Three major themes arose during the analysis: 1) professional identity, 2) lack of priority in the area of GDM and 3) cross-sectoral collaboration.
3.1 Professional Roles and Responsibilities
The HCPs had different tasks and assignments in their interaction with women with GDM. Obstetricians were first and foremost responsible for treating short-term consequences associated with a GDM-affected pregnancy, and thereafter responsible for counselling women with GDM about the excess risk of type 2 diabetes after pregnancy. It was important for the obstetricians to communicate the potential consequences in the limited time available in the consultation.
”I also tell them that there is already a risk related to their children becoming overweight and developing metabolic disturbances in childhood, and emphasise the importance of thinking about diet and exercise for their children” (Obstetrician, N)
The diabetes nurse also perceived their time with the pregnant women with GDM to be very time-restricted. The diabetes nurse viewed their profession as critical in disseminating knowledge about the implications of GDM on the body and more practically how to measure blood sugar levels making it difficult to integrate other conversation topics within the available consultation time.
"They receive a basic knowledge about what happens in the body to make them well-informed. Also, that it is important to keep an eye on their blood sugars in pregnancy and we teach them how to do blood sugar measurements. (Diabetes Nurse, S)
The obstetricians and diabetes nurse underlined the importance of reinforcing dietary restrictions during pregnancy to ensure that the health of the baby was prioritised. Furthermore, although they were aware of the emotional burden women might feel about the GDM regime, it was not a primary focus in the consultations.
The midwives reported focusing on the health of the fetus, but also attending to the health of the mother in a more general sense. The conversation between the mother and the midwife comprised each woman presenting her narrative about her pregnancy. A midwife pointed out how it helped to motivate the women to make healthy decisions during pregnancy.
“So, I always make them reflect on both what it is that makes them overweight, but also so I can help and motivate them as well. In terms of where there is something they can work with." (Midwife, I)
The midwives’ felt inclined to support the women to cope with the pregnancy affected by GDM. One midwife even used the term ‘pregnancy prison’ to illustrate the strict regimen women with GDM had to follow during pregnancy.
“So, they [women with GDM] feel that they are in a rather pregnancy prison-like state. And when they get rid of all the controls they have during pregnancy, [they feel like] "they can live their lives completely free again." Then they really forget what the motivation was to hold on to the good habits." (Midwife, K)
Health visitors manage the well-being of the baby and encouraging a healthy family dynamic. They perceive themselves as having a close relationship with mothers after a GDM-affected pregnancy as they interact with the woman outside the hospital setting. Still, the health visitors noted they had limited knowledge about GDM. This was revealed when they explained how they comforted the women by telling them that developing GDM was out of their control. However, as stated in the background, this is not the case.
“We try to hold on to the fact that it’s because of genes for the most part. And they can’t do anything about that. Not that we want to take the responsibility away from them, but it brings no good that you walk around feeling guilty” (Health visitor, A)
GPs are in contact with women with GDM both during pregnancy and after birth. After pregnancy, the GPs stated they would let it be up to the women to decide what to discuss during the consultations as they did not want to burden the women with the risks associated with having had GDM.
“Whether we start talking about what it may have meant during pregnancy or that the child has an increased risk? No, I do not think so. […] It is the pregnant women who sets the agenda. So, sitting and giving long speeches - we don’t do that. If she is worried then we will talk about it, but there is a lot to be done in the consultation that does not necessarily relate to gestational diabetes.” (GP, P)
Thus, while the GPs, midwives, and health visitors described difficulties addressing health behaviours as diet and physical activity relevant to a GDM diagnosis, the obstetricians and diabetes nurse were more likely to talk about risk as they perceived this to be their main task and prioritised it within the limited time available. The midwives did not want to blame the women by addressing the GDM-related health risks for the child as they were already provided overwhelming amounts of information in pregnancy. Often, health visitors did not know about the implications of a GDM-related pregnancy, which made them avoid conversations about diabetes risk or the need to prioritise health behaviours after birth. The GPs focused on addressing other relevant topics making the women’s risk unlikely to be included in the consultation. Thus, health behaviour (and long-term prevention) was rarely discussed as it depended on whether the women brought it up herself, and whether it was deemed appropriate and relevant by the individual HCP to prioritise it in the consultation.
3.2 Lack of priority in the area of GDM
A concern that was widely addressed by HCPs was the lack of importance given to GDM by other caregivers and hospital management by not providing training on the special needs of this group. The HCPs reported that the lack of resources allocated to GDM reduced their flexibility in working with GDM-affected women. It created a feeling that the management was not supportive of HCPs working with GDM and there was consequently a shortage of HCPs specialising in caring for women with prior GDM.
"I'm not sure it's that prestigious to work with it [GDM]. It is when they are pregnant, but afterwards I don’t think it's that prestigious. I just think we don’t have enough focus on it. I don’t think it's prioritised enough." (Obstetrician, O)
The HCPs reported that women with GDM were likely to be consulted by several different midwives, which the midwives perceived to be due to the lack of resources allocated to GDM. The midwives felt it could lead to information loss and create an inconsistent care pathway for women with GDM. Further, they perceived the lack of information flow between HCPs as a serious challenge as much time was spent catching up on the woman’s special needs in the consultation. Thus, important information on the woman’s medical and social circumstances was lost in the knowledge transfer between providers. The HCPs wanted to ensure good practice but noted that more resources were needed to allow flexible schedules and personalised treatment.
