Benefits of Screening women for Diabetes after Delivery

SYNTHESIS
Gestational diabetes mellitus (GDM), glucose intolerance recognized during pregnancy, affects approximately 7% of all pregnancies in the United States. GDM, diagnosed by an abnormal oral glucose tolerance test (OGTT) done during the second trimester. Women diagnosed with GDM are at a high risk of developing type 2 diabetes, cardiovascular disease, and hypertension. With this prevalence, the American Diabetes Association (ADA) has recommended screening women with GDM 6-12 weeks after delivery, which roughly coincides with the timing of their first postpartum visit. For almost 90% of women diagnosed with GDM, glucose intolerance will resolve immediately after delivery, but their risk of developing type 2 diabetes mellitus is 35% to 60%. There is also a likelihood of the woman adversely affecting their future offspring when they become pregnant again with undiagnosed type 2 diabetes mellitus or they experience recurrent GDM. There is a need to analyze the factors contributing to and hinder women's screening during their postpartum visit. The literature review will be structured using identified variables to focus on the barriers, attitude, knowledge and awareness, and postpartum screening visits. These themes will establish the importance of screening for GDM during the postpartum visit and its impact on compliance with healthcare.
Synthesis of Literature
Postpartum Screening Visits
A majority of new mothers will not miss out on their first postpartum visit, which would be the opportune time for them to undergo GDM screening. As posited by Bandyopadhyay, Small, and Davey (2015), many women are aware of the risks and perceived inevitability of developing type 2 diabetes. Hence, they would be willing to present themselves for GDM screening during their 6-week postpartum visit. However, as Cho et al. (2015) noted, 51% of women who had been diagnosed with GDM failed to return to complete their postpartum glucose testing. Therefore, there is a need to determine the reasons for these high noncompliance numbers and determine ways of increasing compliance (Korpi-Hyövälti et al., 2012). Carson et al. (2015) established one of the reasons for noncompliance was directing the women to undergo testing at an outside laboratory instead of the same hospital where they are undergoing their postpartum visit. Having the women going to an outside laboratory becomes hectic, and most women will not present to the laboratory due to the time-consuming nature of the process. Considering the recommended screening time for GDM by the ADA is an arbitrary endpoint. Women diagnosed with GDM can be screened immediately after delivery and before their discharge as a way of increasing compliance with postpartum testing (Carter et al., 2018). Early testing increases the rates of tested women since the patients are relaxed and still in the hospital. With the initial postpartum OGTT results, patients can be informed of their abnormal results early, which would encourage them to come for their follow-up test during their first postpartum visit (Sunny et al., 2020).
Knowledge and Awareness
The underlying reason for the low numbers of women who return for GDM screening is the lack of knowledge and awareness. When the women are first diagnosed with GDM during their pregnancy, the physician will inform them of the need for a follow-up test after delivery (Carter et al., 2018). However, the way the information is shared might not be conducive, which limits patient knowledge and awareness of their condition. The knowledge and awareness are not only limited to patients but healthcare staff as well. As noted by Carson et al. (2015), many women will see a doctor within six months of them delivering, and even with a recent history of GDM, they will still not receive postpartum testing. Cho et al. (2015) support this finding, indicating women are less likely to receive postpartum testing when they visit private clinics and community clinics than those who visit hospital-based clinics. The researchers established the physicians seeing the women for their postpartum visit might not have access to the patient's antenatal records.
Rosenbloom and Blanchard (2018) established the need to increase providers' and patients' training to increase screening for diabetes among GDM patients. The researchers noted a general failure of compliance with diabetes screening recommendations made by physicians. The provider training level contributes to resident physicians being more likely to follow guidelines and orders for the postpartum screening test. Shah, Lipscombe, Feig, and Lowe (2011) have shown the patient's lack of knowledge to be a contributing factor. The failure to educate patients on the risk factors does play a massive role in reducing postpartum screening. Sunny et al. (2020) and Tang et al. (2015) indicate the importance of educating women as they have demonstrated women who have excellent knowledge about the risk of GDM were more likely to request and take up screening.
Barriers to Testing
Barriers faced by the women include the lack of time for the test, physicians not making the test request, being overwhelmed by the baby, and fear of a positive result. The recommended test is a 2-hour GTT postpartum screening test. The women have indicated they feel the test is too long, which was a huge deterrent for the women (Carson et al., 2015). Having a young baby and leaving the baby or going to the clinic with the baby and staying there for those extended periods was not favorable for most women (Sunny et al., 2020). The women have to choose between their health and caring for their young baby. In most cases, the women will opt to postpone the test, which results in them never taking the test as they continue to lack the time. Physicians have been a barrier too, numerous women have visited clinics multiple times, having been diagnosed with GDM, and they still did not get the test (Rosenbloom & Blanchard, 2018). Bandyopadhyay et al. (2015) found the physician's lack of information or the failure to hand over patient records to be the underlying cause of this issue. Korpi-Hyövälti et al. (2012) added communication needs to be improved between primary care physicians and obstetrics and gynecology care providers, ensuring patient information is appropriately shared and follow-up done.
New mothers feel overwhelmed by the baby, especially if they do not receive any support from family members. In most cases, the women did not have someone to leave the baby with, and the healthcare facility did not have baby care services (Cho et al., 2015). Mothers had to stay with the baby for the test's duration, which prevented many mothers from doing the test (Shah et al., 2011). The lack of assistance for the mothers in caring for the baby when they go for the test is a hindrance that echoed by Bandyopadhyay et al. (2015). Without any assistance or someone to leave the baby with, mothers get overwhelmed, preferring the comfort of their homes, instead, of spending extended hours in the hospital with a young baby. Sunny et al. (2020) and Man (2016) noted the fear of a positive result, where women would genuinely express, they feared being diagnosed with type 2 diabetes mellitus. Some mothers failed to undergo the testing as they were reluctant to find out if they had diabetes. The stigma associated with the diagnosis of diabetes was enough to discourage the mothers from undergoing the test.
Attitude
Compounded with the fear of receiving a positive result is the attitude some women have towards the disease. According to Bandyopadhyay et al. (2015), women who are in their twenties are highly likely to ignore recommendations for further screening as they would like to enjoy their life without any restrictions. The young women felt restricted during their pregnancy, and they did not want to continue with this restriction after delivery, contributing to them not wanting to know or worrying about type 2 diabetes mellitus (Carter et al., 2018). However, Man (2016) discovered that women with a more significant number of health visits are most likely to undergo postpartum screening. Their frequent interaction with healthcare professionals, which also increases their awareness of the disease and the need for testing, could be the reason.
There was a change in attitude amongst women with frequent health visits. With this information, Carter et al. (2018) pushed for early screening of the women. Screening after delivery and before leaving the hospital raises the patient's awareness of the condition and increases their likelihood of returning for their postpartum screening. Even with the women who would be willing to undergo the testing, some did not like the glucose syrup (Shah et al., 2011). After taking the OGTT during their pregnancy, some women would do anything to avoid retaking it. They stated the drink was too sweet and cannot drink water to reduce its sweetness. Tang et al. (2015) noted the best way to change the women's attitude is to link the diagnosis of GDM with the risk of developing type 2 diabetes mellitus and leverage the women's focus on their children to encourage them to change their behavior.

