Despite their elevated risk for developing future T2DM, women with a recent history of GDM described multiple types of barriers to follow-up medical care and monitoring. We categorized these barriers into four major themes, which are described as distinct but clearly have some overlap: Delivery and baby's health; Personal and family adjustment to the baby; Concerns about postpartum and future health; and Experiences with medical care and services. We also identified six key facilitator themes that motivated women to return for care. Our findings provide an important, yet previously understudied window into the lives of women with GDM in the postpartum period to better understand their experiences and to identify specific reasons why they do or do not follow recommendations to return for postpartum follow-up care.
Prior studies have evaluated patient-level barriers to and facilitators of follow-up care in the postpartum period for women with a history of GDM. Our study findings were consistent with survey-based studies showing that some women with recent GDM do not perceive themselves to be at high risk for diabetes.15,17
Some of the participants described perceived good health as a reason for not returning for follow-up care. Patients who had specific questions or concerns, especially about GDM and diabetes risk, were likely to return for care. It is not clear if these concerns stemmed from prior conversations with their providers. A cross-sectional survey of 228 women with a history of GDM enrolled in a university-affiliated managed care program showed the receipt of advice from providers about postpartum diabetes screening increased women's completion of follow-up glucose testing.14
Notably, we elucidated two clinically important barriers to follow-up care that will be important to address in future interventions. First, some women reported postpartum stressors and mood symptoms, such as anxiety and feeling overwhelmed, as barriers to follow-up care. Perinatal depression affects between 6% and 13% of women within 3 months after delivery,18
and there is an association between GDM and depression.19
Future interventions that focus on postpartum follow-up care in women with GDM will need strategies to improve the recognition and management of postpartum mood symptoms. The second clinically important and also unexpected finding from our study was participants' fear of receiving bad news, particularly a diagnosis of diabetes, at their follow-up visit. Women perceived their risk for developing diabetes as an immediate instead of a long-term risk. They often preferred the state of “unknowing,” as 1 participant described it, to continuing with the significant behavioral changes, such as frequent blood glucose monitoring and dietary restrictions, during the all-too-recent GDM-complicated pregnancy. Anticipating and addressing this concern through improved patient-provider communication may alleviate some of their fears and improve adherence to follow-up recommendations.
Several limitations of this qualitative study should be considered. First, like other qualitative studies, our goal was to obtain an in-depth perspective in a smaller sample. Even within our local clinical population, however, we excluded women without health insurance beyond the postpartum visit, limiting our ability to comment on barriers to care for these disadvantaged patients. Therefore, results from this study likely represent a best-case scenario. In addition, we selected our sample from an academic high-risk obstetric practice setting, with obstetric resident physicians as providers. Because women were often referred to this practice for GDM management from both community and academic practices, we believe that our sample contains patients with a diversity of experiences and perspectives. However, concerns about the practice's logistics, wait time, and ratings of satisfaction may be unique to the teaching-hospital setting. Nonetheless, our results may be particularly useful for other providers in teaching hospitals who are interested in developing interventions to improve aspects of care. Second, the focus of this study was on postpartum follow-up care in the clinic, which in our setting is the first step toward receiving an order for a screening test for T2DM. Because patients were interviewed at or around the time of their postpartum visit, many commented about postpartum diabetes screening. However, it was not the goal of this study to report screening rates, as our clinical tracking system may have missed some results, such as if patients received orders from outside providers or laboratory results were not received or entered into the medical record. We believe that the barriers and facilitators we presented from this study may apply to receiving all aspects of postpartum care, inclusive of laboratory testing.
We plan to use these results to inform the development of interventions to improve postpartum follow-up care. To our knowledge, only one trial has focused on the outcome of return rates for postpartum care or testing. Clark et al.20
used a 2
2 factorial design to randomly assign patients with GDM to receive a postal reminder about postpartum diabetes screening, a reminder sent to their physicians, reminders to both physician and patient, or neither. Mailing postal reminders to the patient, physician, or to both resulted in a 3–4-fold increase in postpartum glucose screening rates.20
Informed by our findings about barriers to care, other interventions focused on improving attendance at postpartum clinical care or diabetes screening may include the following components: Enhancement of patient-provider communication about the risk of developing T2DM and anticipatory guidance on preventive health behaviors, in particular breastfeeding21
and diet and exercise22
; Recognition and treatment of mood symptoms; Practice-level changes to improve logistics, in particular for undergoing postpartum diabetes screening, for women facing the demands of a baby's unpredictable schedule.
Our qualitative findings about barriers to and facilitators of postpartum follow-up care provide important groundwork to developing comprehensive interventions that have the potential to decrease the risk of T2DM and CVD in women with recent GDM.