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Postpartum care of women with gestational diabetes: survey of healthcare professionals
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Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb 1
Postpartum care of women with gestational diabetes: survey of healthcare professionals
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Rayanagoudar a,c,*, Misha Moore c, Javier Zamora a,b, Philippa Hanson c, Mohammed S.B. Huda c, Graham A. Hitman a,c, Shakila Thangaratinam a,c,d
Q1 Girish
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a
Women’s Health Research Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS) and CIBER Epidemiologia y Salud Publica, Madrid, Spain Barts Health NHS Trust, London, UK d Multidisciplinary Evidence Synthesis Hub (mEsh), Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 June 2015 Received in revised form 27 August 2015 Accepted 17 September 2015
Objective: To assess the knowledge and practices of healthcare professionals on the postpartum care of women with gestational diabetes. Study design: We surveyed 106 healthcare professionals including obstetricians, diabetologists, general practitioners and midwives in East London and West Midlands in England (September 2014). The questionnaire assessed postpartum screening practices, care provision, future risk and strategies to prevent diabetes in women with gestational diabetes. Results: The response rate was 87% (92/106). Nearly all respondents offered advice on diet (99%; CI 95%, 100%) and exercise (92%; CI 85%, 97%) postnatally in women with diagnosis of gestational diabetes. The preferred screening time for diabetes was 6 weeks to 3 months postpartum (76%; CI 66%, 85%). Overall, oral glucose tolerance test was the preferred test (57%; CI 46%, 67%), although general practitioners preferred fasting glucose (50%; CI 33%, 67%) and glycated hemoglobin (47%; CI 30%, 64%). Most midwives (81%, 17/21) and obstetricians (52%, 11/21) either underestimated or were unsure of the future risk of diabetes. There was lack of consensus on responsibility for immediate postpartum screening. Conclusion: The survey highlights the need for improved awareness of future risk of diabetes in women with gestational diabetes, consensus on optimal postpartum screening and identification of the main healthcare provider responsible for further management. This is particularly important for areas of social deprivation. ß 2015 Published by Elsevier Ireland Ltd.
Keywords: Gestational diabetes Type 2 diabetes Postpartum screening Healthcare professionals Survey
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Introduction Q2
Gestational diabetes is glucose intolerance that first develops or is first identified in pregnancy [1]. Women with gestational diabetes are at higher risk of developing subsequent type 2 diabetes compared to women with normoglycemic pregnancy [2], resulting in significant morbidity and mortality and healthcare costs [3]. With increasing rates of obesity, sedentary lifestyle and unhealthy diet, the prevalence of gestational diabetes is increasing worldwide, with rates as high as 30% [1].
* Corresponding author at: Women’s Health Research Unit, The Blizard Institute, Queen Mary University of London, London, UK. Tel.: +44 20 7882 5884; fax: +44 20 7882 6047. E-mail address: [email protected] (G. Rayanagoudar).
Current national and international guidelines recommend regular screening for type 2 diabetes after delivery in women with gestational diabetes [4,5]. Early identification of diabetes or impaired glucose tolerance in these women can prevent the associated complications. However, the rates of post-partum testing have been very low. In England, less than one in five women with gestational diabetes are followed up within 6 months of delivery with the annual follow-up rate also being around 20% [6]. Women with gestational diabetes are followed up after delivery by multiple healthcare providers such as obstetricians, diabetologists, midwives and general practitioners. These providers have the opportunity to influence care including screening for glucose intolerance followed by interventions such as diet and lifestyle modification that have the potential to prevent type 2 diabetes [7]. Existing studies have mainly focused on the role of obstetricians and physicians in postpartum care of women with gestational
http://dx.doi.org/10.1016/j.ejogrb.2015.09.019 0301-2115/ß 2015 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Rayanagoudar G, et al. Postpartum care of women with gestational diabetes: survey of healthcare professionals. Eur J Obstet Gynecol (2015), http://dx.doi.org/10.1016/j.ejogrb.2015.09.019
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diabetes [8]. We conducted a survey to assess the knowledge and practices of all relevant healthcare professionals including midwives in the care of these women.
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Materials and methods
41 We undertook a questionnaire-based survey of clinicians 42 including consultants and senior trainees in obstetrics and 43 diabetes, general practitioners and midwives between May and 44 September 2014. The questionnaire focused on the following 45 domains in the care of women with gestational diabetes after 46 delivery: screening for type 2 diabetes and strategies to prevent 47 type 2 diabetes, risk perception and responsibility for care. 48 Questions related to diagnostic approach explored the preferred 49 timing, method and frequency of postpartum screening for glucose 50 intolerance. Preventative action focused on the steps taken by 51 healthcare professionals to prevent or delay progression to type 2 52 diabetes in women with gestational diabetes. We studied the 53 variation in healthcare professionals’ perception of gestational 54 diabetes as a future risk factor for type 2 diabetes, among relevant 55 specialties. We obtained their opinion on whom they consider 56 responsible for postpartum follow-up of women with gestational 57 diabetes. Ethical approval was not needed and informed consent 58 was implied by completion of survey. 59 The survey questionnaire was available in paper and email 60 format. Healthcare professionals in the hospital, where study 61 authors are based, were approached at work with survey 62 information and questionnaire. Other hospital professionals based 63 outside East London, mainly in West Midlands, were identified by 64 professional networks of authors and received email question65 naires. The general practitioners surveyed were based in Essex and 66 West Midlands and were identified by authors’ clinical and 67 professional connections. The healthcare professionals surveyed 68 received up to three reminders to help complete the survey. The final 69 Q3 version of the questionnaire had 12 questions (Supplementary 70 Material S1). The questions were short and closed-ended with 71 multiple-choice options, and the form was designed to be completed 72 in 5–10 min. Statistical analyses were conducted to describe, for 73 each specialty, the number and proportion of respondents in each 74 choice of the 12 questions included in the questionnaire. As 75 there was a slight variation in the number of respondents among the 76 specialties, overall specialties proportions were computed by the 77 inverse of variance weighted average. Exact 95% CI intervals for 78 proportions were computed using the Wilson method [9]. Between79 specialty homogeneity of proportions was tested using a chi80 squared test. All analyses were performed using Stata 12 statistical 81 software [10]. 82
