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Gestational diabetes mellitus: experiences of pregnant women, midwives, and obstetricians and the performance of screening
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

In Sweden, there is currently no consensus addressing the screening, diagnostics and treatment of gestational diabetes mellitus (GDM). In addition, there is little knowledge on the impact of GDM on the daily life of pregnant women and the experiences of health care professionals providing maternal health care to women with GDM. Using different perspectives, this thesis examines the experiences of GDM and the performance of screening for GDM in a regional context in Sweden. The studies used qualitative and quantitative methods. In the qualitative studies, grounded theory was applied in two studies and qualitative content analysis in one study. In the quantitative study, a combination of questionnaire data and data from medical records of pregnancy and birth were processed.

Surprisingly, screening for GDM was reduced despite local clinical guidelines stipulating the risk factors indicating an OGTT. Furthermore, the prevalence of the risk factors for GDM in the population investigated was almost doubled compared to previous Swedish studies. Pregnant women developing risk factors for GDM during pregnancy were found to be at substantially increased risk of giving birth to an infant with macrosomia. The experiences of pregnant women with GDM revealed that being diagnosed with and living with GDM during pregnancy might be understood as a process ‘from stun to gradual balance’. The experience comprised both negative and positive dimensions. Despite the challenges, the inconveniences and the changes involved, gradually adapting to an altered lifestyle and finding their balance in daily life was ‘the prize’ the women ‘were willing to pay’ to secure optimal maternal and foetal health. The experiences of midwives comprised managing conflicting demands providing antenatal care to pregnant women diagnosed with GDM. Most midwives felt the obligation to control and monitor the complicated pregnancy, to initiate and motivate the recommended changes in life style together with providing an empowering and caring relation with the women. These assignments disclosed complex conflicting situations and the midwives appeared to choose strategy for managing the situation depending on their perception of the circumstances. The experiences of the obstetricians were understood as ‘dealing with ambiguity’. The ambiguity permeated all aspects of working as an obstetrician within the maternal health care counselling women with GDM: the role of the obstetrician, the context of the organization, balancing the multifaceted interests of the maternal and foetal conditions and the lack of consensus, recommendations and evidence-based knowledge.  

The studies revealed the complexity of the situation for the affected pregnant women as well as for the health care professionals providing antenatal care to women diagnosed with GDM. Furthermore, the performance of screening of GDM in pregnant women with risk factors for GDM was insufficient in the investigated region. The findings in this thesis may be useful to increase knowledge of the experiences of pregnant women living with or managing GDM. The findings may also be useful when planning for improvements of maternal health care directed to pregnant women diagnosed with GDM during pregnancy.

Place, publisher, year, edition, pages
Umeå: Umeå university , 2009. , 112 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1316
Keyword [en]
Gestational diabetes mellitus, pregnant women, midwife, obstetrician, grounded theory, qualitative content analysis, questionnaire, medical data, experiences, antenatal care, organization of antenatal care, maternal health care
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
URN: urn:nbn:se:umu:diva-27761ISBN: 978-91-7264-902-6 (print)OAI: oai:DiVA.org:umu-27761DiVA: diva2:277550
Public defence
2009-12-11, Sal B, 9tr, Tandläkarhögskolan, Norrlands Universitetssjukhus, 901 87 Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2009-11-23 Created: 2009-11-19 Last updated: 2011-04-07Bibliographically approved
List of papers
1. 'From stun to gradual balance': women's experiences of living with gestational diabetes mellitus
Open this publication in new window or tab >>'From stun to gradual balance': women's experiences of living with gestational diabetes mellitus
2010 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 24, no 3, 454-462 p.Article in journal (Refereed) Published
Abstract [en]

Background and aim: In most parts of the western world, screening routines for gestational diabetes mellitus (GDM) are implemented, however, knowledge of the impact GDM has on the experience of pregnancy and life situation is sparse. The aim of this study was to describe pregnant women's experiences of acquiring and living with GDM during pregnancy.

