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Perspectives on Prevention of Type 2 Diabetes After Gestational Diabetes: A Qualitative Study of Hispanic, African-American and White Women

Joyce W. Tang • Krys E. Foster • Javiera Pumarino •

Ronald T. Ackermann • Alan M. Peaceman •

Kenzie A. Cameron

Published online: 25 November 2014

� Springer Science+Business Media New York 2014

Abstract Women with gestational diabetes (GDM) have

a fivefold higher risk of developing type 2 diabetes

(T2DM). Furthermore, Hispanic and African-American

women are disproportionately affected by GDM, but their

views on prevention of T2DM after gestational diabetes are

largely unknown. We conducted semi-structured inter-

views with 23 women (8 Hispanic, 8 African-American, 7

non-Hispanic White) from two academic clinics in Chi-

cago, IL. Interview questions elicited perspectives on pre-

vention of T2DM; the interview protocol was developed

based on the Health Belief Model. Two investigators

applied template analysis to identify emergent themes.

Women conceptualized risk for T2DM based on family

history, health behaviors, and personal history of GDM. A

subgroup of women expressed uncertainty about how

GDM influences risk for T2DM. Women who described a

strong link between GDM and T2DM often viewed the

diagnosis as a cue to action for behavior change. T2DM

was widely viewed as a severe condition, and desire to

avoid T2DM was an important motivator for behavior

change. Children represented both a key motivator and

critical barrier to behavior change. Women viewed pre-

ventive care as important to alert them to potential health

concerns. Identified themes were congruent across racial/

ethnic groups. Diagnosis with GDM presents a potent

opportunity for engaging women in behavior change. To

fully harness the potential influence of this diagnosis,

healthcare providers should more clearly link the diagnosis

of GDM with risk for future T2DM, leverage women’s

focus on their children to motivate behavior change, and

provide support with behavior change during healthcare

visits in the postpartum period and beyond.

Keywords Gestational diabetes � Type 2 diabetes � Qualitative research � Risk perception � Barriers and motivators

Background

Gestational diabetes (GDM) affects approximately 4 % of

women [1], of whom an estimated 20–60 % will develop

type 2 diabetes (T2DM) within 5–10 years of initial diag-

nosis [2]. In addition, for women who become pregnant

again, their future offspring also may be adversely affected

if women enter a subsequent pregnancy with undiagnosed

T2DM or experience recurrent GDM [3–5]. Racial and

ethnic minorities are disproportionately affected by GDM:

the incidence of GDM among Hispanic women is 1.5 times

that of White women [6, 7]. While the incidence of GDM is

only marginally higher for African-American than for

White women, their rate of progression to T2DM is much

more rapid than for other racial/ethnic groups [8, 9]. Both

intensive lifestyle modification and use of metformin can

J. W. Tang (&) � J. Pumarino � R. T. Ackermann � K. A. Cameron

Division of General Internal Medicine and Geriatrics,

Feinberg School of Medicine, Northwestern University,

750 N. Lake Shore Drive, 10th floor, Chicago, IL 60611, USA

e-mail: [email protected]

K. E. Foster

Department of Family Medicine, Jefferson Medical College,

Philadelphia, PA, USA

A. M. Peaceman

School of Population and Public Health, University of British

Columbia, Vancouver, Canada

A. M. Peaceman

Department of Obstetrics and Gynecology, Feinberg School of

Medicine, Northwestern University, Chicago, IL, USA

123

Matern Child Health J (2015) 19:1526–1534

DOI 10.1007/s10995-014-1657-y

help prevent T2DM, but remain underutilized [10]. Prior

studies have demonstrated low participation rates in life-

style interventions during the postpartum period [11–13].

Willingness to engage in preventive behaviors may be

influenced by the perceived threat of T2DM, barriers and

motivators to making lifestyle changes, and the presence of

a cue to action [14–16]. Although several qualitative

studies have examined how postpartum women interpret

the impact of GDM on their future health, most of these

studies were conducted outside of the United States [16–

20]. Few studies have included African-American and

Hispanic women [15]. Because differences in health care

systems, cultural beliefs and community norms can influ-

ence risk perception and perceived motivators and barriers

to preventive health behaviors [21–24] we designed this

qualitative study to explore the perspectives of Hispanic,

African-American, and White women affected by GDM.