Results
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We distributed questionnaires to 106 healthcare professionals through paper-based and electronic methods, and ninety-two (87%) responded. The response rate among diabetologists was 87% (20/23), obstetricians 84% (21/25), midwives 84% (21/25) and general practitioners 91% (30/33). The respondents practiced in East London (73%, 67/92) and in the West Midlands (27%, 25/92) in England. Table 1 outlines the important findings of the survey. Oral glucose tolerance test (OGTT) was the most preferred test for postpartum screening (57%, 52/92) although there was a significant difference in preference of glucose tolerance test between specialties (p = 0.00). While more than 70% (44/62) as a whole in secondary care preferred OGTT, only 27% (8/30) of general practitioners reported this as their choice of test. The general practitioners instead preferred fasting glucose (50%, 15/30) and glycated hemoglobin (HbA1c; 47%, 14/30). Just a quarter of diabetologists (25%, 5/20), one-third of obstetricians (33%, 7/21)
and 14% (3/21) of midwives chose fasting glucose. One in seven secondary care professionals (15%, 9/62) chose HbA1c as their preferred test. The most common reason for choosing a test was a protocol being in place, but the diabetologists and general practitioners considered sensitivity of a test as more important. The majority of the respondents (75%, 69/92) preferred to test for glucose intolerance between six weeks and three months after delivery, with no significant difference (p = 0.083) when stratified by specialty. Nearly one in four general practitioners (23%, 7/30) opted to screen from three to six months following delivery, while only 3% (2/62) of hospital practitioners preferred this timeframe. If the initial test for post-partum diabetes was normal, two-thirds (65%, 60/92) opted to follow them up annually, with no significant difference among specialties (p = 0.123). Some respondents, including 29% of midwives (6/21), one-fifth of obstetricians (19%, 4/21) and one in ten general practitioners (10%, 3/30), indicated that they would not screen for diabetes long-term if the initial post-partum test was normal. In women with a history of gestational diabetes, nearly all respondents (98%, 90/92) would offer dietary recommendations, with 91% (84/92) also suggesting exercise to prevent progression to diabetes. There was no significant difference in approach among specialties. Approximately 12% (11/92) of all respondents, including one in four obstetricians (24%, 5/21), were in favor of metformin therapy in addition to diet and exercise. In pregnant women with risk factors for gestational diabetes, a vast majority of respondents (95%, 87/92) reported that they would make dietary recommendations. More than three quarters (76%, 70/92) would also advise about importance of exercise. A small proportion (10%, 9/92) also felt that metformin would be an useful adjunct for primary prevention of gestational diabetes. The respondents (63%, 58/92) were receptive toward participating in future clinical trials on newer interventions in preventing gestational diabetes. There was a significant difference, among the different specialties, in the perception of gestational diabetes as a predictor of progression to type 2 diabetes. Many obstetricians (43%, 9/21) felt that the risk of future diabetes is only increased 2-fold. A third of midwives (33%, 7/21) and approximately a quarter of general practitioners (23%, 7/30) felt the same. However, majority of the diabetologists (90%, 18/20) and general practitioners (60%, 18/30) perceived the lifetime risk of type 2 diabetes as being 4-fold or 7-fold. Nine midwives (43%, 9/21) were unsure about the risk. One in six general practitioners (17%, 5/30) was not confident of the estimated magnitude of risk of progression to type 2 diabetes. There were significant differences in opinion, among the specialties, regarding the healthcare professionals responsible for early post-partum testing for glucose abnormalities. Half of the diabetologists (50%, 10/20) and 81% (17/21) of midwives felt that their own colleagues were responsible. A quarter of diabetologists (25%, 5/20) and 43% (9/21) of obstetricians believed that general practitioners should be testing for diabetes, while a significant proportion of general practitioners felt that diabetologists (30%, 9/30) or obstetricians (23%, 7/30) were responsible. Overall, 82% (75/92) of respondents believed that general practitioners were responsible for long-term follow-up. Although 90% (27/30) of general practitioners who responded agreed with this, 10% (3/30) were either unsure or felt that long-term follow-up was the responsibility of secondary care.
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Discussion
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Our survey identified differences in risk perception of gestational diabetes as a prediabetic state, and the preferred screening strategy for progression to type 2 diabetes among relevant healthcare providers. There was a lack of consensus on who was responsible for postnatal screening for type 2 diabetes.
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Table 1
Q5 Healthcare professionals’ perception of risk of type 2 diabetes, and reported strategies for screening and follow-up of women with gestational diabetes. Total (n = 92)
Diabetologists (n = 20)
Obstetricians (n = 21)
Midwives (n = 21)
General practitioners (n = 30)
%
%
%
%
%
