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Identifying Postpartum Intervention Approaches to Reduce  Cardiometabolic Risk Among American Indian Women With Prior Gestational Diabetes, Oklahoma, 2012–2013

Emily J. Jones, PhD, RNC-OB; Michael Peercy, MPH, MT(ASCP)H; J. Cedric Woods, PhD; Stephany P. Parker, PhD; Teresa Jackson, MS, RD, LD; Sara A. Mata, PhD; Shondra McCage, MPH; Sue E. Levkoff, ScD, SM, MSW; Jacinda M. Nicklas, MD, MPH, MA; Ellen W. Seely, MD

Introduction Innovative approaches are needed to reduce cardiometabolic risk among American Indian women with a history of gestational diabetes. We assessed beliefs of Oklahoma American Indian women about preventing type 2 diabetes and cardiovascular disease after having gestational diabetes. We also assessed barriers and facilitators to healthy lifestyle changes postpartum and intervention approaches that facilitate participation in a postpartum lifestyle program.

Methods In partnership with a tribal health system, we conducted a mixedmethod study with American Indian women aged 19 to 45 years who had prior gestational diabetes, using questionnaires, focus groups, and individual interviews. Questionnaires were used to identify womens cardiometabolic risk perceptions and feasibility and acceptability of Internet or mobile phone technology for delivery of a postpartum lifestyle modification program. Focus groups and individual interviews were conducted to identify key perspectives and preferences related to a potential program.

Results Participants were 26 women, all of whom completed surveys; 11 women participated in focus group sessions, and 15 participated in individual interviews. Most women believed they would inevitably develop diabetes, cardiovascular disease, or both; however, they were optimistic that they could delay onset with lifestyle change. Most women expressed enthusiasm for a family focused, technology-based intervention that emphasizes the importance of delaying disease onset, provides motivation, and promotes accountability while accommodating womens competing priorities.

Conclusions Our findings suggest that an intervention that uses the Internet, text messaging, or both and that emphasizes the benefits of delaying disease onset should be tested as a novel, culturally relevant approach to reducing rates of diabetes.

A1c Testing May Fail to Spot Post Partum Diabetes Mellitus - This article originally posted 26 July, 2012 and appeared in Women's Health and OB-GYN Issue 636


Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial

Heather D. Clark, MD, MSc; Ian D. Graham, PhD; Alan Karovitch, MD, MEd; Erin J. Keely, MD. American Journal of Obstetrics & Gynecology JUNE 2009

OBJECTIVE: Women with previous gestational diabetes mellitus rarely receive the recommended 2-hour oral glucose tolerance test (OGTT) after delivery. We sought to determine whether postal reminders to be sent after delivery to a patient, her physician, or both would increase screening rates.
STUDY DESIGN: Patients were assigned randomly to 4 groups: reminders sent to both physician and patient, to physician but not patient, or to patient but not physician or no reminders were sent. The primary outcome was the proportion of patients who underwent an OGTT within 1 year after delivery. The secondary outcome was the
performance of other postpartum screening tests.
RESULTS: OGTT rates were significantly increased in the physician/patient reminder group (49/81 women; 60.5%), in the patient-only reminder group (42/76 women; 55.3%), and in the physician-only reminder group (16/31 women; 51.6%) compared with the no reminder group (5/35 women; 14.3%; P < .05).
CONCLUSION: Postpartum reminders greatly increased screening rates for women with gestational diabetes mellitus.


Gestational Diabetes Mellitus and Postpartum Care Practices of Nurse-Midwives.

Jean Y. Ko, PhD, Patricia M. Dietz, DrPH, Elizabeth J. Conrey, RD, PhD, Loren Rodgers, PhD, Cynthia Shellhaas, MD, MPH, Sherry L. Farr, PhD, Cheryl L. Robbins. 
J Midwifery Womens Health 2013;00:1–8. 