Our goal is for this work to inform the development of

effective approaches to engage diverse populations affec-

ted by GDM in taking steps to reduce their risk for T2DM.

Materials and Methods

Conceptual Framework

The study design was informed by the Health Belief Model

(HBM), which is a framework for understanding individual

perceptions that affect personal engagement in behavior

change [26, 27]. According to the HBM, individuals will

take action to improve their health if they think (1) they are

susceptible to the health threat, (2) the health threat has

serious consequences, (3) taking the action will decrease

their risk of developing the health threat, (4) benefits out-

weigh the barriers to taking action, and (5) a cue to action

exists [26, 27].

Sample and Recruitment

We conducted semi-structured, face-to-face interviews

with a purposive sample of women diagnosed with GDM,

with stratification across 3 racial/ethnic groups (African-

American, Hispanic, and non-Hispanic White). We started

with a goal of conducting 12 interviews total to identify

overarching common themes, as prior research has identi-

fied that 12 interviews often are adequate to achieve the-

matic saturation [28]. We chose to conduct additional

interviews to further explore if differences by race/ethnic-

ity emerged [28].

Participants were recruited from two academic clinics

affiliated with a women’s hospital in Chicago, Illinois.

Together, the clinics have a staff of 28 obstetrician/gyne-

cologists, 44 resident physicians, and a volume of 1,200

deliveries per year. The patient population served is eth-

nically and socioeconomically diverse: 50 % are African-

American or Hispanic; approximately 47 % have Medic-

aid. During the study period, the clinics utilized a universal

1-step screening protocol for GDM (2 h 75 g glucose tol-

erance test) [29]. Using this screening method, approxi-

mately 200 women were diagnosed with GDM per year.

Per clinic protocol, women identified with GDM were seen

by a nutritionist for at least one visit, and saw a nurse

practitioner every 2 weeks to discuss glucose control and

nutrition during their pregnancy. Women requiring medi-

cation for their GDM received insulin under the supervi-

sion of an endocrinologist.

Eligible participants were within 12 months of delivery at

the time of initial contact and spoke either English or

Spanish. A programmer analyst identified eligible patients at

each of the clinics through query of electronic health record

databases. Eligible women had a positive glucose tolerance

test result per the IADPSG guidelines: C1 abnormal value

on their 2 h (75 g) GTT obtained between 24 and 28 weeks

(i.e., fasting glucose C92 mg/dl, 1 h glucose C180 mg/dl or

2 h glucose C153 mg/dl). A research assistant contacted

potential participants by phone to assess their interest in

participation. We excluded participants who reported a

history of T2DM prior to their pregnancy or diagnosis with

T2DM subsequent to delivery. Patients also could self-

identify in response to a flyer in one of the obstetrics clinics.

This research was approved by the Northwestern University

Institutional Review Board.

Development of Interview Guide

A multidisciplinary research team, including 2 general

internists, an obstetrician/gynecologist, and a communica-

tion expert, devised a semi-structured interview guide (See

Appendix). Three team members had training and experi-

ence with qualitative research methods [30–33]. Interview

questions were designed based on the constructs of the

Health Belief Model to elicit perspectives relevant to

engagement in diabetes prevention behaviors (perceived

susceptibility to T2DM, perceived severity of GDM and

T2DM, motivators and barriers to improving lifestyle

behaviors, cue to action, see Appendix). Demographic

characteristics (age, race/ethnicity, education) were

obtained through self-report. The interview guide was

translated to Spanish by a bilingual research assistant.

