Women's experiences of gestational diabetes self-management: A qualitative study

Abstract

Objective

to explore women's experiences of self-managing their gestational diabetes.

Design and participants

the study design was informed by interpretive phenomenological analysis. Data was collected using semi-structured interviews and one focus group. Participants included 15 women with a diagnosis of gestational diabetes who had experienced self-management of their condition.

Results

incremental adjustment occurred over 4 discrete themes, including: (1) the shock of diagnosis; (2) coming to terms with GDM; (3) working it out/learning new strategies; (4) looking to the future. Each adjustment phase was underpinned by the fifth theme (5) having a supportive environment. Throughout, participants reported that thinking about the baby was a powerful motivator for adherence to gestational diabetes management regimens.

Key conclusions and implications for practice

this study has shown that women undergo a process of adjustment following GDM diagnosis as they learn to self-manage their condition. The process is largely facilitated by the women's interest in maximising fetal health which may make them receptive to interventions to improve GDM control and to prevent type 2 diabetes in the future.

Introduction

Gestational diabetes mellitus (GDM) is one of the greatest health challenges of the 21st century, and key risk factors for this condition include maternal age over 30 years, obesity and non-Caucasian ethnicity (Hoffman et al., 1998, Ferrara et al., 2004, AIHW: Australian Institute of Health and Welfare, 2008, Carolan et al., 2011). Rates of GDM have increased globally in recent years and Australia is no exception. Two factors appear to fuel this epidemic: increasing population rates of obesity (Chu et al., 2004) and large numbers of new arrivals from high risk ethnic groups (Carolan et al., 2011, Gagnon et al., 2011). At present, GDM affects 4.6% of women in Australia overall (AIHW, 2008), although women born in Polynesia, South Asia, Indian subcontinent, the Middle East and other Asian countries develop GDM at almost three times the rate of women born in Australia (AIHW, 2008). Moreover, figures for GDM are likely to increase still further in the future, as obesity, ethnic diversity and older maternal age become more widespread in the population (AIHW, 2010).

This increase is of concern as GDM is associated with serious health concerns for both mothers and infants. For the mother, this means higher rates of hypertension, pre-eclampsia (Coghill et al., 2011). and more intervention in birth, including caesarean section (Langer et al., 2005b). Of perhaps of even greater concern is the impact of GDM on type 2 diabetes. Women who have developed GDM in pregnancy incur a six times greater lifetime risk of developing type 2 diabetes (Bellamy et al., 2009). and type 2 diabetes, in turn, is strongly associated with serious morbidity such as cardiovascular disease (Dailey, 2011). Infants of mothers with GDM are more susceptible to stillbirth (Hoffman et al., 1998, Mohsin et al., 2006, Rao et al., 2006) and are otherwise predisposed to a poorer start in life (Langer et al., 2005b, Yogev and Visser, 2009). This is because maternal hyperglycaemia often results in macrosomia (birth weight >4 kg) and due to their large size, many infants sustain birth injuries such as fractures and nerve damage (Alwan et al., 2009). Infants of mothers with GDM are more likely to be admitted to special care nursery for hypoglycaemia and respiratory problems (Phung et al., 2005, Langer et al., 2005b). They are also more likely to develop childhood obesity and adolescent type 2 diabetes (Ferrara et al., 2004). The infants most at risk of these serious outcomes are those born to disadvantaged mothers with GDM (Silva et al., 2006, Anna et al., 2008).

When inadequately managed, GDM results in a 2–3 times higher morbidity rate for women and infants (Langer et al., 2005a). However, when GDM is well managed, these risks are greatly reduced. Usual care of GDM is self-management, wherein the woman learns to test her blood sugars and adjust what she eats to maintain her blood sugar levels within normal ranges. Self-management thus requires understanding, motivation, knowledge of different food types and the amount to eat, and exercise to increase metabolism (Hoffman et al., 1998). This process is fraught with difficulty and many women struggle initially to adopt GDM self-management principles (Evans and O'Brien, 2005, Persson et al., 2010). For this reason, health professionals, such as diabetes educators, midwives and doctors work with women to assist them with dietary modifications and self-management strategies, with a view to effecting diet control. Women who are unable to achieve glycaemic goals with diet and exercise commence on insulin injections (Lee-Parritz, 2011) and, according to recent studies, approximately 15–35% of women with GDM will require insulin to control their BSLs (Lemieux and Ryan, 2004, Crowther et al., 2005). Not all cases of GDM are controllable with diet and exercise regimes and GDM that requires insulin control is associated with a greater likelihood of developing type 2 diabetes in the future (Dalfrà et al., 2001, Chodick et al., 2010).

Several factors impact negatively on successful GDM self-management and there is evidence to suggest that maternal disadvantage, limited education and limited understanding of the English language, all result in a lesser appreciation of GDM and poorer adherance to self-management plans (Ko et al., 2001, Schrauwers and Dekker, 2009). Earlier studies have shown that women from disadvantaged and migrant backgrounds are the most at risk of both developing GDM and of mismanaging their condition (Carolan et al., 2010b, Carolan et al., 2010a). The transient and asymptomatic nature of GDM may also contribute as women may underestimate the seriousness of the condition (Carolan et al., 2010b). Lower maternal educational level may lead to a lower understanding of the value of blood sugar control and a limited understanding of the association between GDM and future type 2 diabetes for both mother and child (Carolan et al., 2010a, Carolan et al., 2010b).

Against this background of rapidly increasing GDM and a clear link between poorer understanding of GDM and sub-optimal self-management, this study was undertaken at a metropolitan Maternity Unit, located at (blinded for review), Australia. This unit serves a socially disadvantaged area with a large multi-ethnic population, who are at high-risk of developing GDM and of poorer self-management. The study sought specifically to understand the experiences of these women when self-managing their GDM.