Synthesis Table

Postpartum Screening Visits
Knowledge and Awareness
Barriers to Testing
Attitude

Bandyopadhyay et al. (2015)
X

X
X

Carson et al. (2015)
X
X
X


Carter et al. (2018)
X
X

X

Cho et al. (2015)
X
X
X


Korpi-Hyövälti et al. (2012)
X

X


Man (2016)


X
X

Rosenbloom and Blanchard (2018)

X
X


Shah et al. (2011)

X
X


Sunny et al. (2020)
X
X
X
X

Tang et al. (2015)

X

X






References

Bandyopadhyay, M., Small, R., & Davey, M.-A. (2015). Attendance for postpartum glucose tolerance testing following gestational diabetes among South Asian women in Australia: A qualitative study. J Womens Health Issues Care, 4(1), 1-8.
Carson, M. P., Morgan, B., Gussman, D., Brown, M., Rothenberg, K., & Wisner, T. A. (2015). SUGAR: spotting undiagnosed glucose abnormal results—a new protocol to increase postpartum testing among women with gestational diabetes mellitus. American journal of perinatology, 32(03), 299-306.
Carter, E. B., Martin, S., Temming, L., Colditz, G., Macones, G. A., & Tuuli, M. G. (2018). Early versus 6–12 week postpartum glucose tolerance testing for women with gestational diabetes. Journal of Perinatology, 38(2), 118-121.
Cho, G. J., An, J.-J., Choi, S.-J., Oh, S.-y., Kwon, H.-S., Hong, S.-C., & Kwon, J.-Y. (2015). Postpartum glucose testing rates following gestational diabetes mellitus and factors affecting testing non-compliance from four tertiary centers in Korea. Journal of Korean medical science, 30(12), 1841-1846.
Korpi-Hyövälti, E., Laaksonen, D. E., Schwab, U., Heinonen, S., & Niskanen, L. (2012). How can we increase postpartum glucose screening in women at high risk for gestational diabetes mellitus? International journal of endocrinology, 2012.
Man, B. (2016). Diabetes Screening in US Women with a History of Gestational Diabetes. Division of Epidemiology and Biostatistics Michelle A. Kominiarek ….
Rosenbloom, J. I., & Blanchard, M. H. (2018). Compliance with postpartum diabetes screening recommendations for patients with gestational diabetes. Journal of women's health, 27(4), 498-502.
Shah, B., Lipscombe, L., Feig, D., & Lowe, J. (2011). Missed opportunities for type 2 diabetes testing following gestational diabetes: a population?based cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 118(12), 1484-1490.
Sunny, S. H., Malhotra, R., Ang, S. B., Lim, C. D., Tan, Y. A., Soh, Y. B., . . . Lock, S. S. (2020). Facilitators and Barriers to Post-partum Diabetes Screening Among Mothers With a History of Gestational Diabetes Mellitus–A Qualitative Study From Singapore. Frontiers in Endocrinology, 11.
Tang, J. W., Foster, K. E., Pumarino, J., Ackermann, R. T., Peaceman, A. M., & Cameron, K. A. (2015). Perspectives on prevention of type 2 diabetes after gestational diabetes: a qualitative study of Hispanic, African-American and White women. Maternal and child health journal, 19(7), 1526-1534.