Data Collection

A total of 23 interviews were conducted: we conducted an

additional 11 interviews following our initial 12 to explore

if racial/ethnic differences emerged. Analysis, as is com-

mon in qualitative research, was on-going, and upon

Matern Child Health J (2015) 19:1526–1534 1527

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reaching 23 interviews the team agreed that we had reached

thematic saturation of our data. The in-person interviews

were conducted either in the Division of General Internal

Medicine research office (n = 21) or in the home of the

participant (n = 2), and were led by either a bilingual

(English and Spanish) research assistant (JP) or an inves-

tigator (JT). Participants provided written, informed con-

sent. Interviews lasted approximately 30–60 min. Women

received $50 cash on completion of the interview.

Data Analysis

All interviews were digitally recorded and professionally

transcribed. Interviews conducted in Spanish (n = 2) were

translated to English. We conducted qualitative analysis

applying template analysis to code and organize themes

[34]. Template analysis provides a systematic process for

organizing important themes through use of a hierarchical

coding template, which has previously been applied in

qualitative healthcare research studies [35, 36]. Codes were

generated through two strategies. First, a limited set of

tentative a priori codes was developed by the study team

based on elements of the Health Belief Model (e.g., per-

ceived risk for T2DM). Second, additional codes were

added based on new ideas that emerged from review of the

transcripts. An initial coding template was developed after

reviewing an initial set of 5 transcripts (representing

women from each of the three racial/ethnic groups). This

coding template organized the codes within a hierarchical

structure under tentative overarching themes. Subse-

quently, two investigators independently applied the cod-

ing template to all 23 interviews, using NVivo 9 to

organize the data. We added additional codes as needed

when new ideas emerged. The template was iteratively

modified after reviewing subsequent transcripts to more

clearly reflect the relationships between the codes; all

discrepancies were resolved by consensus. The frequency

with which codes and themes were mentioned by unique

participants was also tabulated.

Results

Baseline Sample Characteristics

We completed interviews with 23 women [8 Hispanic (H),

8 African-American (AA), and 7 non-Hispanic White

(NHW)]. Twenty-two women were recruited via phone

outreach; 1 self-identified in response to a flyer. The

average age was 33.1 years (SD 6.0) (Table 1). Eighty-two

percent of the women had completed at least some college

education. Eight women (35 %) had two or more children.

One participant had previously been diagnosed with GDM.

Most women managed their GDM through diet only

(78 %); the remainder used insulin. Women completed

interviews on average 7 months after delivery (range

3–13 months). No significant differences in age or educa-

tion level emerged across racial/ethnic groups.

Perceived Susceptibility to T2DM

Women considered multiple factors in conceptualizing

their risk for T2DM, including both unmodifiable risk

factors (family history of T2DM [n = 18], personal history

of GDM [n = 14]), and modifiable risk factors (i.e.,

weight, current and future health behaviors [n = 20])

(Table 2). A subgroup of women expressed uncertainty

about the relationship between GDM and T2DM (n = 6).

These women expressed confusion about whether there

was an association, the magnitude of the association, and

the timing of the association. Half of the participants

(n = 12) described high risk for developing T2DM: ‘‘High,

very high, due to the fact that my father’s side has diabetes,

I obviously had the gestational diabetes so I am more at

high risk, and because I am overweight.’’ (33, H). Only 3

women felt their risk of T2DM was low: ‘‘I am confident.

Nobody in my family ever had it. I am a pretty active

person. I do not eat, how can I say, I think I eat pretty

healthy. I am not a big fan of fast food and things like that.

Table 1 Participant demographics (n = 23)

Age, mean (SD) 33.1 (5.9)

Race, n (%)

White 7 (30 %)

Black 8 (35 %)

Hispanic 8 (35 %)

Language, n (%)

English 21 (91 %)

Spanish 2 (9 %)

Education, n (%)

Less than high school 2 (9 %)

High school graduates 2 (9 %)

Some college 7 (30 %)

College graduates 12 (52 %)

Postpartum GTT obtained 16 (70 %)

Number of children

1 15 (65 %)

2 4 (17 %)

3 4 (17 %)

Previous GDM 1 (4 %)

Management of GDM

Diet 18 (78 %)

Insulin 5 (22 %)

Interviews were conducted on average 6.9 months after delivery

(range was from 3 to 13 months after delivery)

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Table 2 Key themes related to engaging women in type 2 diabetes prevention, based on the health belief model

HBM construct Theme Illustrative quotes Implications for future work

Perceived

susceptibility

Personal risk for

diabetes is

driven by…

Women attributed perceived risk for T2DM to

family history, health behaviors, and GDM.

