The final interpretation of the results of this study revealed a need to clarify responsibility for diabetes during pregnancy and childbirth, both between different care providers and between the care provider and the woman/her partner. Although diabetes care providers have the medical responsibility to minimize adverse outcomes of pregnancy, women with type 1 diabetes must, and want to, cope with the need for strict glycaemic control. In earlier research, this has been described as 'being in the grip of blood glucose levels
] (page 300), and as 'being controlled by the blood glucose levels for the child's sake
] (page 39).
A noteworthy negative experience during pregnancy reported in our study was to be a messenger between different care providers, prominent in disconnected care organisations, which also led to experiences of distrust and uncertainty concerning the professionals' diabetes competence and a perceived need for the woman to serve as her own expert. This echoes other research showing that women were less satisfied with the support provided by care providers with limited experience of and knowledge gaps concerning diabetic pregnancies [12
]. A care organisation in which the woman is required to act as a messenger does not provide 'good quality of care'. To be in transition to motherhood requires a supportive environment, particularly when a mother-to-be is at high risk. In general, the women in our study felt prioritized as receiving more diabetes support during pregnancy than ever else, which can be considered as "high marks" for diabetes midwives and physicians. Local differences in access to specialist antenatal care, as found in this study in which the women had been given care in four different settings, seem to explain the negative consequences of the disconnected model of care. Based on our findings, we suggest that a multi-professional team should manage care of pregnant women with diabetes, in rural as well as urban areas, with as few care providers as possible. Moreover, in line with Lavender et al. [19
] we suggest the existing diabetes pregnancy care programs to be more extensive concerning psycho-social support. All women, both from urban and rural areas, in our study as well as in others [12
] wanted contact with others with similar experiences during pregnancy and childbirth. Websites offering both professional support and support from women in similar situations (via chats and forums) might alleviate the effects of insufficient access to face-to-face professional care.
Our findings concerning the women's experience of childbirth complement earlier studies. In order to decrease feelings of vulnerability, uncertainty and guilt in women with diabetes, we suggest that care during childbirth include support for the women to stay in control [18
]. Based on our findings, we suggest that this should include relieving them of 'being in charge' when they need and wish for such relief. The respective, and contrasting, desires to stay in control and to be relieved of control during labour and childbirth place high demands on care providers to be sensitive and flexible towards the woman's and her partner's needs. The feeling of abandonment during childbirth expressed by some women might have been avoided by mutual agreement and the clarification of responsibility, for instance by a written birth plan. At admission to the labour ward the midwife might, for example, ask, 'How would you like things done? Do you want to check your blood glucose or just leave it to us?'
It is well known that negative birth experiences are associated with women's worries regarding their own and the baby's health during pregnancy [20
], and that worry is more common among women at high risk, including women with diabetes [10
]. Therefore, attentiveness in midwives and obstetricians to the individual needs of the woman and her partner is crucial. This should include participation in decision-making and supportive behaviour as it has been shown to reduce negative experiences [20
Combining FG discussions and individual interviews was not a decision made beforehand. Instead, the aim was to explore the phenomenon in the best possible way, while respecting individual preferences. Of course it can be questioned if it is possible to acquaint oneself with individual lifeworlds in a FG in which several lifeworlds are encountered and mixed, sometimes creating collective meanings.
Concerning the trustworthiness of our study we aimed at using the interaction effects related to the FGs by means of an additional layer of data. This is enhanced by the social space that FGs provide, in which the participants view and experience constructs through evolving discussions and interactions [17
]. However, in order to reach the full potential of FGs it is essential to pay particular attention to analysis of the unique effects of the interaction [22
]. In this study, such insights were obtained in some FGs more than in others, probably related to the atmosphere and personalities combined in each constellation. Similar to the descriptions by Lambert & Loiselle [23
], different patterns were illuminated and discussed in each group according to what was experienced and relevant in that FG context. During the individual interviews, on the other hand, the woman's experience was expressed without being contrasted and reflected upon by others, occasionally leading to more detailed and rich descriptions. Thus, the methods complemented each other, yielding differing layers of data. In the analysis, both individual and contextual interpretations of the phenomenon were developed in the integration of data. It is essential to critically scrutinize strengths and weaknesses pertaining to both data collection methods, while acknowledging that the combination of methods can create a better understanding of different representations of the phenomenon [23
Another credibility issue is the authors' proximity to the research field; one of us (MB) has extensive experience as a "diabetes midwife" and the other (CS-L) as a neonatal nurse, both at one of the four included hospitals. However, we did not treat any of the included participants during the study period. We are aware that closeness to a study phenomenon may have an impact on the data but we consider this to be an asset, rather than a problem, especially when applying a hermeneutical approach, which is based on the assumption that there can be no understanding without pre-understanding. In order to achieve scientific reliability, we have critically examined all developed interpretations, including our own pre-understandings related to the studied phenomenon, until we reached the final interpretation [15
Regarding the transferability of our findings, the participants represent a panorama of women with type 1 diabetes in the region; they come from both rural and urban areas and have been provided with a variation of antenatal care models, depending on which health care institution they belong to. Their educational level is fairly comparable to that in a normal population.