Women’s experiences of factors that facilitate or inhibit gestational diabetes self-management

Gestational Diabetes Mellitus (GDM), or glucose intolerance that first presents in pregnancy, affects approximately 12,000 pregnant women in Australia annually [1]. This figure represents approximately 4.5-5.0% of all births, although specific groups are at greater risk of developing this disorder [1]. GDM rates have increased dramatically in the past twenty years [2‐4] and this pattern of increase appears to relate primarily to the obesity epidemic [5], increasing maternal age [4, 6], and migration from high risk areas, such as South East Asia [7]. In Australia, highest rates of GDM are reported among women born in Polynesia, Asia, South Asia (Indian subcontinent) and the Middle East. These populations are at least three times more likely to develop GDM compared to locally-born women [1, 8]. Factors such as low socio-economic status and concomitant levels of obesity compound the risk of developing GDM [4].

GDM impacts on the health of both mothers and infants, and gives rise to higher rates of maternal hypertension and pre-eclampsia [9] increased intervention in birth, such as caesarean section [10] and later development of type 2 diabetes [11]. This risk is substantial and women who have had GDM in pregnancy, are at least 6 times more likely to develop type 2 diabetes during their lifetime [11, 12]. Gestational diabetes also exposes the fetus to hyperglycemia, which stimulates an increase in fetal insulin and an increased rate of fetal fat storage [6, 13]. These two factors in turn predispose the fetus to future obesity and type 2 diabetes. More immediately, the infants of mothers with GDM are more likely to be stillborn [14] or to suffer a range of perinatal morbidities such as birth injuries [15], macrosomia, hypoglycaemia and respiratory problems [10, 16]. These morbidities result in higher rates of neonatal nursery admission [16]. Overall, the evidence suggests that women from disadvantaged and migrant communities are the most at risk of both developing GDM [4, 17, 18] and of misunderstanding and mismanaging the condition [19, 20]. Risks of GDM complications are highest for these groups [4, 21].

First-line management of GDM involves a complicated self-care regimen of regular blood glucose level (BGL) testing, and dietary adjustment based on the woman’s BGLs. An increase in exercise is also encouraged in a bid to boost the woman’s metabolism [22]. The overall aim of treatment is to maintain BGLs within recommended ranges [22] and this is achieved primarily by reducing energy intake by replacing calorie dense foods with healthier choices [23]. This approach of dietary and exercise adjustment is suitable for approximately 65–90% of women diagnosed with GDM [24‐26]. Women with more severe hyperglycaemia and those who are unable to achieve glycaemic goals with diet and exercise require insulin to control their GDM [27]. High levels of insulin administration are a concern however, as women who require insulin to control their GDM are considered to be at higher risk of developing type 2 diabetes in the future [28‐30].

In light of these serious implications, for morbidity among both mothers and infants, it is critical that women with GDM are supported to take on the tasks of self-management. This study builds on earlier research which found that knowledge of GDM, food values and GDM management plans was deficient among women in this region [19, 20]. This situation of poorer comprehension seemed to relate principally to lower socio economic status, poorer levels of maternal education and lower health literacy (the ability to read and comprehend health related material, such as food labels). The current study sought specifically to understand the factors that facilitated or inhibited women’s understanding and adherence to GDM dietary self-management principles. It was intended as the initial step in the development of an educational and self-management program, aimed specifically at supporting women, with GDM, from disadvantaged and migrant backgrounds.