Some women were unclear about the link

between GDM and T2DM

Due to women’s uncertainty related to the risk

of GDM leading to diabetes, healthcare

providers should provide clearer messages

about the degree to which GDM increases

women’s personal risk for T2DM and the

timeframe over which diabetes may develop

Health behaviors

(n = 20)

If I don’t change what I am doing now, I think I

will get it…Because I eat a lot of sweets… Chocolate donuts, coffee, chocolate (32 H)

Family history

(n = 18)

It’s still something that can occur because it is

something that is hereditary within my family.

It’sjustallamatterofwhenandwhatage(39AA)

GDM (n = 14) I am concerned about having diabetes in the

future. That is one of the risks for patients with

gestational diabetes (39 H)

Unclear how

GDM affects

risk for diabetes

(n = 6)

If I do get pregnant again, is there a chance,

what is the percent chance that I will get it

again? Does that affect me getting regular

diabetes? I just want to know if that has any

affect later on me having diabetes (28 NHW)

Perceived severity Diabetes is a

severe illness

(n = 11)

I don’t want my toes to get numb and have to be

cutoff. Just amounts of medications or just

even I think I ran into someone who was like

…I need to hurry up and get something sweet in my mouth because I am a diabetic and I

haven’t eaten anything and it was just like oh

my god, you know (40 AA)

Women already recognize the severity of

T2DM. Rather than attempting to increase

perceptions of severity of T2DM, healthcare

providers should focus on linking the

existence of GDM with personal risk of future

T2DM

Perceived benefits to

engaging in healthy

behaviors

Avoid diabetes

(n = 11)

I go running around the park… It is something I never ever did in my life and it is because of

that… It is just in my mind that I do not want to get diabetes in the long run (40 H)

When motivating women to engage in healthy

behaviors, healthcare providers should focus

not only on ability to avoid T2DM, but also

leverage women’s focus on their children. For

example, providers could emphasize the

importance of staying healthy to care for

children (long term benefit) and the potency of

role modeling (short term benefit)

Stay healthy to

care for

children

(n = 8)

I am definitely more worried about what my kids

eat than what I eat and so that always makes

me feel bad because then I think well no, I

want to be alive for my kids. I want to be

healthy for my kids (38 NHW)

Serve as a role

model for

children

(n = 5)

I don’t [change my eating habits] so much for

protecting me from getting diabetes; I do it so

that my son, as he is learning to eat, he learns

to eat healthier (39 AA)

Perceived barriers to

engaging in healthy

behaviors after

delivery

No time/lack of

childcare

(n = 11)

So the baby still gets up a bunch during the

middle of the night…then he needs to be cared for in the morning and then I go to work and

then he needs to be cared for and put to bed… I can’t leave the house with as much

flexibility…Time is the biggest barrier (35 NHW)

Physical activity that involves one’s child(ren)

or that could be done while at home may be

more effective in engaging women with GDM

Emotional

barriers to

accepting

childcare

(n = 8)

Now you see on the news that babysitters hurt

the baby, or the father hurts the baby. My

sister-in-law tells me to leave him with her,

but I can’t. I could have left him there now to

be here, but I can’t do it. I can’t explain it. If I

go to my brother’s house and his wife tells me

that she’ll take care of him, I’m always after

her checking on him. I think it’s normal for

first-time mothers to be afraid (25 H)

Lack of

motivation

(n = 10)

I am not motivated to do what I need to do and

that is my fault. I need to eat right and lose

weight. Slowly but surely I will but now I am

just not motivated to do it…I need someone there to help motivate me (33 AA)

Motivation is difficult to sustain. Strategies that

integrate social support (e.g., peer support

models) may be more effective in enhancing

motivation

Matern Child Health J (2015) 19:1526–1534 1529

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It is going to be hard to get it’’ (35, NHW). The remainder

of the women expressed uncertainty about their risk, using

terms such as ‘‘more at risk,’’ ‘‘probable,’’ ‘‘possible,’’ or

‘‘can occur.’’ Women were well aware that T2DM could be

prevented through lifestyle change (n = 20).