Method: A Grounded Theory approach was used. Ten pregnant women diagnosed with GDM in current pregnancy were interviewed. Data collection was performed in the north of Sweden over two periods; a first set of interviews in 1998-2000 and additional interviews in 2006 to further explore the experience and reach saturation.

Findings: 'From stun to gradual balance' emerged as the core category, encompassing of the categories 'Struck by lightning', 'Having a personal responsibility', 'Being under surveillance', 'Struggling for protection', 'Feeling socially apart', 'Being sufficiently supported', 'Changing the self-image', 'Adapting to a new situation' and 'Waiting for the 'Moment of truth''. Our findings indicated that the diagnosis of GDM initiated a number of challenges and demands for the pregnant women. Further, being diagnosed with GDM was not only perceived as a medical complication threatening the pregnancy, moreover as an indicator of a future diabetes mellitus.

Conclusion: The experience of being diagnosed with and living with GDM during pregnancy may be understood as a process 'from stun to gradual balance'. The experience comprises positive and negative dimensions. Despite the challenges, the inconveniences and the changes involved, gradually adapting to a lifestyle and balancing the every day life is the prize most of these women are willing to pay in order to secure optimal maternal and foetal health. Knowledge of the experiences of women diagnosed with GDM may enable midwives to provide increased support as well as provide information and preventive measures in order to delay future diabetes mellitus.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2010
Keyword
Gestational diabetes mellitus, pregnancy, pregnant women, experiences, Grounded Theory
National Category
Obstetrics, Gynecology and Reproductive Medicine Nursing
Identifiers
urn:nbn:se:umu:diva-27730 (URN)10.1111/j.1471-6712.2009.00735.x (DOI)000281000800005 ()19878489 (PubMedID)
Available from: 2009-11-18 Created: 2009-11-18 Last updated: 2012-06-29Bibliographically approved
2. Surprisingly low compliance to local guidelines for risk factor based screening for gestational diabetes mellitus: a population-based study
Open this publication in new window or tab >>Surprisingly low compliance to local guidelines for risk factor based screening for gestational diabetes mellitus: a population-based study
2009 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, Vol. 9, no 1, 53- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Screening for gestational diabetes mellitus (GDM) is routine during pregnancy in many countries in the world. The screening programs are either based on general screening offered to all pregnant women or risk factor based screening stipulated in local clinical guidelines. The aims of this study were to investigate: 1)the compliance with local guidelines of screening for GDM and 2)the outcomes of pregnancy and birth in relation to risk factors of GDM and whether or not exposed to oral glucose tolerance test (OGTT).

METHODS: This study design was a population-based retrospective cross-sectional study of 822 women. A combination of questionnaire data and data collected from medical records was applied. Compliance to the local guidelines of risk factor based screening for GDM was examined and a comparison of outcomes of pregnancy and delivery in relation to risk factor groups for GDM was performed.

RESULTS: Of the 822 participants, 257 (31.3%) women fulfilled at least one criterion for being exposed to screening for GDM according to the local clinical guidelines. However, only 79 (30.7%) of these women were actually exposed to OGTT and of those correctly exposed for screening, seven women were diagnosed with GDM. Women developing risk factors for GDM during pregnancy had a substantially increased risk of giving birth to an infant with macrosomia.

CONCLUSION: Surprisingly low compliance with the local clinical guidelines for screening for GDM during pregnancy was found. Furthermore, the prevalence of the risk factors of GDM in our study was almost doubled compared to previous Swedish studies. Pregnant women developing risk factors of GDM during pregnancy were found to be at substantially increased risk of giving birth to an infant with macrosomia. There is a need of actions improving compliance to the local guidelines.

