Between 10% and 31% of type 2 diabetes (T2DM) cases among women are reported to be associated with previous gestational diabetes mellitus (GDM), and the risk of developing T2DM is increased more than 7 fold for women who had GDM compared to those without [1, 2]. The national prevalence of gestational diabetes (GDM) in South Africa was estimated at 9.1% in a 2018 study . The authors of the study warned of subsequent Type 2 diabetes (T2DM) for these women and their children along with complications, reduced longevity and impacts on the national health system .
The first step towards optimal management of GDM and prevention or delay of subsequent T2DM is diagnosis. GDM screening for all pregnant women has therefore been recommended by several professional bodies [4, 5]. Currently, only a minority of women get screened worldwide for GDM , using many GDM testing and diagnostic criteria that have not been standardised despite efforts to do so  (See Table 1 for different GDM diagnostic criteria).
|DIFFERENT DIAGNOSTIC CRITERIA TO DIAGNOSE GDM|
|GROUP/ORGANISATION||SCREENING TEST||DIAGNOSTIC CRITERIA: BLOOD GLUCOSE LEVEL THRESHOLDS|
|American Diabetes Association [6, 7]||One step: 2 hr 75 g OGTT||At least one of the following must be met:
Fasting: ≥5.1 mmol/l (92 mg/dl)
1 hr: ≥10.0 mmol/l (180 mg/dl)
2 hr: ≥8.5 mmol/l (153 mg/dl)
|OR Two step:
1) 1 hr 50 g (non-fasting) screen
2) 3 hr 100 g OGTT
If 1 hr: ≥10.0 mmol/l (180 mg/dl) proceed with step 2
3 hr: ≥7.8 mmol/l (140 mg/dl)
|Carpenter and Coustan ||3 hr 100 g OGTT||At least two of the following must be met:
Fasting: ≥5.3 mmol/l (95.4 mg/dl)
1 hr: ≥10.0 mmol/l (180 mg/dl)
2 hr: ≥8.6 mmol/l (154.8 mg/dl)
3 hr: ≥7.8 mmol/l (140 mg/dl)
|Diabetes Pregnancy Study Group (DPSG) of the European Association for the Study of Diabetes (EASD) ||2 hr 75 g OGTT||Fasting: >5.2 mmol/l (93.6 mg/dl)
2 hr: >9.0 mmol/l (162 mg/dl)
|International Association of Diabetes and Pregnancy Study Groups (IADPSG) ||2 hr 75 g OGTT||At least one of the following must be met:
Fasting: ≥5.1 mmol/l (92 mg/dl)
1 hr: ≥10.0 mmol/l (180 mg/dl)
2 hr: ≥8.5 mmol/l (153 mg/dl)
|National Diabetes Data Group (NDDG) (1979) ||3 hr 100 g OGTT||At least two of the following must be met:
Fasting: ≥5.8 mmol/l (105 mg/dl)
1 hr: ≥10.6 mmol/l (190 mg/dl)
2 hr: ≥9.2 mmol/l (165 mg/dl)
3 hr: ≥8.0 mmol/l (145 mg/dl)
|World Health Organisation (1985) ||2 hr 75 g OGTT||Fasting: ≥7.8 mmol/l (140 mg/dl)
2 hr: ≥7.8 mmol/l (140 mg/dl)
|World Health Organisation (1999) ||2 hr 75 g OGTT||Fasting: ≥7.0 mmol/l (126 mg/dl)
2 hr: ≥7.8 mmol/l (140 mg/dl)
|World Health Organisation (2013) ||2 hr 75 g OGTT||At least one of the following must be met:
Fasting: 5.1–6.9 mmol/l (92–125 mg/dl)
1 hr: ≥10.0 mmol/l (180 mg/dl)
2 hr: 8.5–11.0 mmol/l (153–199 mg/dl)
While necessary, screening and diagnosis alone are insufficient. Better follow up of women with GDM in order to reduce the risks of developing T2DM requires better coordination between antenatal and postnatal care [15, 16]. Ideally, this could be achieved through integrated services for all conditions, or which tackle specific diseases and populations – notably the post-partum care of women’s obstetric and other health care needs, and the care of infants and children. Therefore, such strategy would be feasible with an approach integrating prevention, diagnosis, treatment, and palliative care for all conditions that could be managed within PHC .