Perceived Severity of T2DM and GDM

Women perceived T2DM to be a severe condition

(n = 11), which could result in blindness or amputation,

and which reduced both lifespan and quality of life. Many

women described knowledge about T2DM in relation to

experiences with family members, spouses, or colleagues:

‘‘It is not a nice experience. It is not. I don’t want to be just

tired all the time and just in bed because that is how I also

see my family members, in bed, tired, don’t feel like doing

anything, you know, losing their eyesight’’ (40, H). Beyond

severity of the condition, women also mentioned signifi-

cant inconvenience in managing the condition, specifically

fear of needles or requiring insulin.

While women were familiar with T2DM and generally

felt T2DM to be a severe condition, women reported

having little understanding of GDM prior to diagnosis and

perceived severity of GDM was more variable. For many

participants, fear about serious consequences to the baby

was pervasive at the time of diagnosis (n = 19): ‘‘I was

scared for the baby’s sake… Are there any irreversible effects that I cost the baby?’’ (28, NHW). As the preg-

nancy progressed, many described eventual minimization

of the diagnosis because it was common, mild, easy to

control, and temporary (n = 10). As one woman stated,

‘‘A lot of people I talked to were like oh everybody gets it,

it’s 50/50 and if you get it is not a big thing’’ (39, AA).

Another woman described: ‘‘It is like a cold, but it lasts a

little bit longer because of the baby, but you stay on the

diet or take the medicine and you will be fine afterwards’’

(35, NHW).

Perceived Benefits to Health Behavior Change

Women described several motivations for improving their

health behaviors. These motivations included to avoid

T2DM (n = 11), to stay healthy to care for children

(n = 8), and to serve as a role model for their children

(n = 5): ‘‘You want to stay healthy, especially when you

are dealing with young kids or a new child. You want to be

there for your child. You don’t want to get sick. You don’t

want it to get worse. You don’t want them to start taking

care of you and have insulin and things like that, so it has

definitely changed’’ (40, AA).

While prevention of T2DM was a motivator for

behavior change, women did not spontaneously describe

prevention of GDM in a future pregnancy as a motivator.

When queried about ability to prevent GDM in the future,

many women described benefits to behavior change as

being limited to the time of a subsequent pregnancy

(n = 10), with fewer describing benefit to initiating pre-

ventive behaviors prior to a subsequent pregnancy.

Potential Barriers to Behavior Change

While children were an important motivator to behavior

change, they were also a key barrier to implementing

behavior change. Needing to care for their newborn child

and older children and lack of childcare took away time

from opportunities to exercise or plan meals (n = 11).

Although women desired assistance with child care, many

women expressed emotional barriers to accepting avail-

able child care options (n = 8). Some women described

lack of trust in non-familial caregivers or concern for

Table 2 continued

HBM construct Theme Illustrative quotes Implications for future work

Cue to action GDM as a cue to

action (n = 11)

Importance of

preventive care

visits (n = 19)

I think it was a wakeup call for me. I don’t want

to say it was a good thing, but it did kind of put

me into reality that I do have to have a

healthier lifestyle. I do have to eat better. I do

have to watch my carbs. It just kind of puts a

reality on you that you are not immune from it.