A qualitative approach was chosen to address the complex issues of GDM self-management. This approach was informed by Interpretative Phenomenological Analysis (IPA), as endorsed by Smith and Osborn [31] and Chan et al. [32]. Interpretative phenomenology aims to explore participants’ lived experience of events in order to understand how they make sense of their personal and social worlds (p. 3, 31). The main emphasis is on the exploration of personal experience as the individual narrates his/her account and appraises events [31, 32]. This narrative approach also draws on the philosopher Kierkegaard’s [33] insights into the discourses that underpin the lived experience of the narrator in certain situations. Kierkegaard believed that the individual’s stories offered an opportunity for others to see what the storyteller noticed, and to become aware of the particular emphasis he/she accorded to events, including the items that were a concern for him/her [33]. This approach is considered appropriate in this study as it may help uncover the particular concerns and difficulties participants encountered, when self-managing their GDM. The approach is also consistent with an appreciation of the individual woman, which was an important consideration for this study.

Semi structured interviews and one focus group were conducted using a pre-determined set of questions, as below. These questions were intended to loosely guide the interview. A parallel paper, from this study, has reported on the women’s experiences of GDM [34]. This paper reports on the factors that facilitated or hindered the women’s GDM self-management. The study was approved by the Western Health Ethics Committee (Sunshine Hospital). Written consent was obtained prior to interviews and focus group. Pseudonyms were used throughout to ensure the women’s anonymity.

Questions for interview

Participants came from the following self-identified ethnic backgrounds: Caucasian (n = 5), Indian (n = 4), Vietnamese (n = 2), Arabic (n = 1), Chinese (n = 1), Cambodian (n = 1), Filipino (n = 1). Additional demographic characteristics are presented in Table 1. These groups are also similar to the largest groups to give birth in Victoria, Australia [47]. Most women (73%) were aged between 30–39 years, with an age-range of 23–40 years. Educational level was lower than the Australian population average, and the majority of women reported High School (Secondary) level (73%), as their highest academic achievement. Four women (27%) reported a non-school qualification, which included 3 women (20%) with a university degree. This figure is lower than the Australian population average of 59% non-school qualification, which includes approximately 25% university degree [48]. Parity varied, although the majority (9 women) were primiparous (60%), one third of participants (5 women) were expecting their second baby (33%) and the final participant was expecting her fifth baby. Eleven women (73%) were dealing with GDM for the first time (see Table 1).

This study aimed to explore the factors that facilitated or hindered GDM self-management among a group of women attending for pregnancy care in a low socio-economic setting. Findings suggest that women encountered a number of barriers in their quest to self-manage their condition. This included difficulty comprehending the urgency of immediate diet control. Most women spoke of the challenge of implementing a complex regimen of blood testing and dietary manipulation, within a very short time frame, while they were still coming to terms with the shock of diagnosis. Many reported commencing on insulin within 1–2 weeks of GDM diagnosis, and some women felt they would have mastered the requisite GDM self-management behaviours in a more generous time frame. This urgency of immediate treatment of maternal hyperglycaemia is echoed in the literature, where an immediate reduction of maternal blood glucose is recommended in order to minimize adverse pregnancy outcomes [13, 49]. Moreover, recent studies also indicate that maternal hyperglycaemia, at lower levels that those previously recognised, has a detrimental effect on fetal welfare [25] and this finding has further increased pressure on health professionals to effect an immediate reduction in maternal blood glucose levels [13].

Participants in this study, found dietary self-management difficult, related to the time required to learn food values, and to cook healthy food. Social factors such as eating with family and friends also contributed to the dilemmas women faced, while a lack of clear guidelines was identified as hindering the process of diet control. Only two study participants succeeded in self-managing their GDM without insulin and both women, identified personal character strengths and determination as assisting them to master the necessary skills and behaviours. This very low rate of non-insulin use was a surprising finding, particularly as women were recruited on a first come basis rather than on the basis of management regimens. However, further explication of this finding is beyond the scope of this qualitative study of women’s experience and future quantitative evaluation is recommended. The finding may be incidental, however, it is consistent with generally higher use of insulin at the clinic where limited maternal education and understanding are thought to impact on poorer dietary adherence and higher rates of hyperglycaemia [19, 20]. Whatever the reasons, rates of dietary self-management alone were considerably lower, among study participants than the recommended 65–90% of women discussed in the literature [24‐26]. This feature may also reflect limited appropriate, culturally based educational resources for women in this area.