Risk perception/care provision Lifetime risk of developing type 2 diabetes in women with gestational diabetes 0 (0, 4) 0 (0, 16) 0 (0, 15) No Increased risk 2-fold increased risk 25 (16, 34) 5 (1, 24) 43 (24, 63) 4-fold increased risk 30 (21, 41) 50 (30, 70) 38 (21, 59) 7-fold increased risk 22 (13, 31) 40 (22, 61) 10 (3, 29) Not sure 17 (10, 26) 5 (1, 24) 10 (3, 29) Responsibility for first postpartum follow-up test for type 2 diabetes in women with GDM Diabetologists 26 (17, 36) 50 (30, 70) 19 (8, 40) Obstetricians 18 (10, 27) 10 (3, 30) 29 (14, 50) Midwives 42 (32, 53) 30 (15, 52) 43 (24, 63) General practitioners 27 (18, 36) 25 (11, 47) 43 (24, 63) Responsibility for long-term follow-up for type 2 diabetes in women with GDM Diabetologists 16 (9, 25) 25 (11, 47) 5 (1, 23) Obstetricians 0 (0, 2) 0 (0, 16) 0 (0, 15) Midwives 1 (0, 5) 0 (0, 16) 0 (0, 15) General practitioners 83 (74, 90) 80 (58, 92) 90 (71, 97) Diagnostic approach Timing of screening for type 2 diabetes 6 weeks 11 (5, 19) 10 (3, 30) 5 (1, 23) 6 weeks–3 months 76 (66, 85) 85 (64, 95) 90 (71, 97) 3–6 months 8 (2, 14) 5 (1, 24) 5 (1, 23) >6 months 1 (0, 5) 0 (0, 16) 0 (0, 15) Preferred test for postnatal screening for type 2 diabetes Random blood glucose 1 (0, 5) 0 (0, 16) 0 (0, 15) Fasting blood glucose 32 (22, 42) 25 (11, 47) 33 (17, 55) Glucose tolerance test 57 (46, 67) 70 (48, 85) 62 (41, 79) HbA1c 24 (15, 33) 15 (5, 36) 10 (3, 29) If initial postnatal screening test is normal, frequency of subsequent screening for type 2 diabetes Every 6 months 1 (0, 5) 10 (3, 30) 0 (0, 15) Annually 66 (55, 75) 75 (53, 89) 67 (45, 83) Every 2 years 9 (3, 16) 5 (1, 24) 14 (5, 35) Every 3 years 6 (2, 13) 10 (3, 30) 0 (0, 15) No further screening 14 (7, 23) 5 (1, 24) 19 (8, 40) Prevention Strategies to prevent type 2 diabetes in women with history of gestational diabetes Diet 99 (95, 100) 100 (84, 100) Exercise 92 (85, 97) 86 (64, 95) Metformin 11 (5, 19) 10 (3, 30) None of the above 0 (0, 4) 0 (0, 16)
90 95 24 5
(71, 97) (77, 99) (11, 45) (1, 23)
p
5 33 10 10 43
(1, 23) (17, 55) (3, 29) (3, 29) (24, 63)
0 23 30 30 17
(0, 11) (12, 41) (17, 48) (17, 48) (7, 34)
0.634 0.024 0.030 0.043 0.020
10 10 81 5
(3, 29) (3, 29) (60, 92) (1, 23)
30 23 23 37
(17, (12, (12, (22,
48) 41) 41) 54)
0.030 0.304 0.000 0.012
43 0 10 62
(24, 63) (0, 15) (3, 29) (41, 79)
7 0 0 90
(2, 21) (0, 11) (0, 11) (74, 97)
0.005 0.999 0.274 0.083
29 67 0 0
(14, 50) (45, 83) (0, 15) (0, 15)
7 63 23 7
(2, 21) (46, 78) (12, 41) (2, 21)
0.141 0.083 0.030 0.454
14 14 81 19
(5, 35) (5, 35) (60, 92) (8, 40)
0 50 27 47
(0, 11) (33, 67) (14, 44) (30, 64)
0.096 0.053 0.000 0.015
0 43 19 5 29
(0, 15) (24, 63) (8, 40) (1, 23) (14, 50)
0 73 3 13 10
(0, 11) (56, 86) (1, 17) (5, 30) (3, 26)
0.257 0.123 0.258 0.215 0.182
100 95 10 0
(85, 100) (77, 99) (3, 29) (0, 15)
100 90 7 0
(89, 100) (74, 97) (2, 21) (0, 11)
0.274 0.687 0.398 0.634
The numbers in parenthesis indicate confidence interval range.
163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186
There was agreement among specialties on providing lifestyle advice to women at risk of gestational diabetes, and to women with a history of gestational diabetes to prevent future diabetes. All the specialties also agreed that general practitioners are responsible for long-term follow-up of women with gestational diabetes to screen for diabetes. The majority of the respondents also concurred on timing of short-term follow-up and frequency of long-term follow-up of women with gestational diabetes. Our study has various strengths. Firstly, we explored the reported approach of relevant specialties to many important aspects of management of gestational diabetes. We focused on preferred methods for prevention, identification and risk perception of diabetes by specialists who are routinely involved in the care of such women. We explored aspects such as health promotion to prevent diabetes, that have been inadequately addressed in previous surveys [8]. Secondly, we included practitioners of all relevant specialties who are involved in the care of pregnant women with diabetes, including midwives. Thirdly, our response rate was excellent, thus minimizing potential bias from lack of representativeness of the respondents. Fourthly, our survey was multicenter, thereby addressing the issue of poor generalizability of results associated with a single-center study. The main limitation of our survey was the relatively small sample size in individual specialties from only two geographic
areas in the UK, albeit both characterized by high deprivation. Convenience sampling may have introduced some sampling error although we believe the respondents were largely representative of the professional groups we surveyed. Our survey design did not allow for qualitative evaluation of the responses. It is possible that the respondents chose the best possible answer to a question rather than what they would actually do in their day-to-day practice. Such discrepancy between reported and actual practice has been well recognized [11,12]. The cross-sectional nature of the survey meant that we were able to obtain a snapshot of current reported practice. A longitudinal trend survey would have had the added advantage of assessing the change in behavior and approach with time [13]. The study design did not allow us to evaluate other important aspects of care such as ways to improve post-partum care. Finally we did not study the perceptions around future risks to offspring born to women with GDM. This would have provided useful insights on ways in which the respondents could have influenced postpartum care by counseling women with GDM. The latest guidance from NICE recommends screening for diabetes with fasting glucose during the 6–13 week post-partum period, and with HbA1c beyond this time [4]. The majority of the respondents across all specialties in our survey, however, preferred OGTT postpartum except the general practitioners who chose HbA1c with fasting glucose as their preferred approach. There
Please cite this article in press as: Rayanagoudar G, et al. Postpartum care of women with gestational diabetes: survey of healthcare professionals. Eur J Obstet Gynecol (2015), http://dx.doi.org/10.1016/j.ejogrb.2015.09.019
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could be many reasons for this disparity in diagnostic approach. There is a lack of international consensus regarding the recommended test for postpartum evaluation of glucose tolerance, with some advocating OGTT and others fasting glucose alone [4,14–16]. Relying on fasting glucose alone can reduce the sensitivity of diagnosing diabetes or impaired glucose tolerance by 38–60% [17]. Oral glucose tolerance test has been found to be especially useful in high-risk populations such as Asians in identifying cases of type 2 diabetes that would otherwise be missed by fasting glucose alone [18,19]. Also, fasting glucose will not identify patients with impaired glucose tolerance, which is also a prediabetic state. This might explain the preference of secondary care providers to OGTT that has long been regarded as the gold standard. The use of HbA1c for diagnosis of diabetes has been a recent development, with a World Health Organization (WHO) consultation making this recommendation in 2011 [20]. Subsequently, the American Diabetes Association (ADA) also endorsed the use of HbA1c for diagnosis of diabetes, as has the new guidance from NICE [4,14]. A major issue with management of women with gestational diabetes is poor postpartum uptake of screening for diabetes [6]. The HbA1c has clear advantages over glucose tolerance test and fasting glucose test as it does not require fasting, and is hence more acceptable to patients. This may explain why the general practitioners in our survey opted for HbA1c over glucose tolerance test. HbA1c is a less sensitive test compared