That you can get it. I did get it and so what am

I going to do about it and the information that I

learned. I have to move forward with it (28 H)

I have always been a person going to the doctor

on a schedule, like every six months…I want to make sure I am healthy, so the doctor visits

are very, very important, especially now at my

age moving forward (40 AA)

Many women view diagnosis with GDM as a

cue to take action to improve their lifestyle,

but this momentum is not always sustained

after delivery

Given that women value preventive care,

healthcare systems should consider developing

protocols to ensure women have or are

referred to a PCP and that appropriate handoff

(from OB/GYN to PCP) occurs after delivery

such that the focus on diabetes prevention can

be reinforced (i.e., repeated cues to action)

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overburdening relatives: ‘‘I don’t leave the children alone

with non-family members and so that is difficult because

if I am not exercising with them, with me, then I feel I

have really leaned on my mother a lot for sitting so I

don’t want to over-do it’’ (39, H). For other women, guilt

was a primary emotional barrier: ‘‘I don’t want to say that

exercising feels almost selfish. It feels like if it is taking

time. Either I have to get up at five o’clock and do it

before they wake up or it is taking time away that I could

be spending with them’’ (38, NHW). In addition to

childcare related barriers, women also acknowledged that

lack of motivation was an important to making behavior

changes (n = 10).

Cue to Action

Many women described the diagnosis and experience of

having GDM as a cue to take action to improve their health

behaviors (n = 11). These women tended to strongly link

GDM to future T2DM: ‘‘It made me become aware

because you know sometimes you may say ‘yeah it runs in

the family but I won’t get it.’ Then when they diagnosed

me I knew it was a possibility one day I can just have

diabetes so I have changed my eating habits’’ (33, AA).

Despite the importance of GDM as a cue to action, the

momentum created by the diagnosis was not always sus-

tained after delivery, as women became busy with taking

care of a new baby: ‘‘Right now I am just like whatever. It

is just me. I am not worrying about another human being in

my womb. It makes a big difference. Right now, I just need

to get energy to take care of this guy right here’’ (33,

NHW).

Nearly all women also noted preventive health care

visits were important to alert them to potential problems

with their health (n = 19): ‘‘If anything is wrong that I

don’t know about, you know, hopefully they will catch

anything I have in time that we can treat it. If I never go to

the doctor, you know, sometimes you can have something

wrong and feel fine and never know until is too late. This

way, if I do have something wrong, I can catch it in time or

prevent it’’ (28, NHW). Nearly all women (n = 21)

described plans to obtain follow-up care with a general

internist (n = 15) and/or an OB/GYN (n = 8).

Discussion

Within our ethnically diverse sample, the major themes

were remarkably congruent. Women conceptualized their

risk for T2DM in relation to family history of T2DM,

personal history of GDM, and their ongoing and future

health behaviors; a notable sub-group of women were

uncertain about the impact of GDM on future T2DM.

Diagnosis with GDM was perceived to be an important cue

to action for many women, but the momentum of behavior

change initiated during pregnancy was often not sustained.

While women perceived strong benefits to engaging in

healthy behaviors (avoid T2DM, stay healthy for children),

multiple barriers (no time/lack of child care, lack of

motivation) frequently precluded their ability to make

changes.

Perceptions of risk for T2DM were variable within our

sample, with about half perceiving high risk. While prior

survey-based studies in the United States and Australia

have shown that few women with GDM perceive high risk

for T2DM [14, 37], findings from qualitative studies have

been more mixed; some of the variability may relate to the

population studied and proximity to delivery [16, 17, 38].

Similar to prior studies, women in our study linked their

risk for T2DM to presence or absence of family history of

T2DM, their weight status, and current health habits [14,

39]. Our finding that a sub-group of women are uncertain

about the relationship between GDM and T2DM highlights

the need for clearer and ongoing communication in this

area. Healthcare providers should consider providing

messages that clearly describe the magnitude (i.e., fivefold

higher risk) and the timing of risk for T2DM (rare in the

immediate postpartum period, but high over the next

2–10 years).