Postpartum screening for glucose intolerance among women with recent histories of gestational diabetes mellitus (GDM) is important for identifying women with continued glucose intolerance after birth, yet screening rates are suboptimal. In a thorough review of the literature, we found no studies of screening practices among certified nurse-midwives (CNMs). The objectives of our study were to estimate the prevalence of postpartum screening for abnormal glucose tolerance and related care by CNMs for women with recent histories of GDM and to identify strategies for improvement.
Methods: From October through December 2010, the Ohio Department of Health sent a survey by mail and Internet to all licensed CNMs practicing in Ohio. We calculated prevalence estimates for knowledge, attitudes, clinical practices, and behaviors related to postpartum diabetes screening. Chi-square statistics were used to assess differences in self-reported clinical behaviors by frequency of postpartum screening.
Results: Of the 146 CNMs who provided postpartum care and responded to the survey (62.2% response rate), 50.4% reported screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Of CNMs who screened postpartum, only 48.4% used fasting blood sugar or the 2-hour oral glucose tolerance test. Although 86.2% of all responding CNMs reported that they inform women with
recent histories of GDM of their increased risk for type 2 diabetes mellitus, only 63.1% counseled these women to exercise regularly and 23.3% reported referring overweight  / obese women to a diet support group or other nutrition counseling. CNMs reported that identification of community resources for lifestyle interventions and additional training in postpartum screening guidelines may help to improve postpartum care.
Discussion: CNMs in Ohio reported suboptimal levels of postpartum diabetes testing and use of a recommended postpartum test. Providing CNMs with additional training and identifying community resources to support needed lifestyle behavior change may improve care for women with recent GDM-affected pregnancies.

A system-based intervention to improve postpartum diabetes screening among women with gestational diabetes.

Vesco KK, Dietz PM, Bulkley J, et al.  Am J Obstet Gynecol 2012;207:283.e1-6.

OBJECTIVE: We sought to determine whether our process improvement program led to increased postpartum diabetes screening rates among women with gestational diabetes mellitus (GDM).
STUDY DESIGN: In early 2009, we conducted obstetrics department staff education sessions, revised GDM patient care protocols, and developed an electronic system to trigger reminder calls to patients who had not completed diabetes mellitus screening by 3 months postpartum. We then evaluated the rates of postpartum glucose test order entry and completion for women with GDM delivering from July 2009 through June 2010 (n =179) and July 2007 through June 2008 (n = 200).
RESULTS: After the program’s implementation, the proportion of women receiving an order for a postpartum glucose test within 3 months of delivery increased from 77.5-88.8% (P = .004), and test completion increased from 59.5-71.5% (hazard ratio, 1.37; 95% confidence interval, 1.07–1.75).
CONCLUSION: Rates of postpartum diabetes testing can be improved with system changes and reminders.


The effectiveness of implementing a reminder system into routine clinical practice: does it increase postpartum screening in women with gestational diabetes?

A.K. Shea, PhD, MSc; B.R. Shah, MD, PhD; H.D. Clark, MD, MSc; J. Malcolm, MD; M. Walker, MD, MSc; A. Karovitch, MD, MEd; E.J. Keely, MD                                                       

Vol 31, No 2, March 2011 – Chronic Diseases in Canada

Introduction: During regular care, women with previous gestational diabetes mellitus
(GDM) rarely receive the recommended screening test for type 2 diabetes, a 2-hour oral
glucose tolerance test (OGTT), in the postpartum period. The current study examined
whether the implementation of a reminder system improved screening rates.
Methods: Based on our previous randomized control trial, we implemented a postpartum reminder (letter or phone call) protocol into routine care at two of three clinical sites. We verified postpartum testing by searching hospital laboratory databases and by linking to the provincial physician service claims database. The primary outcome was the proportion of patients who underwent an OGTT within 6 months of delivery.
Results: Women who received care in a setting using a reminder system were more likely to receive an OGTT within 6 months postpartum (28%) compared with usual care (14%). The OGTT rates for both reminder groups were lower than that found in our randomized control trial (28% vs. 60%).
Conclusion: Although the screening rates remain low, postpartum reminders doubled
screening rates using the recommended test, the OGTT.

Patient counseling increases postpartum follow-up in women with gestational diabetes mellitus.