to glucose tolerance test [21] but this drawback can be potentially offset by greater testing rates and consequent higher rates of case detection. It should be noted that most of our survey respondents chose to assess glucose status within 3 months of delivery when HbA1c can be unreliable due to the potential impact of antepartum glycaemia, anemia and blood loss during delivery [14,22,23]. There is randomized controlled trial evidence that lifestyle modification prevents diabetes in individuals with a history of gestational diabetes [24,25]. Women with gestational diabetes should be provided lifestyle advice following birth before being transferred to community care [22]. The respondents in our survey consistently said that they would routinely offer this advice to women with gestational diabetes, with a small proportion also considering metformin as an adjunct. The ADA suggests considering metformin in women with history of gestational diabetes who have impaired fasting glucose or impaired glucose tolerance [14]. There is also evidence that antenatal diet and lifestyle changes can reduce the risk of gestational diabetes [26]; the majority of our survey respondents reported that they would offer this advice to women at risk. The risk of type 2 diabetes in women with gestational diabetes is more than 7-fold higher compared to women with normoglycemic pregnancy [2]. It is worrying that over 80% of the midwives underestimated, or were unsure of the potential of gestational diabetes as a prediabetic state. Midwives are often the first point of care with the mother after delivery, and have the ability to influence and plan future care [27]. Their knowledge and attitude toward gestational diabetes is likely to have an impact on the mother’s behavior, especially on compliance with follow-up appointments. Many obstetricians and general practitioners also underestimated, or were uncertain about, the increased risk of subsequent type 2 diabetes. This may explain why some respondents suggested they would discontinue follow-up if initial post-partum screening test was normal. Another major finding in our survey was the disagreement among specialties on who was responsible for immediate postpartum follow-up of women with gestational diabetes. Such gaps in communication among healthcare providers could be contributing to poor post-partum follow-up of these high-risk women [6]. Our study shows similar findings to a nationwide survey in England [28], principally a lack of agreement between primary and
secondary care on who is responsible for follow-up. It also reflected a similar preference among secondary care professionals for OGTT rather than fasting glucose as a postnatal screening test. However there were important differences in the methodology and results of the studies. Although our survey was conducted on a much smaller scale, we compared the responses of individuals in various specialties including midwifery. We assessed the preventative approach by healthcare professionals in pregnant women at risk of gestational diabetes and women with gestational diabetes at risk of type 2 diabetes. Previous studies have identified that many healthcare providers consider screening for type 2 diabetes as ‘low-priority’ [29,30]. Our survey shows that this may reflect, at least in part, lack of true appreciation of the risk of future diabetes due to gaps in knowledge. We also evaluated the reported use of HbA1c as a screening test. HbA1c was not in general use for diagnostic purposes at the time of the previous nationwide survey and hence was not specifically assessed. Our survey showed that there are important differences in the approach of primary and secondary care providers toward women with gestational diabetes. Robust planning and implementation should be encouraged to ensure that these women at high risk of diabetes do not miss post-partum follow-up due to failure of continuity within the healthcare system. A uniform screening strategy for short-term and long-term follow-up should be agreed locally; this may be best achieved in primary care where the systems of call and recall are far superior than in secondary care. Future studies should focus on the effect of such measures on the actual rates of postpartum screening. There is a need to increase awareness of the long-term consequences of gestational diabetes, both in patients as well as in healthcare professionals. Formal teaching sessions should be conducted at a local level for trainee doctors and midwives, and these may be facilitated by diabetologists. Hospital specialists should reach out to general practitioners and community diabetes specialist nurses to emphasize the potential benefits of early identification and prevention of diabetes in these young women.
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Conflict of interest
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The authors have no conflicts of interest.
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References
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[11] Gabbe SG, Gregory RP, Power ML, Williams SB, Schulkin J. Management of diabetes mellitus by obstetrician-gynecologists. Obstet Gynecol 2004;103(6): 1229–34. [12] Almario CV, Ecker T, Moroz LA, Bucovetsky L, Berghella V, Baxter JK. Obstetricians seldom provide postpartum diabetes screening for women with gestational diabetes. Am J Obstet Gynecol 2008;198(5):528.e1–.e5. [13] Kelley K, Clark B, Brown V, Sitzia J. Good practice in the conduct and reporting of survey research. Int J Qual Health Care: J Int Soc Qual Health Care/ISQua 2003;15(3):261–6. [14] American Diabetes Association. Standards of medical care in diabetes – 2014. Diabetes Care 2014;37(Suppl. 1):S14–80. [15] Metzger BE, Buchanan TA, Coustan DR, et al. Summary and recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care 2007;30(Suppl. 2):S251–60. [16] The American College of Obstetricians and Gynecologists. Practice Bulletin No. 137: gestational diabetes mellitus. Obstet Gynecol 2013;122(2 Pt 1): 406–16. [17] Simmons D, McElduff A, McIntyre HD, Elrishi M. Gestational diabetes mellitus: NICE for the U.S.? A comparison of the American Diabetes Association and the American College of Obstetricians and Gynecologists guidelines with the U.K. National Institute for Health and Clinical Excellence guidelines. Diabetes Care 2010;33(1):34–7. [18] McClean S, Farrar D, Kelly CA, Tuffnell DJ, Whitelaw DC. The importance of postpartum glucose tolerance testing after pregnancies complicated by gestational diabetes. Diabet Med 2010;27(6):650–4. [19] Harris TJ, Cook DG, Wicks PD, Cappuccio FP. Impact of the new American Diabetes Association and World Health Organisation diagnostic criteria for diabetes on subjects from three ethnic groups living in the UK. Nutr Metab Cardiovasc Dis: NMCD 2000;10(6):305–9. [20] World Health Organization. Use of glycated haemoglobin (HbA1c) in the diagnosis of diabetes mellitus. Geneva: World Health Organization; 2011. 25.
