Patient Education and Counseling 84 (2011) 78–83
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Provider Perspectives
‘‘Mission Impossible’’? Midwives’ experiences counseling pregnant women with gestational diabetes mellitus Margareta Persson a,b,*, A˚sa Ho¨rnsten b, Anna Winkvist c, Ingrid Mogren a a
Institution of Clinical Science, Obstetrics and Gynecology, Umea˚ University, Sweden Department of Nursing, Umea˚ University, Sweden c Institute of Medicine, Department of Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Sweden b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 September 2009 Received in revised form 12 May 2010 Accepted 5 June 2010
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. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Gestational diabetes mellitus Counseling Support Midwives Qualitative study
1. Introduction Internationally, caring for pregnant women is provided by doctors and/or midwives depending on the organization of the maternity health care within a specific country. Swedish midwives, have a long tradition of independent health care work addressing nursing actions initiated during normal pregnancy, normal birth, and postpartum care as well as for identification of complications and care in case of disease [1]. Obstetricians are mainly responsible for medical complications related to pregnancy and concurrent maternal diseases, prescribing and prioritizing the medical measures. Collaboration between midwives and obstetricians is essential for securing good health care [2]. In Sweden, the antenatal care operates principally through community-based public health clinics located in neighborhoods. The care is free, financed by taxes, and the midwife provides the care and counseling independently as long as the development of
* Corresponding author at: Umea˚ University, Department of Nursing, S-901 87 Umea˚, Sweden. Tel.: +46 907866369; fax: +46 907869169. E-mail addresses:
[email protected],
[email protected] (M. Persson). 0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.06.008
pregnancy is considered normal. The care provided has two major focuses: the medical aspects of supporting health and preventing complications and the psychosocial aspects of pregnancy that address preparations for birth and parenthood, life style and sexuality are addressed [1]. Screening for gestational diabetes mellitus (GDM) is one of the assignments included in the Swedish medical surveillance of pregnancy [1]. The condition of GDM is defined as any degree of glucose intolerance with onset or detection during pregnancy [3]. In Sweden, the screening procedure is based on the WHO recommendation of using 75 g oral glucose tolerance test. The diagnosis of GDM is set when the 2 h value of blood glucose is 9.0 mmol/l [4]. Most Swedish regions apply a selective screening method for GDM based on risk factors in the medical history and/or risk factors developed during pregnancy [5]. In hospital settings, the fundamental nature of midwives’ caring for women at high obstetric risk or with obstetric complications has been described as ‘a struggle for the natural process’, where the midwives use their embodied knowledge and balance between the medical and natural perspectives. In this struggle, the relationship with the woman is essential [6]. Since not all pregnancy-related complications require hospitalization midwives often provide these women with antenatal care and counseling. To the authors’
M. Persson et al. / Patient Education and Counseling 84 (2011) 78–83
best knowledge, no previous studies investigate the midwives’ experiences of providing antenatal health care and counseling when the pregnancy is complicated by GDM. However, a study of the encounters of nurses and patients with diabetes mellitus reveals that nurses feel comfortable in their role of being the expert. Using a patient-centered approach at the same time as implementing the medical guidelines was experienced as being problematic [7]. This study explored the experiences of midwives providing antenatal care and counseling to pregnant women diagnosed with GDM. 2. Methods 2.1. Context The study was carried out in the three northernmost counties (Norrbotten, Va¨sterbotten and Va¨sternorrland) in Sweden; counties consisting of large sparsely populated regions and towns ranging from approximately 7000 to 111,000 inhabitants. At the time of the study, there were some differences in the routines of care for women diagnosed with GDM. The initial treatment was diet, daily physical activity and controlling the glucose levels on a regular basis. In all antenatal care clinics (ACCs) within Va¨sterbotten County, the midwife continued the counseling of the pregnant women as long as her blood glucose was normalized with the recommended regime. For the Norrbotten County, the woman had additional regular contacts with a diabetes nurse and sometimes with an obstetrician. In the Va¨sternorrland County, all women diagnosed with GDM were referred to an antenatal care specialist irrespective of insulin therapy. In the two other counties, the woman was referred to an antenatal care specialist when normalized blood glucose levels were not achieved. 