeyEmail author
  • Marlena L. Sherman
  • Meryl St. John
  • Hannah Siegel
  • Julie Whyte
  • Ronald Iverson
  • Aviva Lee-Parritz
  • Judith Bernstein


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.


Pregnancy 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.


  1. American Congress of Obstetricians and Gynecologists. (2013). ACOG practice bulletin. Gestational diabetes. Obstetrics and Gynecology, 122, 406–416.CrossRefGoogle Scholar
  2. American Congress of Obstetricians and Gynecologists. (2018). ACOG committee opinion number 736. Presidential Task Force on Redefining the Postpartum Visit.Google Scholar
  3. American Diabetes Association. (2004). Gestational diabetes mellitus. Diabetes Care, 27, S88–S90.CrossRefGoogle Scholar
  4. American Diabetes Association. (2017). Standards of medical care in diabetes: Management of diabetes in pregnancy. Diabetes Care, 40, S114–S119.CrossRefGoogle Scholar
  5. Bennett, W., Ennen, C., Carrese, J., Hill-Briggs, F., Levine, D., Nicholson, W., et al. (2011). Barriers to and facilitators of postpartum follow-up care in women with recent gestational diabetes mellitus: A qualitative study. Journal of Women’s Health, 20, 239–245.CrossRefGoogle Scholar
  6. Bennett, W. L., Chang, H. Y., Levine, D. M., Wang, L., Neale, D., Werner, E. F., et al. (2014). Utilization of primary and obstetric care after medically complicated pregnancies: An analysis of medical claims data. Journal of General Internal Medicine, 29, 636–645.CrossRefGoogle Scholar
  7. Carson, M. P., Frank, M. I., & Keely, E. (2013). Postpartum testing rates among women with a history of gestational diabetes: Systematic review. Primary Diabetes Care, 7, 177–186.CrossRefGoogle Scholar
  8. Clancy, C. M., & Massion, C. T. (1992). American women’s health care: A patchwork quilt with gaps. Journal of the American Medical Association, 268, 1918–1920.CrossRefGoogle Scholar
  9. Clark, H. D., Graham, I. D., Karovitch, A., & Keely, E. J. (2009). Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized control trial. American Journal of Obstetrics and Gynecology, 200, 634 e1–634 e7.CrossRefGoogle Scholar
  10. 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
  11. Dabelea, D., Hanson, R. L., Lindsay, R. S., Pettitt, D. J., Imperatore, G., Gabir, M. M., et al. (2000). Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: A study of discordant sibships. Diabetes, 49(12), 2208–2211.CrossRefGoogle Scholar
  12. Dabelea, D., Snell-Bergeon, J. K., Hartsfield, C. L., Bischoff, K. J., Hamman, R. F., & McDuffie, R. S. (2005). Increasing prevalence of gestational diabetes mellitus (GDM) over time and by birth cohort. Diabetes Care, 28, 579–584.CrossRefGoogle Scholar
  13. 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
  14. Glaser, B., & Strauss, A. (1967). The discovery of grounded theory: Strategies for qualitative research. New York: Aldine DeGruyter.Google Scholar
  15. Homer, C. J., Klatka, K., Romm, D., Kuhlthau, K., Bloom, S., Newacheck, P., et al. (2008). A review of the evidence for the medical home for children with special health care needs. Pediatrics, 122, e922–e937.CrossRefGoogle Scholar
  16. Ickovics, J. R., Kershaw, T. S., Westdahl, C., Magriples, U., Massey, Z., Reynolds, H., et al. (2007). Group prenatal care and perinatal outcomes. Obstetrics and Gynecology, 110, 330–339.CrossRefGoogle Scholar
  17. Kim, C., Berger, D. K., & Chamany, S. (2007). Recurrence of gestational diabetes: A systematic review. Diabetes Care, 30, 1314–1319.CrossRefGoogle Scholar
  18. Kim, C., Newton, K. M., & Knopp, R. H. (2002). Gestational diabetes and the incidence of type 2 diabetes. Diabetes Care, 25, 1862–1868.CrossRefGoogle Scholar
  19. 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