In South Africa, women are screened for GDM based on risk factors, as one element of ante-natal care (ANC) [18, 19, 20]. Women diagnosed with GDM are then referred to tertiary hospitals for their pregnancy follow-up and delivery, but only a small proportion of these women return for postpartum assessment, including an oral glucose tolerance test (OGTT), and management [21, 22]. This gap between antenatal care and postnatal follow-up is being investigated in high income settings where many women report intentions to change their lifestyle post GDM to prevent T2DM onset, even though they find it challenging [15, 23]. There is little evidence from low and middle-income countries like South Africa on actual implementation of guidelines, nor of the feasibility and acceptability of potential strategies to improve continuity and integration of care for women who have had GDM .
In contrast to the very low levels of routine post-partum glucose assessment following a GDM pregnancy , women in South Africa routinely bring their newborns and infants to clinics for immunization and well-baby care [25, 26]. Integrating GDM care and prevention of T2DM post GDM within primary health care (PHC) in South Africa would facilitate women’s access to services in one place. This would decrease the burden of navigating a fragmented health system for their own care and the care of their babies. In recognition of this fragmentation of care in South Africa, experts have called for integrated health systems and services that are easy for patients to navigate .
This study explored women’s perspectives and knowledge of their own GDM and post-partum care, as well as the perspectives of health care providers, in order to assess both the current degree of integration of GDM screening and prevention of T2DM post-GDM within routine, community-based primary health care (PHC) services in South Africa. The perceived acceptability and feasibility of greater integration of these critical aspects of women’s health care to these key stakeholders were also explored.
The Behaviour Change Wheel (BCW) framework  (Figure 1), was used for this study. BCW has been effectively applied to planning and evaluating interventions targeting individuals, groups, programmes and behaviours [29, 30]. While motivation, capability and opportunity from the model’s inner circle are seen as the enablers for both individual and collective behaviour change, they must be assessed in relation to programme implementation, its mechanism and context [31, 32]. In this study, the BCW was used to understand the policies, practices and barriers to change among health workers and women.
This study contributes to the process evaluation of an ongoing complex intervention implementation research project, IINDIAGO (an Integrated health system Intervention aimed at reducing type 2 Diabetes risk in women after Gestational diabetes in South Africa, Trial ID: PACTR201805003336174), which aims to integrate improved post-partum follow up for women with GDM into PHC and thus contribute to T2DM prevention in two South African cities: Cape Town, Western Cape province and Soweto township in Johannesburg, Gauteng province). The IINDIAGO trial was in the recruitment stage among women from disadvantaged communities in Cape Town and Soweto, South Africa, when data were collected for this nested study. Data collection was conducted among women who attended Groote Schuur Hospital (GSH) and health care providers in health care facilities within the public health care system in the Western Cape province. Western Cape serves its population primarily through a network of clinics providing PHC services and serving as the entry point into the health care system, including two central, tertiary university teaching hospitals, an obstetrics referral hospital and one specialized pediatric hospital (Tygerberg Hospital, GSH, Mowbray Maternity Hospital and Red Cross War Memorial Children’s Hospital) for specialist services . PHC services in the Western Cape province are managed by two separate health authorities, Municipal City Health (in the Cape Metro Health District) and provincial Department of Health (DoH). Most district facilities are managed by the provincial DoH. The exception is Cape Metro Health District, which is managed by both City Health and provincial DoH. The Western Cape Province has 479 public PHC centres and these include clinics, of which some mobile and satellite clinics are under the authority of City Health. The provincial DoH manages Community Day Centres and Community Health Centres. All these clinics refer patients to the district provincially aided, regional, specialist and tertiary hospitals available in different parts of the province . Health care providers who participated in the study were recruited from some of these clinics.
The data sources included: Firstly, semi-structured in-depth qualitative interviews with key informants (KIs) (N = 5) and health care providers (HCPs) (N = 18). Secondly, focus group discussions (FGDs) with women diagnosed with GDM (N = 35 women in 4 FGDs) and community health workers (CHWs) (N = 15 CHWs in 2 FGDs). Additionally, exit interview questionnaires with the 35 women who participated in FGDs for further exploration of associations between qualitative variables.