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[21] Picon MJ, Murri M, Munoz A, Fernandez-Garcia JC, Gomez-Huelgas R, Tina376 hones FJ. Hemoglobin A1c versus oral glucose tolerance test in postpartum 377 diabetes screening. Diabetes Care 2012;35(8):1648–53. 378 [22] National Institute for Health and Care Excellence. Diabetes in pregnancy – 379 management of diabetes and its complications from preconception to the 380 postnatal period. Clinical Guideline 63. London: National Institute for Health 381 and Care Excellence; 2008. 382 [23] Kim C, Herman WH, Cheung NW, Gunderson EP, Richardson C. Comparison of 383 hemoglobin A1c with fasting plasma glucose and 2-h postchallenge glucose 384 for risk stratification among women with recent gestational diabetes mellitus. 385 Diabetes Care 2011;34(9):1949–51. 386 [24] Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes 387 mellitus by changes in lifestyle among subjects with impaired glucose toler388 ance. N Engl J Med 2001;344(18):1343–50. 389 [25] Ratner RE, Christophi CA, Metzger BE, et al. Prevention of diabetes in women 390 with a history of gestational diabetes: effects of metformin and lifestyle 391 interventions. J Clin Endocrinol Metab 2008;93(12):4774–9. 392 [26] Artal R. The role of exercise in reducing the risks of gestational diabetes 393 mellitus in obese women. Best Pract Res Clin Obstet Gynaecol 2014. Q4394 [27] Persson M, Hornsten A, Winkvist A, Mogren I. ‘Dealing with ambiguity’ – the 395 role of obstetricians in gestational diabetes mellitus. Acta Obstet Gynecol 396 Scand 2012;91(4):439–46. 397 [28] Pierce M, Modder J, Mortagy I, Springett A, Hughes H, Baldeweg S. Missed 398 opportunities for diabetes prevention: post-pregnancy follow-up of women with 399 gestational diabetes mellitus in England. Br J Gen Pract 2011;61(591):e611–9. 400 [29] Ko JY, Dietz PM, Conrey EJ, et al. Gestational diabetes mellitus and postpartum 401 care practices of nurse-midwives. J Midwifery Women’s Health 2013;58(1): 402 33–40. 403 [30] Hunsberger ML, Donatelle RJ, Lindsay K, Rosenberg KD. Physician care patterns 404 and adherence to postpartum glucose testing after gestational diabetes mel405 litus in Oregon. PLoS ONE 2012;7(10):e47052. 406
Please cite this article in press as: Rayanagoudar G, et al. Postpartum care of women with gestational diabetes: survey of healthcare professionals. Eur J Obstet Gynecol (2015), http://dx.doi.org/10.1016/j.ejogrb.2015.09.019
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Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb 1
Postpartum care of women with gestational diabetes: survey of healthcare professionals
2 3 4
Rayanagoudar a,c,*, Misha Moore c, Javier Zamora a,b, Philippa Hanson c, Mohammed S.B. Huda c, Graham A. Hitman a,c, Shakila Thangaratinam a,c,d
Q1 Girish
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a
Women’s Health Research Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS) and CIBER Epidemiologia y Salud Publica, Madrid, Spain Barts Health NHS Trust, London, UK d Multidisciplinary Evidence Synthesis Hub (mEsh), Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 June 2015 Received in revised form 27 August 2015 Accepted 17 September 2015
Objective: To assess the knowledge and practices of healthcare professionals on the postpartum care of women with gestational diabetes. Study design: We surveyed 106 healthcare professionals including obstetricians, diabetologists, general practitioners and midwives in East London and West Midlands in England (September 2014). The questionnaire assessed postpartum screening practices, care provision, future risk and strategies to prevent diabetes in women with gestational diabetes. Results: The response rate was 87% (92/106). Nearly all respondents offered advice on diet (99%; CI 95%, 100%) and exercise (92%; CI 85%, 97%) postnatally in women with diagnosis of gestational diabetes. The preferred screening time for diabetes was 6 weeks to 3 months postpartum (76%; CI 66%, 85%). Overall, oral glucose tolerance test was the preferred test (57%; CI 46%, 67%), although general practitioners preferred fasting glucose (50%; CI 33%, 67%) and glycated hemoglobin (47%; CI 30%, 64%). Most midwives (81%, 17/21) and obstetricians (52%, 11/21) either underestimated or were unsure of the future risk of diabetes. There was lack of consensus on responsibility for immediate postpartum screening. Conclusion: The survey highlights the need for improved awareness of future risk of diabetes in women with gestational diabetes, consensus on optimal postpartum screening and identification of the main healthcare provider responsible for further management. This is particularly important for areas of social deprivation. ß 2015 Published by Elsevier Ireland Ltd.
Keywords: Gestational diabetes Type 2 diabetes Postpartum screening Healthcare professionals Survey
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Introduction Q2
Gestational diabetes is glucose intolerance that first develops or is first identified in pregnancy [1]. Women with gestational diabetes are at higher risk of developing subsequent type 2 diabetes compared to women with normoglycemic pregnancy [2], resulting in significant morbidity and mortality and healthcare costs [3]. With increasing rates of obesity, sedentary lifestyle and unhealthy diet, the prevalence of gestational diabetes is increasing worldwide, with rates as high as 30% [1].
* Corresponding author at: Women’s Health Research Unit, The Blizard Institute, Queen Mary University of London, London, UK. Tel.: +44 20 7882 5884; fax: +44 20 7882 6047. E-mail address: [email protected] (G. Rayanagoudar).
Current national and international guidelines recommend regular screening for type 2 diabetes after delivery in women with gestational diabetes [4,5]. Early identification of diabetes or impaired glucose tolerance in these women can prevent the associated complications. However, the rates of post-partum testing have been very low. In England, less than one in five women with gestational diabetes are followed up within 6 months of delivery with the annual follow-up rate also being around 20% [6]. Women with gestational diabetes are followed up after delivery by multiple healthcare providers such as obstetricians, diabetologists, midwives and general practitioners. These providers have the opportunity to influence care including screening for glucose intolerance followed by interventions such as diet and lifestyle modification that have the potential to prevent type 2 diabetes [7]. Existing studies have mainly focused on the role of obstetricians and physicians in postpartum care of women with gestational
http://dx.doi.org/10.1016/j.ejogrb.2015.09.019 0301-2115/ß 2015 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Rayanagoudar G, et al. Postpartum care of women with gestational diabetes: survey of healthcare professionals. Eur J Obstet Gynecol (2015), http://dx.doi.org/10.1016/j.ejogrb.2015.09.019
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diabetes [8]. We conducted a survey to assess the knowledge and practices of all relevant healthcare professionals including midwives in the care of these women.