  20. Martinez, N. G., Charlotte, C. M., & Yee, L. (2017). Optimizing postpartum care for the patient with gestational diabetes mellitus. American Journal of Obstetrics & Gynecology. Scholar
  21. McCloskey, L., Bernstein, J., Winter, M., Iverson, R., & Lee-Parritz, A. (2014). Follow-up of gestational diabetes mellitus in an urban safety net hospital: Missed opportunities to launch preventive care for women. Journal of Women’s Health, 23, 327–334.CrossRefGoogle Scholar
  22. National Committee for Quality Assurance. (2013). Patient-centered medical homes [fact sheet]. Retrieved from
  23. Oza-Frank, R., Ko, J. Y., Wagner, A., Rodgers, L., Bouchard, J. M., & Conrey, E. J. (2014). Improving care for women with a history of gestational diabetes: A provider perspective. Maternal and Child Health Journal, 18, 1683–1690.CrossRefGoogle Scholar
  24. Paez, K. A., Eggleston, E. M., Griffey, S. J., Farrar, B., Smith, J., Thompson, J., et al. (2014). Understanding why some women with a history of gestational diabetes do not get tested for diabetes. Women’s Health International, 24, e373–e379.CrossRefGoogle Scholar
  25. Pies, C., & Kotelchuck, M. (2013). Bringing the MCH life course perspective to life. Maternal and Child Health Journal, 18, 335–338.CrossRefGoogle Scholar
  26. 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
  27. Rice, P. L., & Ezzy, D. (1999). Qualitative research methods: A health focus. Oxford: Oxford University Press.Google Scholar
  28. Shah, B. R., Lipscombe, L. L., Feig, D. S., & Lowe, J. M. (2011). Missed opportunities for type 2 diabetes testing following gestational diabetes: A population-based cohort study. British Journal of Obstetrics and Gynecology, 118, 1484–1490.CrossRefGoogle Scholar
  29. Shai, I., Jiang, R., Manson, J. E., Stampfer, M. J., Willett, W. C., Colditz, G. S., et al. (2006). Ethnicity, obesity and risk of type 2 diabetes in women: A 20 year follow-up study. Diabetes Care, 29, 1585–1590.CrossRefGoogle Scholar
  30. Steub, A., Ecker, J., Bates, D., Zera, C., Bentley-Lewis, R., & Seely, E. (2010). Barriers to follow-up for women with a history of gestational diabetes. American Journal of Perinatology, 27, 705–710.CrossRefGoogle Scholar
  31. Thorne, S. (2008). Interpretive description. Walnut Creek: Left Coat Press.Google Scholar
  32. Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19, 349–357.CrossRefGoogle Scholar
  33. 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
  34. 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
  35. Van Ryswyk, E. M., Middleton, P. F., Hague, W. M., & Crowther, C. A. (2015b). Postpartum SMS reminders to women who have experienced gestational diabetes to test for type 2 diabetes: The DIAMIND randomized trial. Diabetic Medicine, 32(10), 1368–1376.CrossRefGoogle Scholar
  36. Walker, L. O., Murphey, C. L., & Nichols, F. (2015). The broken thread of health promotion and disease prevention for women during the postpartum period. Journal of Perinatal Education, 24, 81–92.CrossRefGoogle Scholar
  37. Yee, L., Martinez, N. G., Nguyen, A. T., Hajjar, N., Chen, M., & Simon, M. (2017). Using a patient navigator to improve postpartum care in an urban women’s health clinic. Obstetrics & Gynecology, 129, 925–933.CrossRefGoogle Scholar
  38. Zapka, J. G., Puleo, E., Taplin, S. H., Goins, K. V., Yood, M. U., Mouchawar, J. et al. (2004). Processes of care in cervical and breast cancer screening and follow-up: The importance of communication. Preventive Medicine, 39, 81–90.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Community Health SciencesBoston University School of Public HealthBostonUSA
  2. 2.Department of Obstetrics and GynecologyBoston University School of MedicineBostonUSA

Personalised recommendations