While women generally perceived T2DM as a severe

illness, perceptions about the severity of GDM were more

variable. While it is expected that fear related to a new

diagnosis will decrease over time as individuals develop

new skills to manage a new diagnosis [17], the degree to

which women in our study minimized the diagnosis was

surprising. Women’s minimization of the diagnosis of GDM

have only been raised in one prior study, conducted among

women in Australia, in which women based such beliefs on

the evidence that their test results were borderline and their

blood sugars remained normal on subsequent evaluation

despite unchanged diet [20]. It is possible that we may have

seen more frequent minimization of GDM in our study

population as the use of a more sensitive screening test

(following IADPSG guidelines) for GDM led to identifica-

tion of a larger group of women with relatively mild (diet-

controlled) disease [40]. Further studies should assess the

prevalence with which women minimize risk and if mini-

mization of risk influences health behavior change during

pregnancy and after delivery (to prevent recurrent GDM).

The centrality of children in women’s lives as both a

prominent motivator and barrier to adopting healthy habits

has been well documented [16, 17, 41], and was a con-

sistent finding across our diverse sample. Healthcare pro-

viders should leverage women’s focus on their children,

using messages that emphasize the importance of staying

healthy to care for children (long term benefit) and the

Matern Child Health J (2015) 19:1526–1534 1531

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potency of role modeling healthy behaviors (short term

benefit). Our study highlighted also additional complexities

that should be considered in developing future preventive

interventions: despite the need for instrumental support

with childcare, women often faced emotional barriers to

accepting help with child care (mistrust, guilt). Such bar-

riers could make it difficult for women to participate in

intensive, group-based classes such as offered under the

Diabetes Prevention Program. Prior studies have described

low uptake and adherence in class-based interventions

among this population [42, 43]. In contrast, interventions

that could be done during flexible hours within the home

(e.g., delivered via the internet) may have higher uptake

among women with GDM. Physical activity that involves

one’s children may also be of interest to women.

While GDM represents a potentially important cue to

action, this momentum is often not sustained after delivery.

Given that women in our study planned to seek preventive

care and expected providers to alert them to potential

health concerns, healthcare settings appear to be a suitable

channel through which to engage women in preventive

behaviors. Prior studies conducted in England, Canada, and

Australia have described that women felt abandoned after

delivery due to the transition from close monitoring to

minimal contact in the postpartum period [16, 41, 44].

Ideally, healthcare systems might strengthen their role in

these areas by developing protocols to ensure women have

or are referred to a PCP, and that appropriate handoff (i.e.,

from OB/GYN to a PCP) occurs after delivery. This

handoff could help promote a consistent message in the

postpartum period regarding risk for T2DM (despite the

apparent resolution of GDM after delivery), improve

receipt of recommended follow-up glycemic testing, and

increase opportunities to activate and provide resources to

support behavior change.

The overall consistency in themes across racial/ethnic

groups in our sample was striking. One explanation for the

consistency in themes is that the universal challenges of

being the mother of a young child may have surpassed and

overwhelmed other lesser challenges, particularly in the first

year after a child’s birth. Second, many women across all

racial/ethnic groups had a family history of diabetes, and the

experiences of their family members were closely tied to

their perceptions about risk for diabetes, severity of diabetes,

and desire to avoid diabetes. Our results did not identify

unique experiences among African-American or Hispanic

that might impact behavior change, and do not support the

need for tailored approaches to engage African-American or

Hispanic women in behavior change for T2DM prevention.

There are several limitations to this study. First, it is

possible that our results may have been influenced by

selection bias. Women who participated in our study, as

compared with those who chose not to participate, may have

greater knowledge about GDM and T2DM, may be more

motivated to improve their health, may face fewer barriers to

behavior change, and may utilize healthcare more fre-

quently. However, we believe that our use of a proactive

outreach strategy for recruitment should have minimized

this bias. Second, because most women in our study were

able to control their GDM through dietary changes alone, it

is possible that the lower disease severity in our sample may

have increased the frequency with which women minimized

the diagnosis of GDM. Third, although the patient sample

was racially and ethnically diverse, the overall educational

level of the participants was very high. Women with lower

levels of education may have access to fewer resources and

may have different perspectives about their diagnosis and

future health risks. Fourth, our sample size may have been

insufficient to identify minor differences between the racial/

ethnic groups. However, given the striking concordance of

themes across our sample of 23, we feel this would be

unlikely [28]. Fifth, our study was focused more narrowly on

understanding individual level factors influencing behavior

change, and thus did not assess multiple, broader level

contextual factors influencing uptake of diabetes prevention

behaviors at the organizational, community and policy levels

[25].