Marina Stasenko, BA; Jennifer Liddell, RN, CDE; Yvonne W. Cheng, MD, MPH; Teresa N. Sparks, MD; Molly Killion, RN; Aaron B. Caughey, MD, PhD.  American Journal of Obstetrics & Gynecology JUNE 2011

OBJECTIVE: The objective of the study was to evaluate the efficacy of an educational intervention at increasing the rates of postpartum (PP) follow-up for women with gestational diabetes mellitus (GDM).
STUDY DESIGN: A retrospective cohort study of all patients with GDM delivering during 2002-2009 was conducted. The primary outcome was obtaining PP diabetes testing. The 2002-2006 cohort was advised to obtain PP testing by their providers. The 2007-2009 cohort received educational counseling at the 37-38 week visit by a nurse educator. Univariate and multivariable statistical tests were utilized.
RESULTS: The PP testing frequency was 53% for the 2007-2009 cohort, compared with 33% for the 2002-2006 cohort (P < .001). When stratified by race/ethnicity, increased rates of testing were seen in whites (28% to 53%, P < .001), Latinas (15% to 50%, P < .001), and Asians (43% to 59%, P = .005). There was a nonsignificant decrease in the African American follow-up, 28% to 17% ( P = .414).
CONCLUSION: GDM precedes the development of type 2 diabetes. Antepartum education counseling increases postpartum diabetes testing. More efforts are needed to obtain universal screening.

Physician Care Patterns and Adherence to Postpartum Glucose Testing after Gestational Diabetes Mellitus in Oregon.

Monica L. Hunsberger, Rebecca J. Donatelle, Karen Lindsay, Kenneth D. Rosenberg

PLoS ONE 7(10): e47052. 

Objective: This study examines obstetrician/gynecologists and family medicine physicians’ reported care patterns, attitudes and beliefs and predictors of adherence to postpartum testing in women with a history of gestational diabetes mellitus.
Research Design and Methods: In November–December 2005, a mailed survey went to a random, cross-sectional sample of 683 Oregon licensed physicians in obstetrician / gynecologists and family medicine from a population of 2171.
Results: Routine postpartum glucose tolerance testing by both family physicians (19.3%) and obstetrician/gynecologists physicians (35.3%) was reportedly low among the 285 respondents (42% response rate). Factors associated with high adherence to postpartum testing included physician stated priority (OR 4.39, 95% CI: 1.69–7.94) and physician beliefs about norms or typical testing practices (OR 3.66, 95% CI: 1.65–11.69). Specialty, sex of physician, years of practice, location, type of practice, other attitudes and beliefs were not associated with postpartum glucose tolerance testing.
Conclusions: Postpartum glucose tolerance testing following a gestational diabetes mellitus pregnancy was not routinely practiced by responders to this survey. Our findings indicate that physician knowledge, attitudes and beliefs may in part explain suboptimal postpartum testing. Although guidelines for postpartum care are established, some physicians do not prioritize these guidelines in practice and do not believe postpartum testing is the norm among their peers.

Window of Opportunity: Postpartum Screening of Women with Gestational Diabetes for Early Detection of Prediabetes and Type 2 Diabetes.

Cassandra E. Henderson, Jan Kavookjian, Harris Leitstein, June M. McKoy, Wambui Jane Murage, and Ruth d. Lipman
The Open Diabetes Journal, 2012, 5, 25-28

Abstract: Gestational diabetes is a condition characterized by glucose intolerance during pregnancy, with defined approaches for screening, treatment, and follow-up. It is associated with a variety of adverse birth outcomes, including excessive fetal weight gain and related increases in the rate of cesarean delivery and perinatal injury as well as increased risk for developing type 2 diabetes for women who have had gestational diabetes. A diagnosis of gestational diabetes may also be a manifestation of pre-existing type 2 diabetes. Nonetheless, a substantial proportion of women with a history of gestational diabetes fail to receive the recommended postpartum glucose screening. This failure to conduct follow-up screening of women with gestational diabetes after delivery represents a missed opportunity for earlier diagnosis of diabetes, and chance to increase the awareness of women of their future risk for developing diabetes. This paper explores the barriers contributing to the lack in follow-up screening and makes recommendations about addressing these problems.