40
Materials and methods
41 We undertook a questionnaire-based survey of clinicians 42 including consultants and senior trainees in obstetrics and 43 diabetes, general practitioners and midwives between May and 44 September 2014. The questionnaire focused on the following 45 domains in the care of women with gestational diabetes after 46 delivery: screening for type 2 diabetes and strategies to prevent 47 type 2 diabetes, risk perception and responsibility for care. 48 Questions related to diagnostic approach explored the preferred 49 timing, method and frequency of postpartum screening for glucose 50 intolerance. Preventative action focused on the steps taken by 51 healthcare professionals to prevent or delay progression to type 2 52 diabetes in women with gestational diabetes. We studied the 53 variation in healthcare professionals’ perception of gestational 54 diabetes as a future risk factor for type 2 diabetes, among relevant 55 specialties. We obtained their opinion on whom they consider 56 responsible for postpartum follow-up of women with gestational 57 diabetes. Ethical approval was not needed and informed consent 58 was implied by completion of survey. 59 The survey questionnaire was available in paper and email 60 format. Healthcare professionals in the hospital, where study 61 authors are based, were approached at work with survey 62 information and questionnaire. Other hospital professionals based 63 outside East London, mainly in West Midlands, were identified by 64 professional networks of authors and received email question65 naires. The general practitioners surveyed were based in Essex and 66 West Midlands and were identified by authors’ clinical and 67 professional connections. The healthcare professionals surveyed 68 received up to three reminders to help complete the survey. The final 69 Q3 version of the questionnaire had 12 questions (Supplementary 70 Material S1). The questions were short and closed-ended with 71 multiple-choice options, and the form was designed to be completed 72 in 5–10 min. Statistical analyses were conducted to describe, for 73 each specialty, the number and proportion of respondents in each 74 choice of the 12 questions included in the questionnaire. As 75 there was a slight variation in the number of respondents among the 76 specialties, overall specialties proportions were computed by the 77 inverse of variance weighted average. Exact 95% CI intervals for 78 proportions were computed using the Wilson method [9]. Between79 specialty homogeneity of proportions was tested using a chi80 squared test. All analyses were performed using Stata 12 statistical 81 software [10]. 82
Results
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We distributed questionnaires to 106 healthcare professionals through paper-based and electronic methods, and ninety-two (87%) responded. The response rate among diabetologists was 87% (20/23), obstetricians 84% (21/25), midwives 84% (21/25) and general practitioners 91% (30/33). The respondents practiced in East London (73%, 67/92) and in the West Midlands (27%, 25/92) in England. Table 1 outlines the important findings of the survey. Oral glucose tolerance test (OGTT) was the most preferred test for postpartum screening (57%, 52/92) although there was a significant difference in preference of glucose tolerance test between specialties (p = 0.00). While more than 70% (44/62) as a whole in secondary care preferred OGTT, only 27% (8/30) of general practitioners reported this as their choice of test. The general practitioners instead preferred fasting glucose (50%, 15/30) and glycated hemoglobin (HbA1c; 47%, 14/30). Just a quarter of diabetologists (25%, 5/20), one-third of obstetricians (33%, 7/21)
and 14% (3/21) of midwives chose fasting glucose. One in seven secondary care professionals (15%, 9/62) chose HbA1c as their preferred test. The most common reason for choosing a test was a protocol being in place, but the diabetologists and general practitioners considered sensitivity of a test as more important. The majority of the respondents (75%, 69/92) preferred to test for glucose intolerance between six weeks and three months after delivery, with no significant difference (p = 0.083) when stratified by specialty. Nearly one in four general practitioners (23%, 7/30) opted to screen from three to six months following delivery, while only 3% (2/62) of hospital practitioners preferred this timeframe. If the initial test for post-partum diabetes was normal, two-thirds (65%, 60/92) opted to follow them up annually, with no significant difference among specialties (p = 0.123). Some respondents, including 29% of midwives (6/21), one-fifth of obstetricians (19%, 4/21) and one in ten general practitioners (10%, 3/30), indicated that they would not screen for diabetes long-term if the initial post-partum test was normal. In women with a history of gestational diabetes, nearly all respondents (98%, 90/92) would offer dietary recommendations, with 91% (84/92) also suggesting exercise to prevent progression to diabetes. There was no significant difference in approach among specialties. Approximately 12% (11/92) of all respondents, including one in four obstetricians (24%, 5/21), were in favor of metformin therapy in addition to diet and exercise. In pregnant women with risk factors for gestational diabetes, a vast majority of respondents (95%, 87/92) reported that they would make dietary recommendations. More than three quarters (76%, 70/92) would also advise about importance of exercise. A small proportion (10%, 9/92) also felt that metformin would be an useful adjunct for primary prevention of gestational diabetes. The respondents (63%, 58/92) were receptive toward participating in future clinical trials on newer interventions in preventing gestational diabetes. There was a significant difference, among the different specialties, in the perception of gestational diabetes as a predictor of progression to type 2 diabetes. Many obstetricians (43%, 9/21) felt that the risk of future diabetes is only increased 2-fold. A third of midwives (33%, 7/21) and approximately a quarter of general practitioners (23%, 7/30) felt the same. However, majority of the diabetologists (90%, 18/20) and general practitioners (60%, 18/30) perceived the lifetime risk of type 2 diabetes as being 4-fold or 7-fold. Nine midwives (43%, 9/21) were unsure about the risk. One in six general practitioners (17%, 5/30) was not confident of the estimated magnitude of risk of progression to type 2 diabetes. There were significant differences in opinion, among the specialties, regarding the healthcare professionals responsible for early post-partum testing for glucose abnormalities. Half of the diabetologists (50%, 10/20) and 81% (17/21) of midwives felt that their own colleagues were responsible. A quarter of diabetologists (25%, 5/20) and 43% (9/21) of obstetricians believed that general practitioners should be testing for diabetes, while a significant proportion of general practitioners felt that diabetologists (30%, 9/30) or obstetricians (23%, 7/30) were responsible. Overall, 82% (75/92) of respondents believed that general practitioners were responsible for long-term follow-up. Although 90% (27/30) of general practitioners who responded agreed with this, 10% (3/30) were either unsure or felt that long-term follow-up was the responsibility of secondary care.