The KIs included researchers, policy makers and clinicians who have been involved in DM policies and care, especially for GDM and T2DM, at national and provincial levels. They were interviewed about GDM policies and their experiences and perspectives on integrated GDM screening and T2DM prevention within PHC services. HCPs included managers, nurses or midwives from the public health sector in Cape Town (WC province), South Africa. They were interviewed about their practices or processes for GDM screening and care in facilities, including referral pathways. Drawn from these same local facilities, CHWs were recruited to FGDs to share their experiences and roles working with patients including those who had GDM and T2DM. Women with GDM referred by different clinics in Cape Town and attending GSH for their GDM follow-up and delivery, were identified from hospital records, contacted and recruited to participate in the FGDs and share their GDM knowledge and the challenges they face while seeking care. These women also completed the brief exit interviews using questionnaires, regarding their background and on how their own GDM is being managed. These datasets were used to measure the correlation between qualitative variables. All research participants discussed their views of whether and how integrated health services such as those proposed in the IINDIAGO trial could help with GDM screening and initiatives for T2DM prevention among women in SA.
Participants aged more than 18 years without any cognitive disabilities were included in this study. All were able to communicate in English. In cases of women with GDM and CHWs who did not speak English well, participants were encouraged to express themselves in isiXhosa or Afrikaans and their responses were contemporaneously translated into English by the research assistant who was fluent in these local languages. The KIs and HCPs were offered no compensation upon completion of interviews. Women with GDM who participated in this study were provided with a R100 ZAR (around $7 USD) voucher while CHWs shared refreshments after FGDs. Fieldwork and data collection were conducted between March, 2018 and August, 2018.
Beginning with two experts recommended by the IINDIAGO principal investigators, sequential referral snowball sampling  was used to identify and recruit other KIs, who were then approached and recruited for this study. Criterion sampling [37, 38] was used to identify all other respondents depending on their occupations or their GDM diagnosis and referral to GSH. Managers and nurses or midwives involved in GDM screening at the clinics, CHWs who (in coordination with the local facilities) deliver services to women with different health problems in the community and assist at the clinics when called upon, were selected using this sampling strategy.
Interview/FGD guides and exit interview questionnaires were respectively used as tools to collect qualitative and quantitative data. KIs were interviewed in their offices at the hospital, clinic or research facilities. The two FGDs conducted with CHWs were organised in collaboration with the two local clinics with which they were affiliated. The four patient FGDs included 6-10 women diagnosed with GDM and receiving care at GSH (N = 35), followed by individual exit interview questionnaires that took place in a room provided by the maternity ward at GSH. All interviews and FGDs were conducted by a trained researcher (JCM), assisted by a trained research assistant (SK) fluent in local languages, under the supervision of experienced qualitative researchers (KM and CZ). The researcher (JCM) introduced himself as a doctoral student and briefly interacted with the participants about the study before commencing the interviews and FGDs. Interviews with HCPs and FGDs with CHWs took place at the clinics, in their clinic offices for HCPs and in the rooms provided by the local clinics for CHWs. Each interview lasted between 30 and 45 minutes. FGDs lasted between 45 minutes and 1 hour. The Exit interviews lasted between 10 and 15 minutes. All interviews and FGDs were audio recorded and ATLAS.ti software was used to assist data analysis and management.
The interviews and FGDs were transcribed and a coding system was developed by JCM in collaboration with CZ using an inductive/deductive approach. All discrepancies in the coding process were discussed and resolved between these two investigators. Thematic analysis was generally used but content analysis was applied on a few occasions in order to check the frequency of important codes [39, 40]. For statistical analysis of the 35 exit interviews questionnaires, categorical variables were summarized using absolute frequencies and relative frequencies. Continuous variables were synthesized using central trend statistics (mean, median) and dispersion statistics (standard deviation (SD), interquartile range (IQR)). Qualitative variables were four advices for women (improve diet, reduce sugar intake, physical exercise and regularly take prescribed medication) to improve their GDM and prevent T2DM and Nurse’s concerns about health of these women. The correlation between these qualitative variables measured using Cramér’s V coefficient which is interpreted as follows: from 0.0 to <0.1 negligible association, from ≥0.1 to <0.3 weak association, from ≥0.3 to <0.5 moderate association and ≥0.5 strong association .
This analysis has also contributed to the ongoing process evaluation of the IINDIAGO study.