Prevention of Diabetes after Gestational Diabetes: Better Translation of Nutrition and Lifestyle Messages Needed

Sharleen L. O’Reilly, Centre for Physical Activity and Nutrition Research, Deakin University, 221 Burwood Highway, Burwood, Victoria 3125, Australia; E-Mail:; Tel.: +61-3-9244-6778; Fax: +61-3-9244-4219. External Editor: Samir Samman and Ian Darnton-Hill.  Received: 28 July 2014; in revised form: 14 October 2014 / Accepted: 10 November 2014 / Published: 21 November 2014

Abstract: Type 2 Diabetes Mellitus (T2DM) and Gestational Diabetes (GDM) are important and escalating problems worldwide. GDM increases the risk of complications in pregnancy and birth, as well as a 1 in 2 chance of developing T2DM later in life. The burden of GDM extends to offspring, who have an increased risk of obesity and diabetes—further perpetuating the cycle of diabetes within families. Clinical trial evidence demonstrates T2DM incidence reduced by up to 50% for women with GDM with nutrition and physical activity changes and the economic modeling suggests cost effectiveness. The key diet-related changes to reduce T2DM risk are reviewed, in addition to breastfeeding. The difficulties associated with the delivery of dietary and lifestyle behaviour change to women after GDM are discussed and focus on: complex healthcare system interactions needed for care delivery; women finding postpartum self-care challenging; and low levels of awareness being present across the board. In addition, studies currently underway to improve care provision in this important area will be examined.

Primary Care of Women after Diabetes Mellitus: mapping the evidence–practice gap


Wilkinson SA, Brodribb WE, Upham S, Janamian T, Nicholson C, Jackson CL.

MJA 201 (3) · 4 August 2014  Online first 21/07/14


Objective: To determine the extent to which preventive activities, including the ordering of an oral glucose tolerance test (OGTT) between 6 and 12 weeks of birth, are integrated into women’s primary care postpartum visits after a gestational diabetes mellitus (GDM)-affected pregnancy.

Design and setting: Prospective survey and retrospective chart audit of general practices that provide maternity shared care in south-east Queensland, July 2011 to June 2012. Participants: General practitioners (n = 38) and medical records of women to whom they provided care (n = 43 women). Main outcome measures: GPs’ awareness and knowledge of GDM guidelines and delivery of postpartum preventive care.

Results: The response rate for the survey/chart audit was 47%. All respondents recommended an OGTT between 6 and 12 weeks; a variety of guidelines informed practice; and weight, blood pressure and infant feeding practices were regularly checked. Mental health status and diet and exercise were discussed less consistently.

Conclusions: GPs surveyed knew guidelines around the timing and type of test for women who have experienced GDM, and the audit   demonstrated that this knowledge is translated into practice. Adherence to preventive screening and advice was less consistent. This problem may exist due to the absence of a systems approach to care, resulting in a lost opportunity to systematically reduce the incidence of type 2 diabetes and promote the wellbeing of women and their infants.


Low Rates of Postpartum Glucose Screening Among Indigenous and non-Indigenous Women in Australia with Gestational Diabetes.

Chamberlain C, McLean A, Oats J, Oldenburg B, Eades S, Sinha A, Wolfe R. Matern Child Health J. 2014 Jul 1. [Epub ahead of print]

Women with gestational diabetes have a high risk of type 2 diabetes postpartum, with Indigenous women particularly affected. This study reports postpartum diabetes screening rates among Indigenous and non-Indigenous women with gestational diabetes, in Far North Queensland, Australia. Retrospective study including 1,012 women with gestational diabetes giving birth at a regional hospital from 1/1/2004 to 31/12/2010. Data were linked between hospital records, midwives perinatal data, and laboratory results, then analyzed using survival analysis and logistic regression. Indigenous women had significantly longer times to first oral glucose tolerance test (OGTT) [hazards ratio (HR) 0.62, 95 % confidence interval (CI) 0.48-0.79, p < 0.0001) and 'any' postpartum glucose test (HR 0.81, 95 % CI 0.67-0.98, p = 0.03], compared to non-Indigenous women. Postpartum screening rates among all women were low. However, early OGTT screening rates (<6 months) were significantly lower among Indigenous women (13.6 vs. 28.3 %, p < 0.0001), leading to a persistent gap in cumulative postpartum screening rates. By 3 years postpartum, cumulative rates of receiving an OGTT, were 24.6 % (95 % CI 19.9-30.2 %) and 34.1 % (95 % CI 30.6-38.0 %) among Indigenous and non-Indigenous women, respectively. Excluding OGTTs in previous periods, few women received OGTTs at 6-24 months (7.8 vs. 6.7 %) or 2-4 years (5.2 vs. %), among Indigenous and non-Indigenous women, respectively. Low rates of postpartum diabetes screening demonstrate that essential 'ongoing management' and 'equity' criteria for population-based screening for gestational diabetes are not being met; particularly among Indigenous women, for whom recent guideline changes have specific implications. Strategies to improve postpartum screening after gestational diabetes are urgently needed.