Identifiers
urn:nbn:se:umu:diva-27731 (URN)10.1186/1471-2393-9-53 (DOI)19917091 (PubMedID)
Available from: 2009-11-18 Created: 2009-11-18 Last updated: 2011-03-31Bibliographically approved
3. "Mission Impossible"? Midwives' experiences counseling pregnant women with gestational diabetes mellitus.
Open this publication in new window or tab >>"Mission Impossible"? Midwives' experiences counseling pregnant women with gestational diabetes mellitus.
2011 (English)In: Patient Education and Counseling, ISSN 0738-3991, E-ISSN 1873-5134, Vol. 84, no 1, 78-83 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Since not all pregnancy-related complications require hospitalization midwives often provide these women with antenatal care and counseling. This study explored the experiences of midwives providing antenatal care and counseling to pregnant women with gestational diabetes mellitus (GDM). METHODS: Twelve midwives participated in the interview study performed in the three northernmost counties in Sweden. Grounded theory was used for analysis. RESULTS: The emerging core category was 'Balancing fear of failure'. The unexpected disease increased the demands and the pressure. Three major conflicting situations were revealed. The midwives believed they were obligated to monitor and control the pregnancy, to initiate and motivate the necessary changes in lifestyle and provide empowering relationships with their patients. The fear of failure with these assignments made the midwives chose different strategies to manage the conflicting situations. CONCLUSIONS AND PRACTICE IMPLICATIONS: The midwives described conflicting encounters providing antenatal care to pregnant women with GDM. The fear of failing to fulfill the assignments caused by the GDM made the midwives chose strategies to handle the conflicting encounters. Similar conflicting situations might be present for other health care professionals promoting lifestyle changes. The challenges might be addressed with an organization focusing on support and coaching sessions.

Keyword
Gestatinal diabetes mellitus, counseling, support, midwives, qualitative study
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:umu:diva-36860 (URN)10.1016/j.pec.2010.06.008 (DOI)000292674000013 ()20634024 (PubMedID)
External cooperation:
Available from: 2010-10-12 Created: 2010-10-12 Last updated: 2016-09-06Bibliographically approved
4. 'Dealing with ambiguity': the role of obstetricians in gestational diabetes mellitus
Open this publication in new window or tab >>'Dealing with ambiguity': the role of obstetricians in gestational diabetes mellitus
(English)Article in journal (Other academic) Submitted
Abstract [en]

Objective: As gestational diabetes mellitus (GDM) is a pregnancy-related complication, obstetricians provide these women with maternal health care and counselling during pregnancy. This study described obstetricians’ experiences providing maternal health care to pregnant women with GDM.

Methods: A consecutive purposive national sample of seventeen obstetricians providing maternal health care to pregnant women diagnosed with GDM on a regular basis participated in the interview study. The data were analyzed using qualitative content analysis.

Results: During the analysis, eight sub-categories, three categories and one theme were identified. The overall theme describing the experiences of the obstetricians was labelled ‘Dealing with ambiguity’. This ambiguity permeated all aspects of working as an obstetrician within the maternal health care; the role of the obstetrician, the context of organisation, the multifaceted maternal and foetal interests to balance and lack of consensus, recommendations and evidence-based knowledge.

Conclusions and Practice Implications: Dealing with ambiguity permeated all aspects of the role of the obstetrician in the maternal health care provided to pregnant women with GDM. This ambiguity comprised the role of the obstetrician and the context of organisation, the multifaceted interests the obstetricians had to balance and the lack of consensus, recommendations and evidence-based knowledge. The study indicates the need for national guidelines and standardised maternal health care services regarding GDM as to fulfil the intentions of the health care system. Such recommendations may be beneficial and supportive for the health care professionals as well as for the mother-to-be and her foetus.

Keyword
Gestational diabetes mellitus, experiences, counselling, obstetricians, qualitative study
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:umu:diva-27740 (URN)
Available from: 2009-11-18 Created: 2009-11-18 Last updated: 2011-03-31Bibliographically approved

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