2.2. Participants Midwives who provide antenatal care and counseling for women diagnosed with GDM on a regular basis were eligible to participate. A purposive sample of 14 midwives was invited, however, two midwives declined, leaving 12 participants. Eight midwives were recruited from the Va¨sterbotten County and two midwives were recruited from each of the other counties. Midwives with different experiences (such as experienced vs. novice; working in a team vs. on their own and rural area vs. town setting) were approached. For the other counties, information about organization and suitable participants were obtained from the midwives serving as administrators. The characteristics of the participants are presented in Table 1. Eight midwives had other specialist nurse competencies or academic education in addition to their midwifery exam. The majority of midwives were professionally experienced; they worked as a midwife for a median of 20.0 years (range: 1–35
79
years). The median age of the midwives was 51.0 years (range: 33– 62 years). 2.3. Procedures The study was approved by the Regional Ethical Review Board, Umea˚ University, Sweden. The voluntarism of participating as well as the confidentiality of participants was stressed and the potential informants did not have to provide a reason for not participating. The second author (A˚H) performed the interviews within the region where the first author was working. All potential informants were contacted by the first author and informed about the study. Informed consent was obtained and the confidentiality of the informant was stressed before the interviews started. An interview guide addressing different domains of interest was developed by the authors. Main guiding domains included successful and unsuccessful counseling, sources of support and knowledge and perception of the condition. In accordance with GT methodology, the interview guide was slightly adjusted after a few initial interviews and analysis, as additional questions that deserved further exploration emerged. Examples of final interview questions were ‘Please, describe a situation when you perceived your counseling as successful/unsuccessful’, or ‘Where do you find your sources of support?’ In addition, probing questions further encouraged the participants to reveal their experiences. The interviews were performed from November 2005 to August 2007 at a place chosen by the participant. Previous to and after each interview, the participant and the interviewer talked shortly about the aim and procedure of the study [8]. The interviews varied in length from approximately 25 to 50 min. All interviews were taperecorded. A brief analysis and discussion of the content in the interview was performed by MP and A˚H after each interview to evaluate the data for saturation and, if necessary, to adjust the interview guide. After 10 interviews, no major new topics emerged. However, an additional two interviews were performed in another part of the region to confirm the saturation of data. 2.4. Analysis The methodology used for this study was Grounded theory (GT), an inductive approach that generates a theoretical explanation of the phenomena or process of interest [9]. In our study, GT was used to uncover the experiences of the midwives. All interviews were transcribed verbatim. All authors participated in the analysis. The first author is an experienced midwife. The second author is an experienced diabetes nurse and senior lecturer with focus on diabetes care. The third author is a nutritionist with a focus on women’s health. The fourth author is a gynecologist/ obstetrician with a focus on reproductive health. The analysis followed the basic steps of GT [9–11]. Memos comprising ideas and reflections about the data were made
Table 1 The characteristics of participating midwives and settings of the antenatal care at the local health care centers. Registered nurse-midwife
Age
Number of years as a midwife
Setting of care and numbers of midwives working in the antenatal care clinic
I II III IV V VI VII VIII IX X XI XII
36 33 62 52 43 60 60 50 52 41 60 50
8 1 23 18 10 15 35 25 25 17 23 22
Town, 2 midwives Rural, 1 midwife Rural, 1 midwife Town, 2 midwives Rural, 1 midwife Town, 1 midwife Town, 2 midwives Town, 4 midwives Town, 2 midwives Town, 2 midwives Town, 2 midwives Town, 3 midwives
80
M. Persson et al. / Patient Education and Counseling 84 (2011) 78–83
Fig. 1. An explanatory model of the midwives’ experiences of providing antenatal care and counseling to pregnant women diagnosed with gestational diabetes mellitus(GDM).