Reminder systems for women with previous gestational diabetes mellitus to increase uptake of testing for type 2 diabetes or impaired glucose tolerance.

Middleton P, Crowther CA.  ARCH: Australian Research Centre for Health of Women and Babies, The Robinson Institute, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Women's and Children's Hospital, 72 King William Road, Adelaide, South Australia, Australia, 5006. Cochrane Database Syst Rev. 2014 Mar 18;3:CD009578.

BACKGROUND: The early postpartum period is an important time in which to identify the risk of diabetes in women with a history of gestational diabetes mellitus (GDM). Oral glucose tolerance and other tests can help guide lifestyle management and monitoring to reduce the future risk of type 2 diabetes mellitus.
OBJECTIVES: To assess whether reminder systems increase the uptake of testing for type 2 diabetes or impaired glucose tolerance in women with a history of GDM.
RESEARCH METHODS: We searched MEDLINE and EMBASE (last searched 1 June 2013) and The Cochrane Library (last searched April 2013).
SELECTION CRITERIA: We included randomised trials of women who had experienced GDM in the index pregnancy and who were then sent any modality of reminder (or control) to complete a test for type 2 diabetes after giving birth.
DATA COLLECTION AND ANALYSIS: Two authors independently screened titles and abstracts for relevance. One author extracted the data, carried out 'Risk of bias' assessments and evaluated the overall study quality according to GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria; the other author double-checked these procedures. Meta-analysis was not possible as only one study was eligible for inclusion.


Risk factors for poor compliance with postpartum oral glucose tolerance testing in women with gestational diabetes mellitus.

Amorosa JM, Do S, Son M, Gilroy L, Gyamfi Bannerman C. Obstet Gynecol. 2014 May;123 Suppl 1:135S.
INTRODUCTION: Women with gestational diabetes mellitus (GDM) are at increased risk to develop overt diabetes; however, compliance with the postpartum 75-g oral glucose tolerance test (OGTT) is poor. We assessed rates of postpartum OGTT compliance at our institution and identified risk factors for the suspected poor compliance.
METHODS: We performed a retrospective cohort study of singleton pregnancies with GDM who delivered at Columbia University Medical Center in 2011. Women were identified from institutional databases; data were abstracted from electronic medical records. Women with postpartum OGTT testing were compared with women without, and characteristics of these two groups-insurance status, parity, race, body mass index, and a history of prior GDM-were compared using χ, Fisher's exact test, and Student's t test where appropriate. We also examined causes for noncompliance.
RESULTS: Of the 6,272 women identified, 235 patients had GDM (4%). Of those, 21% had a postpartum OGTT (n=50). When compliant and noncompliant patients were compared, no significant differences existed in insurance status, age, race, parity, body mass index, or history of GDM. Privately insured patients were more likely to attend their postpartum visit than publicly insured patients (94% compared with 82%, P=.01). Patients who attended their postpartum visit were ordered for (63% compared with 53%, P=.19) and obtained postpartum OGTT (29% compared with 22%, P=.31) at similar rates.
CONCLUSIONS: Compliance rates for postpartum diabetes testing are low. Regardless of compliance, the majority of women attended their postpartum visit; however, they were either not ordered a postpartum OGTT or failed to obtain it. These data are useful to develop a program targeting methods to increase compliance.

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