In general, dietary self-management is recognised as challenging [50, 51] and as requiring motivation, understanding of food values and of the amount to eat [22]. This knowledge and motivation may have been deficient in our population due to their social circumstances and may have also been affected by cultural beliefs about particular foods, such as rice. Many participants struggled to believe that traditional foods such as rice could be considered ‘bad’ food, in terms of excess calories, related to portion sizes. Parallel findings present in the literature and dietary change is recognized as difficult to achieve, particularly among low socio-economic and migrant groups [52, 53]. Such difficulties relate to cultural mores, views about traditional foods and a lack of appropriate food alternatives [50, 51, 53, 54]. Many participants in our study were hesitant to change their diet, while at the same time they were willing to eat less in order to avoid hyperglycaemia. Parallel findings present in the literature, and participants in Rhoads-Baeza and Reis’ study among low income Latino women with GDM, were also reluctant to change from their traditional consumption of fatty meats to healthier alternatives [53]. On the other hand, Bandyopadhyay et al. [54] who studied South Asian women with GDM in Australia, found that participants predominantly changed to the recommended diet, but were nonetheless unhappy about the type and quantity of food allowed, and complained of always feeling hungry.

One surprising factor in this study, was the frequency with which women identified the use of insulin as an easier option, rather than dietary control alone. This finding is not evident in the literature and appears to relate to the women’s concerns about hyperglycaemia at the same time as encountering difficulties with dietary restrictions and behavioural change. Women who regarded insulin as easier than diet control alone, expressed limited concerns about insulin use and regarded it simply as a solution to their current dilemma of high blood glucose and difficulty in effecting diet control. None of these women displayed any knowledge of a possible link between insulin use in GDM and subsequent development of type 2 diabetes.

In terms of facilitators, women in this study were intensely interested in maximizing fetal health and this finding of concern for the fetus is echoed in other research on women’s experiences of GDM [53‐55]. Concern for the fetus motivated participants to take on the tasks of GDM self-management and, although many women struggled to understand food values and to prepare healthy meals, they remained dedicated to the baby’s welfare. This manifested in the discomfort they endured by eating less than they desired, eating foods they did not enjoy, doing blood glucose levels and administering insulin, and trying to meet with exercise requirements. In the literature, a desire to protect the fetus, or evidence of maternal-fetal attachment, is similarly associated with greater pregnancy investment and adoption of health promoting behaviours, such as healthy diet [56, 57].

Successful GDM self-management in our study was mediated by support from family and health professionals. Women identified husbands and partners as the most important source of psychological support. A less important, but additional form of psychological support was offered by health professionals, including diabetes educators, midwives, doctors, and dieticians. Similar findings of psychological support as important in encouraging GDM self-management, are found in the literature [58, 59]. In particular, the partner’s support is seen as especially valuable in effecting behavioural change such as increasing exercise [59] while support from health professionals was recognised as encouraging women to view GDM as within their control [58].

Finally, this study has some limitations and the recruitment of women who could speak conversational English may have excluded many other migrant women in the area. For this reason, a number of interpreter mediated focus group discussions are planned for the future, which will include representation of the most populous ethnic groups in the area. Additionally, this small sample is from one geographical area, which means that the findings cannot be generalised to the Australian population as a whole [60]. However, the intent of the study was not to provide generalisable information, but to explore the facilitators or impediments to GDM self-management, among women in our area. This aim has been achieved and, although findings are not generalisable, they may also be applicable to other similar populations [60].

In conclusion, this study has indicated that women from low socio-economic and migrant backgrounds often struggle to comprehend and adhere to GDM dietary and exercise guidelines. They require supportive services that are culturally appropriate and pitched at an appropriate level of health literacy. A keen interest in the baby’s welfare is likely to increase women’s receptiveness to interventions.