Policies and clinical practices relating to the management of gestational diabetes mellitus in the public health sector, South Africa – a qualitative study

Abstract

BackgroundWomen with a prior gestational diabetes have an increased lifetime risk of developing type 2 diabetes. Although post-partum follow-up for GDM women is essential to prevent progression to type 2 diabetes, it is poorly attended. The need for health systems interventions to support postpartum follow-up for GDM women is evident, but there is little knowledge of actual current practice. The aim of this study was to explore current policies and clinical practices relating to antenatal and post-natal care for women with GDM in South Africa, as well as health sector stakeholders’ perspectives on the barriers to -- and opportunities for -- delivering an integrated mother - baby health service that extends beyond the first week post-partum, to the infant’s first year of life.MethodsFollowing a document review of policy and clinical practice guidelines, in-depth interviews were conducted with 11 key informants who were key policy makers, health service managers and clinicians working in the public health services in South Africa’s two major cities (Johannesburg and Cape Town). Data were analysed using qualitative content analysis procedures.ResultsThe document review and interviews established that it is policy that health services adhere to international guidelines for GDM diagnosis and management, in addition to locally developed guidelines and protocols for clinical practice. All key informants confirmed that lack of postpartum follow-up for GDM women is a significant problem. Health systems barriers include fragmentation of care and the absence of standardised postnatal care for post-GDM women. Key informants also raised patient - related challenges including lack of perceived future risk of developing type 2 diabetes and non-attendance for postpartum follow up, as barriers to postnatal care for GDM women. All participants supported integrated primary health services but cautioned against overloading health workers.ConclusionAlthough there is alignment between international guidelines, local policy and reported clinical practice in the management of GDM, there is a gap in continuation of care in the postpartum period. Health systems interventions that support and facilitate active follow-up for women with prior GDM are needed if high rates of progression to type 2 diabetes are to be avoided.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3175-x) contains supplementary material, which is available to authorized users.

Public health system challenges in the Free State, South Africa: a situation appraisal to inform health system strengthening

“…In the current study, the public health system was providing poor quality of care and yielding poor health outcomes due mainly to weak leadership and fragmentation of services at the implementation level. Leadership deficits and fragmentation of public healthcare services has also been observed in other South African studies [46][47][48] and research in Gauteng [49] showed that approximately 75% of randomly-selected participants indicated that they were no longer utilising public healthcare services due to the perceived diminished quality of these services. Thereupon, the 2014 Statistics South Africa general household survey indicated though that most (69%) households have a preference for public clinics and hospitals facilities first followed by a private doctor (29%) whenever a member falls ill [50], p. 28.…”

Perspectives on the psychological and emotional burden of having gestational diabetes amongst low-income women in Cape Town, South Africa

“…Antenatal care for women with GDM at this hospital is intensive, highly structured and follows local and international (i.e. ; WHO and NICE) policy guidelines [21].…”

“…The perceived stress of effectively managing GDM through lifestyle change coupled with the fear of failure to achieve glycaemic control may trigger depressive symptoms [19]. The management of GDM is centred on glycaemic control to prevent adverse obstetric outcomes [20][21][22], while the potential impact of the diagnosis on women's psychological and emotional well-being is seldom considered in managing the condition.…”

Prevalence of and risk factors for gestational diabetes mellitus in South Africa

“…[39] In SA, pregnant women with GDM are referred to the nearest secondary or tertiary hospital for management and treatment. [40] At the tertiary level, management of GDM is through counselling and health education provided by obstetricians, endocrinologists, dieticians or nurse educators. The primary form of intervention for women with GDM is lifestyle modification, which involves counselling regarding diet and physical activity.…”

“…A dietary meal plan is provided, which entails reduced sugar and starch intake, increased protein intake and reduced total calorie intake. [40] However, in disadvantaged settings, these lifestyle changes are difficult to adhere to owing to the high cost of healthy food and lack of understanding and social support. A more sustainable approach is to counsel patients on how to reduce the glycaemic index of staple foods.…”