throughout the analysis. Initially, the text was read thoroughly and open codes were created in close relation to the text. During the process of coding and constant comparison, clusters of codes emerged and the groups of similar codes formed categories. To improve the credibility of the analysis, MP and A˚H coded the same text, made comparisons of the coding, and discussed the codes with all authors to reach consensus. Each category constituted new concepts described by the codes. As the analyses advanced, the core category was recognized. The core category represents the most prominent categories that can be traced through most data. The whole data were analyzed further in search of additional codes and properties of the codes to obtain as complete as possible a description of the phenomena. After identifying the main categories of the data, the theoretical coding started trying to link the categories, develop an explanatory model, and investigate links to existing theories [9–11]. 3. Results The core category emerging from the data was ‘Balancing fear of failure’. The core category and four other categories formed a conceptual model that explained the experiences of midwives providing antenatal care and counseling to pregnant women diagnosed with GDM (Fig. 1). The four categories related to the core category were labeled ‘A snake in paradise’, ‘The caring companion’, ‘The medical guardian’, and ‘The moral keeper’. The findings are further presented and instantiated by quotations from the interviews. 3.1. Balancing fear of failure The core category describes the midwives’ experiences of caring for and counseling the pregnant women with GDM. The unexpected disease increased the pressure on the midwives. Three major conflicting situations were revealed in their experiences. They described the demand and obligation to control and watch for further complications of the pregnancy, to initiate and motivate the necessary changes in lifestyle and to create and provide an empowering relationship with the women. This fear of failing with the perceived assignments was expressed as follows: ‘‘There is this pressure, what would happen if one should elude something’’ (Participant #2) and ‘‘I don’t want to make any professional misconduct’’ (Participant #1). Because of their fear of
failing, the midwives chose strategies to balance the conflicting situations. By acting as the caring companion, the midwives stressed the importance of maintaining a good relationship, understanding the life situation of the pregnant woman and empowering her to follow the regime. Acting as ‘the medical guardian’ implied that the pregnant woman was docile and willing to undertake the surveillance and control by the midwives. Because the midwives saw themselves as experts, they expected the women to submit to surveillance. ‘The moral keeper’ strategy was activated when the midwife perceived the woman as unruly and unwilling to adjust to recommendations. The midwives sometimes used the well being of the child as a measure to force the women to obey. 3.2. A snake in paradise The pregnancy was generally considered a ‘‘blessed condition’’ by the midwives. The midwives perceived that the GDM obscured the women’s experience of pregnancy: ‘‘A pregnant woman is somehow selected. She is occupied by becoming a mother and the things happening within her body. Then, this gestational diabetes appears [. . .] Well, it also enters her life, but as disease (Participant #1).’’ The pregnancy was no longer normal. The midwives had experiences of informing women about GDM and the reactions the diagnosis aroused: ‘‘[. . .] and then you notice the panic in their eyes [. . .] that’s an immediate catastrophe (Participant #7).’’ The midwives were aware of the necessary changes of lifestyle the women had to make, not only for the pregnancy, but also for the rest of their lives in order to evade future illness: ‘‘Gestational diabetes is like a tocsin indicating how to live for the rest of their lives. They are not labeled as diabetic now, but this is a warning and more often than not they will develop diabetes as they get older (Participant #7).’’ 3.3. The caring companion Most midwives described how they tried to empower the women when GDM was detected. A caring, respectful and empowering relationship with the women was important to
M. Persson et al. / Patient Education and Counseling 84 (2011) 78–83
maintain. The midwives strived to respect the autonomy and integrity of the women. After providing balanced information and assuring that the women understood the importance of changes of lifestyle, most midwives allowed the women to decide what to do. ‘‘We try to provide them with our experiences, but you don’t want to scare them either. Still, to provide constructive information as to make sure she understands the importance of this, but then it’s up to her to choose how much she wants to carry through (Participant #1).’’ However, sometimes the midwives described a somewhat evasive strategy as not to confront the woman or jeopardize the relationship with the woman: ‘‘One may not nag about things they might not want me to thresh about (Participant #5)’’. Some midwives preferred to keep the focus on the forthcoming birth and parenthood, not on the responsibility of caring for the complications: ‘‘This thing with the diabetes, that’s not really our business so to say. We hand over this aspect to the diabetes nurse and the doctor; somehow this is their medical responsibility (Participant #10).’’ 3.4. The medical guardian The midwives regarded themselves as guardians of the health of the mother and the fetus during pregnancy; this was anticipated as the main objective of their work. The midwives rationalized their paternalistic approach because they saw themselves as a medical guardian. By being the expert the midwives decided what they considered was appropriate for the women to do: ‘‘I have to be distinct and say that I am responsible for the wellbeing of the child and controlling the growth, the development and that everything is OK, so we have to do these tests. I mean, if someone refuses, I just write in the medical record that she is refusing (Participant #2).’’ To make sure that important signs were observed, they intensified their monitoring and control of the mother and fetus. The stress of overlooking deteriorations of the condition had to be handled. They describe strategies when they tried to appear as if everything was under control to create security and trust towards the mother-to-be, at the same time internally searching for signs of adverse outcomes: ‘‘All the time, I think about that I must detect anything as soon as possible so that we can prevent deterioration, but this I never tell the mother. Instead I tell her ‘how wonderful, everything is just as it should’ (Participant #12).’’ 3.5. The moral keeper An explicit assessment by the midwives was that the motherto-be had a moral obligation towards her fetus to make healthy choices. Most women were described as docile and compliant to the counseling of midwives. The care of the docile women was easily manageable; the women’s behavior confirmed the midwife’s sense of competence. ‘‘I talked a little bit more with her about diet and exercise and all that stuff. Well, it felt like the message was received and therefore I was pleased. That’s the way it is (Participant #3).’’ However, all midwives vividly expressed experiences of pregnant women with GDM not responding to the counseling.