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Discussion
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Our survey identified differences in risk perception of gestational diabetes as a prediabetic state, and the preferred screening strategy for progression to type 2 diabetes among relevant healthcare providers. There was a lack of consensus on who was responsible for postnatal screening for type 2 diabetes.
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Table 1
Q5 Healthcare professionals’ perception of risk of type 2 diabetes, and reported strategies for screening and follow-up of women with gestational diabetes. Total (n = 92)
Diabetologists (n = 20)
Obstetricians (n = 21)
Midwives (n = 21)
General practitioners (n = 30)
%
%
%
%
%
Risk perception/care provision Lifetime risk of developing type 2 diabetes in women with gestational diabetes 0 (0, 4) 0 (0, 16) 0 (0, 15) No Increased risk 2-fold increased risk 25 (16, 34) 5 (1, 24) 43 (24, 63) 4-fold increased risk 30 (21, 41) 50 (30, 70) 38 (21, 59) 7-fold increased risk 22 (13, 31) 40 (22, 61) 10 (3, 29) Not sure 17 (10, 26) 5 (1, 24) 10 (3, 29) Responsibility for first postpartum follow-up test for type 2 diabetes in women with GDM Diabetologists 26 (17, 36) 50 (30, 70) 19 (8, 40) Obstetricians 18 (10, 27) 10 (3, 30) 29 (14, 50) Midwives 42 (32, 53) 30 (15, 52) 43 (24, 63) General practitioners 27 (18, 36) 25 (11, 47) 43 (24, 63) Responsibility for long-term follow-up for type 2 diabetes in women with GDM Diabetologists 16 (9, 25) 25 (11, 47) 5 (1, 23) Obstetricians 0 (0, 2) 0 (0, 16) 0 (0, 15) Midwives 1 (0, 5) 0 (0, 16) 0 (0, 15) General practitioners 83 (74, 90) 80 (58, 92) 90 (71, 97) Diagnostic approach Timing of screening for type 2 diabetes 6 weeks 11 (5, 19) 10 (3, 30) 5 (1, 23) 6 weeks–3 months 76 (66, 85) 85 (64, 95) 90 (71, 97) 3–6 months 8 (2, 14) 5 (1, 24) 5 (1, 23) >6 months 1 (0, 5) 0 (0, 16) 0 (0, 15) Preferred test for postnatal screening for type 2 diabetes Random blood glucose 1 (0, 5) 0 (0, 16) 0 (0, 15) Fasting blood glucose 32 (22, 42) 25 (11, 47) 33 (17, 55) Glucose tolerance test 57 (46, 67) 70 (48, 85) 62 (41, 79) HbA1c 24 (15, 33) 15 (5, 36) 10 (3, 29) If initial postnatal screening test is normal, frequency of subsequent screening for type 2 diabetes Every 6 months 1 (0, 5) 10 (3, 30) 0 (0, 15) Annually 66 (55, 75) 75 (53, 89) 67 (45, 83) Every 2 years 9 (3, 16) 5 (1, 24) 14 (5, 35) Every 3 years 6 (2, 13) 10 (3, 30) 0 (0, 15) No further screening 14 (7, 23) 5 (1, 24) 19 (8, 40) Prevention Strategies to prevent type 2 diabetes in women with history of gestational diabetes Diet 99 (95, 100) 100 (84, 100) Exercise 92 (85, 97) 86 (64, 95) Metformin 11 (5, 19) 10 (3, 30) None of the above 0 (0, 4) 0 (0, 16)
90 95 24 5
(71, 97) (77, 99) (11, 45) (1, 23)
p
5 33 10 10 43
(1, 23) (17, 55) (3, 29) (3, 29) (24, 63)
0 23 30 30 17
(0, 11) (12, 41) (17, 48) (17, 48) (7, 34)
0.634 0.024 0.030 0.043 0.020
10 10 81 5
(3, 29) (3, 29) (60, 92) (1, 23)
30 23 23 37
(17, (12, (12, (22,
48) 41) 41) 54)
0.030 0.304 0.000 0.012
43 0 10 62
(24, 63) (0, 15) (3, 29) (41, 79)
7 0 0 90
(2, 21) (0, 11) (0, 11) (74, 97)
0.005 0.999 0.274 0.083
29 67 0 0
(14, 50) (45, 83) (0, 15) (0, 15)
7 63 23 7
(2, 21) (46, 78) (12, 41) (2, 21)
0.141 0.083 0.030 0.454
14 14 81 19
(5, 35) (5, 35) (60, 92) (8, 40)
0 50 27 47
(0, 11) (33, 67) (14, 44) (30, 64)
0.096 0.053 0.000 0.015
0 43 19 5 29
(0, 15) (24, 63) (8, 40) (1, 23) (14, 50)
0 73 3 13 10
(0, 11) (56, 86) (1, 17) (5, 30) (3, 26)
0.257 0.123 0.258 0.215 0.182
100 95 10 0
(85, 100) (77, 99) (3, 29) (0, 15)
100 90 7 0
(89, 100) (74, 97) (2, 21) (0, 11)
0.274 0.687 0.398 0.634
The numbers in parenthesis indicate confidence interval range.