Our study highlights several potential target areas for

future diabetes prevention interventions. Providers should

recognize that women may benefit from clearer messages

about the strong relationship between GDM and T2DM.

Women with GDM also may benefit from a more coordi-

nated healthcare response (i.e., involving OB/GYN provid-

ers as well as PCP’s) after delivery to ensure that women

and their providers fully engage in diabetes prevention.

Acknowledgments We would like to thank the patients and staff of the Prentice Ambulatory Clinic, the Northwestern Medical Faculty

Foundation Obstetrics and Gynecology Clinic, and the Northwestern

Memorial Physician’s Group Obstetrics and Gynecology clinic. Dr.

Tang was supported by a pilot grant through the Feinberg School of

Medicine Center for Equity in Clinical Preventive Services (a Center

of Excellence funded by the Agency of Healthcare Research and

Quality P01 HS021141, David W. Baker, PI). The funding agency

had no involvement in the design and conduct of the study; collection,

management, analysis, and interpretation of the data; and preparation,

review, or approval of the manuscript; and decision to submit the

manuscript for publication. A portion of these results were previously

presented at the 2013 SGIM National Meeting in Denver, CO.

Appendix: Health Beliefs and Lifestyle Behaviors

of Women Diagnosed with Gestational Diabetes

Patient Qualitative Interview Protocol

1. As you know, we are particularly interested in hearing

more about your experience with having gestational

1532 Matern Child Health J (2015) 19:1526–1534

123

diabetes during your recent pregnancy. Take me back

to when you first heard that you had gestational dia-

betes (during your recent pregnancy). Can you

describe how you found out that you had GDM?

2. Can you tell me about what that experience was like

for you?

3. How did you go about learning more about gestational

diabetes? Who are the main people you talked with to

find out more about gestational diabetes?

4. Can you tell me what questions you still have about

gestational diabetes?

5. How did having gestational diabetes affect your pregnancy?

6. How does having had gestational diabetes affect your

health now, if at all, after having your baby?

7. Did you get any testing for diabetes after delivering

your baby?

a. If no or unsure, were you given any information

about needing a test for diabetes?

i. If yes, can you tell me more about what may

have prevented you from getting testing?

b. If yes, what did it show?

8. How would you describe your chance of getting

gestational diabetes with a future pregnancy? Tell me

more, if you will, about your thinking on that.

a. Is there anything you can do to lower your chances

of getting gestational diabetes?

9. How would you describe your chance of getting

diabetes in the future? Tell me more, if you will, about

your thinking on that.

a. Is there anything you can do to lower your chances

of getting diabetes?

We’ve been talking about your experiences with having

had gestational diabetes. Next I’d like to ask you some

general questions about your current health.

10. Tell me about your most important health concerns

right now. Can you tell me more about that?

11. How important, if it all, is it for you to see a doctor

regularly for your health? Can you tell me more

about your thinking on that? Do you plan to see a

doctor for your health in the next year? Who do you

consider your primary doctor (e.g., obstetrician/

gynecologist, family medicine doctor, internist)?

12. How do you feel about your current level of

exercise? What would you like to be doing?

13. How do you feel about your diet?

14. How do you feel about your weight?

15. What are the biggest challenges you face to

exercising more? To improving your diet?

16. Who could help make it easier for you to exercise/eat

more healthily?

That covers the things I wanted to ask. Can you think of

anything else that I should have asked you, but didn’t think

to ask?

Before we finish, do you mind if I ask you… How would you describe your race or ethnicity?

How much schooling have you completed?

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