81
Non-compliance was commonly regarded as irresponsible behavior: ‘‘I mean, if you don’t care for yourself properly, how could you take care for your child? (Participant #2)’’ Apparently, the noncompliance caused frustration. The midwives wanted all mothersto-be to care for themselves and the fetus. However, sometimes they could not create an empowering situation with the woman they perceived as non-compliant. This frustration was obvious: ‘‘I can talk to them hours on end, but they just sit and sneer me right in the face (Participant #3)’’ and ‘‘I don’t know whether to beg and plead or menace or what to do; I only want her to understand (Participant #12)’’ Using the well being of the fetus was one strategy described trying to convince these women to increase their compliance to the counseling: ‘‘You can reach to the woman’s hearth through the fetus, so you may beg and plea by using this [. . .] then it’s easier to get them motivated (Participant #12).’’ The midwives described the necessity to improve the moral obligations of some mothers-to-be; this justified their evaluations of compliance. When the midwives experienced that their advice was not followed they returned the responsibility for the noncompliant behavior to the women: ‘‘If they choose not to take proper care of themselves despite we tried with all methods [. . .] Well, I feel what more can I do? I might be rough, but when it is like that, when my intentions are not followed and only disinclination exists, then I suppose that we have done what we could, the rest is her choice (Participant #1).’’
4. Discussion and conclusion 4.1. Discussion 4.1.1. Interaction between midwives and mothers-to-be Some studies examine the interaction of midwives and the expectant woman. A Swedish study reports that midwives consider themselves as being supportive based on the willingness and an ethical demand of doing the right thing for the woman and her family. This includes advocating for the baby in difficult situations [12]. An important reason for our participants to act as ‘‘the medical guardian’’ and ‘‘the moral keeper’’ was their fear of failing to secure the well being of the fetus. This fear compelled them to sometimes use paternalistic strategies in their quest to avoid adverse outcomes of the pregnancy. Paternalistic attitudes in postnatal care are reported by the parents, expressing that the staff believe they are more capable of promoting the family’s well being than the parents themselves [13]. Midwives in hospital settings express that an organization with early discharge and involved fathers results in a new role where the midwives are no longer valued as the experts; a more supportive and empowering role is expected [14]. Expectations of a new role of the midwives may be the case for the informants in our study as well. The expectant mothers may consider midwives more as counselors, whereas the midwives may consider themselves as experts. Although this study is based on interviews, similar findings were uncovered in an observational study that examined the interaction of midwives and expectant parents [15]. In the videorecorded observations, the midwives appear to steer the consultations by adopting five various patterns of relating. ‘‘The respectful gardener’’ midwife approaches the expectant mother as if she is a gardener caring for the individual developing process of growth. ‘‘The propagandist teacher’’ midwife knows what is worth
82
M. Persson et al. / Patient Education and Counseling 84 (2011) 78–83
knowing about pregnancy and childbirth and tells the expectant woman how it is or should be. ‘‘The steering inspector’’ midwife monitors the physical development of the pregnancy in a generalized manner to make sure there is no harm to the fetus or mother. ‘‘The mediating counsellor’’ midwife counsels as a response to a woman who seeks advice. ‘‘The personal womanfriends’’ midwife provides an atmosphere of equality and friendship, where the midwives focus on understanding and listening [15]. In our study, the category ‘‘The Caring Companion’’ may have similarities with the relating patterns of ‘‘The respectful gardener’’, ‘‘The mediating counselor’’, and ‘‘The personal woman-friends.’’ By acting as a caring companion, the participants aimed at empowering the women to gain individual mastery of their disease at the same time as respecting the autonomy of the women. Furthermore, creating a friendly understanding atmosphere with the women was important for the relationship. By acting as ‘‘the medical guardian’’ our participants described some of the observed patterns used by ‘‘the propagandist teacher’’ and ‘‘the steering inspector’’ such as the paternalistic behavior of the medical expert and the promotion of physical health according to pre-identified limits [15]. A pattern similar to acting as ‘‘The moral keeper’’ was not described in the observational study. However, a linguistic study of midwives and expectant mothers’ encounters describe that morally-loaded aspects of maternity care were not treated as moral in nature, but as issues of medical or practical necessity [16]. This might provide an explanation to the midwives using the well being of the fetus – a medical necessity – as a way to address the morally-loaded aspect of being a responsible motherto-be. 4.1.2. Unsuccessful counseling The midwives in the present study expressed frustration