163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186
There was agreement among specialties on providing lifestyle advice to women at risk of gestational diabetes, and to women with a history of gestational diabetes to prevent future diabetes. All the specialties also agreed that general practitioners are responsible for long-term follow-up of women with gestational diabetes to screen for diabetes. The majority of the respondents also concurred on timing of short-term follow-up and frequency of long-term follow-up of women with gestational diabetes. Our study has various strengths. Firstly, we explored the reported approach of relevant specialties to many important aspects of management of gestational diabetes. We focused on preferred methods for prevention, identification and risk perception of diabetes by specialists who are routinely involved in the care of such women. We explored aspects such as health promotion to prevent diabetes, that have been inadequately addressed in previous surveys [8]. Secondly, we included practitioners of all relevant specialties who are involved in the care of pregnant women with diabetes, including midwives. Thirdly, our response rate was excellent, thus minimizing potential bias from lack of representativeness of the respondents. Fourthly, our survey was multicenter, thereby addressing the issue of poor generalizability of results associated with a single-center study. The main limitation of our survey was the relatively small sample size in individual specialties from only two geographic
areas in the UK, albeit both characterized by high deprivation. Convenience sampling may have introduced some sampling error although we believe the respondents were largely representative of the professional groups we surveyed. Our survey design did not allow for qualitative evaluation of the responses. It is possible that the respondents chose the best possible answer to a question rather than what they would actually do in their day-to-day practice. Such discrepancy between reported and actual practice has been well recognized [11,12]. The cross-sectional nature of the survey meant that we were able to obtain a snapshot of current reported practice. A longitudinal trend survey would have had the added advantage of assessing the change in behavior and approach with time [13]. The study design did not allow us to evaluate other important aspects of care such as ways to improve post-partum care. Finally we did not study the perceptions around future risks to offspring born to women with GDM. This would have provided useful insights on ways in which the respondents could have influenced postpartum care by counseling women with GDM. The latest guidance from NICE recommends screening for diabetes with fasting glucose during the 6–13 week post-partum period, and with HbA1c beyond this time [4]. The majority of the respondents across all specialties in our survey, however, preferred OGTT postpartum except the general practitioners who chose HbA1c with fasting glucose as their preferred approach. There
Please cite this article in press as: Rayanagoudar G, et al. Postpartum care of women with gestational diabetes: survey of healthcare professionals. Eur J Obstet Gynecol (2015), http://dx.doi.org/10.1016/j.ejogrb.2015.09.019
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could be many reasons for this disparity in diagnostic approach. There is a lack of international consensus regarding the recommended test for postpartum evaluation of glucose tolerance, with some advocating OGTT and others fasting glucose alone [4,14–16]. Relying on fasting glucose alone can reduce the sensitivity of diagnosing diabetes or impaired glucose tolerance by 38–60% [17]. Oral glucose tolerance test has been found to be especially useful in high-risk populations such as Asians in identifying cases of type 2 diabetes that would otherwise be missed by fasting glucose alone [18,19]. Also, fasting glucose will not identify patients with impaired glucose tolerance, which is also a prediabetic state. This might explain the preference of secondary care providers to OGTT that has long been regarded as the gold standard. The use of HbA1c for diagnosis of diabetes has been a recent development, with a World Health Organization (WHO) consultation making this recommendation in 2011 [20]. Subsequently, the American Diabetes Association (ADA) also endorsed the use of HbA1c for diagnosis of diabetes, as has the new guidance from NICE [4,14]. A major issue with management of women with gestational diabetes is poor postpartum uptake of screening for diabetes [6]. The HbA1c has clear advantages over glucose tolerance test and fasting glucose test as it does not require fasting, and is hence more acceptable to patients. This may explain why the general practitioners in our survey opted for HbA1c over glucose tolerance test. HbA1c is a less sensitive test compared to glucose tolerance test [21] but this drawback can be potentially offset by greater testing rates and consequent higher rates of case detection. It should be noted that most of our survey respondents chose to assess glucose status within 3 months of delivery when HbA1c can be unreliable due to the potential impact of antepartum glycaemia, anemia and blood loss during delivery [14,22,23]. There is randomized controlled trial evidence that lifestyle modification prevents diabetes in individuals with a history of gestational diabetes [24,25]. Women with gestational diabetes should be provided lifestyle advice following birth before being transferred to community care [22]. The respondents in our survey consistently said that they would routinely offer this advice to women with gestational diabetes, with a small proportion also considering metformin as an adjunct. The ADA suggests considering metformin in women with history of gestational diabetes who have impaired fasting glucose or impaired glucose tolerance [14]. There is also evidence that antenatal diet and lifestyle changes can reduce the risk of gestational diabetes [26]; the majority of our survey respondents reported that they would offer this advice to women at risk. The risk of type 2 diabetes in women with gestational diabetes is more than 7-fold higher compared to women with normoglycemic pregnancy [2]. It is worrying that over 80% of the midwives underestimated, or were unsure of the potential of gestational diabetes as a prediabetic state. Midwives are often the first point of care with the mother after delivery, and have the ability to influence and plan future care [27]. Their knowledge and attitude toward gestational diabetes is likely to have an impact on the mother’s behavior, especially on compliance with follow-up appointments. Many obstetricians and general practitioners also underestimated, or were uncertain about, the increased risk of subsequent type 2 diabetes. This may explain why some respondents suggested they would discontinue follow-up if initial post-partum screening test was normal. Another major finding in our survey was the disagreement among specialties on who was responsible for immediate postpartum follow-up of women with gestational diabetes. Such gaps in communication among healthcare providers could be contributing to poor post-partum follow-up of these high-risk women [6]. Our study shows similar findings to a nationwide survey in England [28], principally a lack of agreement between primary and
secondary care on who is responsible for follow-up. It also reflected a similar preference among secondary care professionals for OGTT rather than fasting glucose as a postnatal screening test. However there were important differences in the methodology and results of the studies. Although our survey was conducted on a much smaller scale, we compared the responses of individuals in various specialties including midwifery. We assessed the preventative approach by healthcare professionals in pregnant women at risk of gestational diabetes and women with gestational diabetes at risk of type 2 diabetes. Previous studies have identified that many healthcare providers consider screening for type 2 diabetes as ‘low-priority’ [29,30]. Our survey shows that this may reflect, at least in part, lack of true appreciation of the risk of future diabetes due to gaps in knowledge. We also evaluated the reported use of HbA1c as a screening test. HbA1c was not in general use for diagnostic purposes at the time of the previous nationwide survey and hence was not specifically assessed. Our survey showed that there are important differences in the approach of primary and secondary care providers toward women with gestational diabetes. Robust planning and implementation should be encouraged to ensure that these women at high risk of diabetes do not miss post-partum follow-up due to failure of continuity within the healthcare system. A uniform screening strategy for short-term and long-term follow-up should be agreed locally; this may be best achieved in primary care where the systems of call and recall are far superior than in secondary care. Future studies should focus on the effect of such measures on the actual rates of postpartum screening. There is a need to increase awareness of the long-term consequences of gestational diabetes, both in patients as well as in healthcare professionals. Formal teaching sessions should be conducted at a local level for trainee doctors and midwives, and these may be facilitated by diabetologists. Hospital specialists should reach out to general practitioners and community diabetes specialist nurses to emphasize the potential benefits of early identification and prevention of diabetes in these young women.
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Conflict of interest
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The authors have no conflicts of interest.
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References
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Please cite this article in press as: Rayanagoudar G, et al. Postpartum care of women with gestational diabetes: survey of healthcare professionals. Eur J Obstet Gynecol (2015), http://dx.doi.org/10.1016/j.ejogrb.2015.09.019