"In fact, the midwives who sit in the consultations with women with GDM must actually have some further training or some courses. I think that something is missing here in terms of resources” (Midwife, I)
According to the HCPs, the limited follow-up of women with prior GDM reduced the possibility of upholding a supportive treatment system, particularly when the possibilities for visits by HCPs after delivery were limited to one follow up visit. The GPs reported that after delivery the primary focus of care shifts from the woman with GDM to the baby. They believed this shift to be partly due to a lack of guidelines on how to communicate the risk of prior GDM to postpartum women.
” These women with gestational diabetes they disappear a little alongside so many other things. There is a lot of focus during pregnancy, but after pregnancy, it disappears into the wellbeing of the baby and illness and so on” (GP, P)
“I think a precise to-do list for gestational diabetes is missing. We should focus on how we most appropriately can follow these women. ‘Here was a gestational diabetes case, but what then?’ It becomes forgotten”. (GP, Q)
The HCPs described a lack of priority given to the area of GDM after delivery as women ‘lost’ their GDM diagnosis. The HCPs who attended women in the hospital (obstetrician, diabetes nurse and midwives) expressed a frustration with the lack of additional care in the period after birth. They saw it as conflicting with their role as caregivers, when they could not support women with GDM with additional care after pregnancy. Further, the midwives argued that women with GDM should gain a special status in the health system, during and after delivery allowing extra training for HCPs to be prepared to handle complex needs. The GPs confirmed that the diagnosis of GDM was forgotten after pregnancy and called for clear guidelines on how to address GDM after the delivery.
3.3 Cross-sectoral Collaboration
The HCPs’ collaboration was described as often being unstructured due to unclear responsibilities in information transfer between providers, particularly when information about women with GDM needed to travel across sectors e.g. from the obstetric departments to GPs or health visitors. Barriers for cross-sectoral collaboration included: working in other hospital departments with no natural day-to-day interaction and not finding information from the other HCPs relevant to their own practice. The midwives specified that interactions with other HCPs benefited collaboration by reducing repetition and losing important knowledge in the consultation. Yet, only a few of the midwives collaborated closely with the outpatient clinic and none of the HCPs worked in physical proximity to the GPs.
“Since we’re placed in two geographically different places, it is hard to have a close collaboration. Of course, we read each other’s notes, but I know that the pregnant women experience that we, as healthcare professionals, say different things. Since I visit the hospital regularly, I don’t think that I communicate that differently from the professionals over there [obstetricians, dieticians, endocrinologists]. […] Because I go there [to the ambulatory] and have the possibility to talk to them [HCPs at the ambulatory]” (Midwife, K)
“Yes, I think you distance yourself from what you don’t know that much about. Then you think: “they [the ambulatory] take care of that over there,” and I take care of mine according to what I usually do.” (Midwife, J)
Divergent messages from dieticians and obstetricians on health risk caused women with GDM to neglect their elevated risk after pregnancy. The HCPs explained how the quality of the information transfer between HCPs largely depended on individual reporting practices as well as the geographical placement of departments. For example, health visitors reported lacking information on whether the woman had GDM in her latest pregnancy as the obstetric departments sometimes did not include it in the correspondence letter. Interacting with other HCPs encouraged coherent communication and awareness of other HCPs’ assignments. The diabetes nurse, midwives, and health visitors explicitly stated that they were unsatisfied with their communication with the GPs.
“My own doctor just said I have to avoid putting sugar in the coffee” [referring to a woman with GDM]. There is a big difference between what they get to know at their GP and what we do. So, we find that there are many practitioners who neglect that young fertile women may develop type 2 diabetes” (Diabetes Nurse, S)
”You have to keep the doctors in general practices’ on their toes. So, they [women with prior GDM] know what they have to go through. Then, the women would tell their doctors: ”Excuse me, but I haven’t received information about a glucose tolerance test”, or something like that” (Health visitor, C)
The lack of information would sometimes become clear to the GPs and health visitors in the consultations and during home visits after pregnancy, respectively, where the women often had to be the one to tell the GP and health visitor about their prior GDM diagnosis. However, GPs were not always provided with adequate information from the hospital about the latest pregnancy to better support and guide the women after a GDM diagnosis. Their understanding of how GDM affected new mothers was also reported to be poor compared to the other types of HCPs, suggesting that further education may be needed.
”I think what I need is a clearer handover of what the task is. What has been said in the diabetes or obstetric departments to these women? And then an early indication of how they should look after themselves and what is the appropriate way to follow up on that” (GP, Q)
It was essential for HCPs in the hospital to inform women about their future risk of diabetes. However, different communication forms across professions could cause the women to perceive their GDM diagnosis as either demanding a lot of changes in everyday life or amenable with just a few changes. For women with GDM who did not perceive the diagnosis to be of great importance, the diabetes nurse and obstetricians felt a need to change the woman’s perspective to ensure that the diagnosis was taken seriously. Various communication strategies across sectors and limited information flow between HCPs to secure optimal follow-up resulted in poor cross-sectoral collaboration. GPs reported that they were not provided with extensive guidance about how to address a woman’s GDM diagnosis after birth while health visitors experienced that women were uncertain about their future contact with the healthcare system. In particular, the health visitors who visited the women after delivery missed the opportunity to include GPs in re-structuring and aligning cross-sectoral communication practices.