when not successful in counseling and motivating the pregnant woman regarding lifestyle changes. The risk of developing GDM is 6-fold for obese pregnant women in relation to pregnant women with normal body weight [17]. Negative attitudes and prejudice by health care professionals (HCPs) have been studied to some extent, mostly in relation to obesity. Obese pregnant women describe humiliating treatment by midwives and physicians during pregnancy and childbirth, where the caregivers are perceived as rude, angry, moody, abrupt, and neglecting their needs [18]. Another question to consider addressing unsuccessful counseling is the issue of reactance theory and compliance. In a medical context, this implies that the patients’ perceived threat to their freedom might negatively influence compliance with recommended treatments [19]. This may explain the perceptions of ‘‘unruly’’ women in the present study; the more the midwives tried to control and force the women, the more the women exhibited non-compliant behaviors. Furthermore, diseases and illness perceived to be under personal behavioral control can lead to more social rejection and stigma [20]. This situation may correspond well with our informants’ negative attitudes about the non-complying women. 4.1.3. Preventive counseling in the future After previous GDM, the risk of diabetes mellitus type 2 increases by more than 7-fold in relation to women with normal blood glucose levels during pregnancy [21]. The midwives have substantial opportunity to induce a healthy lifestyle among these women. However, the findings in the present study indicate that sometimes the conflicting situations of empowering changes in lifestyle and controlling the development of the pregnancy may decrease successful counseling. Similar conflicting situations are described among nurses in diabetes care implementing guidelines or being patient-centered [7]. In our study a similar conflict might
emerge as the well being of the fetus was an extra dimension to account for. 4.1.4. Strengths and limitations The strengths of this study are the vivid narratives of the experiences of the midwives and the variation in the characteristics of the participants. Novice and experienced midwives as well as midwives working in rural and town settings participated, reflecting the clinical situation of midwives. The pre-understanding of the interviewers may have contributed to the relaxed situation, a milieu that may have encouraged the vivid narratives. Despite some differences between the counties, the experiences of midwives did not differ in any major way. Therefore, we consider that these findings most probably may be generalized to midwives working in similar ACC settings. Some limitations to the present study ought to be considered. There was a risk that only talkative informants were willing to participate. As the first author had good knowledge of the midwives in one of the counties, both verbal and less verbal colleagues fulfilling the criteria for participation could be invited. For the other counties, the midwife administrators in the region provided information about eligible participants; hence they could have selected the more talkative midwives. In all qualitative research, the pre-understanding of the authors may influence the analysis. As discussed previously, the first author is familiar with part of the study region. By having some interviews performed by the second author combined with a group of researchers with experience of various parts of the research field, the ethical aspects as well as the possible bias of pre-understanding was addressed. Comparing the coding between authors, discussing the results and reaching consensus was another method used to improve the credibility of the results. 4.2. Conclusion The midwives described conflicting encounters providing antenatal care to pregnant women diagnosed with GDM. The unexpected disease increased the demands on the midwives. They expressed the obligation to monitor and control the pregnancy, to initiate and motivate the necessary changes in lifestyle, and to create an empowering relationship with the woman. Based on the fear of failure with these assignments, the midwives chose different strategies to manage the conflicting encounters. These strategies included evading confrontational topics in order to create an empowering relationship, intensifying the medical surveillance of the mother and fetus to secure maternal and fetal health, and evaluating and questioning the compliance to the recommended regime. 4.3. Practice implications This study addressed midwives’ experiences; however, similar conflicting situations might be present among HCPs promoting lifestyle changes such as in diabetes mellitus, smoking cessation, and weight loss. During pregnancy, the limited time to implement the necessary changes as to secure the well being of the fetus is challenging as well as to provide non-confronting strategies to minimize the effects sometimes described, the more the midwives push the women to change aspects of their lifestyle, the less compliant some women became. A support organization that provides coaching sessions for the midwives who counsel pregnant women about healthy lifestyle choices may improve the situation. Furthermore, researchers should investigate what interventions and strategies are successful in a clinical setting.
M. Persson et al. / Patient Education and Counseling 84 (2011) 78–83
We confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story. Funding The study was supported by grants from The County Council of Va¨sterbotten, Sweden. References [1] Mo¨draha¨lsova˚rd, Sexuell och Reproduktiv Ha¨lsa (Maternal Health Care, Sexual and Reproductive health) [in swedish]. Rapport nr 59. Svensk Fo¨rening fo¨r Obstetrik och Gynekologi (SFOG); 2008. [2] SFOG and SBF, Gemensamma riktlinjer fo¨r svenska Barnmorskefo¨rbundet och Svensk Fo¨rening fo¨r Obstetrik och Gynekologi [in swedish] (Joint guidelines for the Swedish Association of Midwives and the Swedish Society of Obstetrics and Gynecology); 2000, available in www.sfog.se. [3] Buchanan TA, Xiang A, Kjos SL, Watanabe R. What is gestational diabetes? Diabetes Care 2007;30:S105–11. [4] Lind T, Phillips PR. Influence of pregnancy on the 75-g OGTT. A prospective multicenter study. The Diabetic Pregnancy Study Group of the European Association for the Study of Diabetes. Diabetes 1991;40:8–13. [5] Persson M, Winkvist A, Mogren I. No unified guidelines concerning gestational diabetes in Sweden. Noticeable differences between screening, diagnostics and management in maternal health services. Lakartidningen 2007;104:3365–9. [6] Berg M, Dahlberg K. Swedish midwives’ care of women who are at high obstetric risk or who have obstetric complications. Midwifery 2001;17:259–66. [7] Ho¨rnsten A˚, Lundman B, Almberg A, Sandstro¨m H. Nurses’ experiences of conflicting encounters in diabetes care. Eur Diabetes Nursing 2008;5:64–9.
83
[8] Kvale S. Interviews: an introduction to qualitative research interviewing. Thousand Oaks: SAGE; 1996. [9] Glaser B, Strauss A. The discovery of grounded theory. New York: Aldine de Gruyter; 1967. [10] Corbin JM, Strauss A. Basics in qualitative research: techniques and procedures for developing grounded theory. Thousand Oaks: Sage Publications; 2008. [11] Dahlgren L, Emmelin M, Winkvist A. Qualitative methodology for international public health. Umea˚: Umea˚ University; 2004. [12] Hildingsson I, Haggstrom T. Midwives’ lived experiences of being supportive to prospective mothers/parents during pregnancy. Midwifery 1999;15:82–91. [13] Ellberg L, Hogberg U, Lindh V. ’We feel like one, they see us as two’: new parents’ discontent with postnatal care. Midwifery 2008. [14] Lindberg I, Christensson K, Ohrling K. Midwives’ experience of organisational and professional change. Midwifery 2005;21:355–64. [15] Olsson P, Jansson L. Patterns in midwives’ and expectant/new parents’ ways of relating to each other in ante- and postnatal consultations. Scand J Caring Sci 2001;15:113–22. [16] Linell P, Bredmar M. Reconstructing topical sensitivity: aspects of face-work in talks between midwives and expectant mothers. Res Lang Social Interact 1996;29:347–79. [17] Cnattingius S, Lambe M. Trends in smoking and overweight during pregnancy: prevalence, risks of pregnancy complications, and adverse pregnancy outcomes. Semin Perinatol 2002;26:286–95. [18] Nyman VM, Prebensen AK, Flensner GE. Obese women’s experiences of encounters with midwives and physicians during pregnancy and childbirth. Midwifery 2008. [19] Fogarty JS. Reactance theory and patient noncompliance. Soc Sci Med 1997;45:1277–88. [20] Crandall CS, Moriarty D. Physical illness stigma and social rejection. Br J Soc Psychol 1995;34:67–83. [21] Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet 2009; 373:1773–9.