Ethical approval was obtained from the Human Research Ethics Committee, Faculty of Health Sciences, University of Cape Town (HREC REF: 946/2014), the City Health Department, Cape Town and the Department of Health, Western Cape, South Africa; and comité d’éthique de la recherche en sciences et en santé (CERSES), Université de Montréal (CERSES-19-058-D), Canada. Written consent was given for all interviews and the anonymity of participants was maintained throughout the research process.
In total, 73 individuals participated in this study. Participants in the in-depth individual interviews (N = 23), included 4 (17%) clinic managers and 14 (61%) nurses and midwives and 5 expert KIs (22%). Of these 23 respondents, 19 (83%) were female, with a mean age (SD) of 42.7 (SD 10.6) years and 16.1 (SD 11.0) years of experience in health care (see Table 2). Participants in FGDs (N = 50) included women with GDM and CHWs and were all female.
|Age (in years)||mean (SD)||42.7 (10.6)|
|median (IQR)||41.0 (35.0, 47.0)|
|Experience (in years)||mean (SD)||16.1 (11.0)|
|median (IQR)||12.0 (7.0, 23.0)|
|Category||Clinic managers||4 (17%)|
|Nurses and midwives||14 (61%)|
The four thematic categories that emerged from the analysed data were interpreted using three BCW layers from outer to inner: policy categories, intervention functions and sources of behaviour respectively. Each category was linked to a specific layer except the third and the fourth categories that were classified using the same “inner” layer (See Table 3).
|CATEGORY||BCW LAYER AND MAIN CONTENT, FROM OUTER TO INNER|
|I. Existing guidelines, services and current practices in the clinics||Outer layer: policy categories|
|II. Effective antenatal referral procedures but lack of follow-up after delivery||Middle layer: intervention functions|
|III. IINDIAGO, an intervention with potential to bridge the gaps||Inner layer: sources of behaviour|
|IV. Encouraged role of CHWs involvement toward community based T2DM prevention intervention||Inner layer: sources of behaviour|
Each category had different themes with each illustrated by a single quote from one of the participant groups. More illustrative quotes from various participants are depicted in Table 4.
|KEY FINDINGS AND ILLUSTRATIVE QUOTES|
|Category 1: Existing guidelines, services and current practices in the clinics|
|Category 2: Effective antenatal referral procedures but lack of follow-up after delivery|
|Category 3: IINDIAGO, an intervention with potential to bridge the gaps|
|Category 4: Encouraged role of CHWs involvement toward community based T2DM prevention intervention|
The BCW’s policy categories or outer layer  was used to assess the process of policy development, analyse its implementation and interpret insights from the KIs and the HCPs regarding the existing guidelines, services and current practices in the clinics regarding GDM screening, care and post-partum T2DM prevention initiatives. Perspectives and experiences of CHWs and women who participated in FGDs mostly referred to services they received and the practices in the clinics they attended. The results for this thematic category were subsequently grouped into 3 headings: 1. Current GDM screening/care guidelines and their implementation; 2. From no testing to risk-based screening of GDM; and 3. Barriers to GDM screening in PHC.
Both National and Western Cape departments of health introduced guidelines developed by experts based on international protocols to screen, diagnose and treat GDM , in all public health facilities. However, challenges arise in the implementation of these guidelines at local facilities. While discussing how GDM is diagnosed within ANC, KIs and HCPs reported that GDM screening guidelines have been poorly implemented at primary care level, resulting in missing some women with potential GDM.
“We have screening protocols, and the South African Endocrinology Society has put out screening guidelines [for GDM]. Unfortunately, I think our screening is poor. We don’t screen widely enough, and there are many risk factors that aren’t screened….”. KI1
Another implementation issue raised by participants related to counselling sessions regarding lifestyle changes to deal with diabetes and its devastating consequences. This included existing group counselling in ANC clinics and the individual and group sessions conducted through the IINDIAGO trial. Crowded clinics and inadequately equipped staff in some health settings were not conducive to effective group sessions and made individual counselling sessions almost impossible.
Based on the current guidelines, GDM screening was supposed to be included in all ANC services and uniformly conducted in all local facilities. However, clinics approach GDM screening for pregnant women in different ways; some only test urine and then refer those with glycosuria, while others conduct confirmatory blood glucose tests before referring women to the next level of care. HCPs emphasised that screening decisions depend on the HCP’s assessment of risk factors that women present with during their ANC visits. Thus, not all women who attend ANC are tested for GDM in all clinics despite the ANC guidelines.
“Firstly, I think I should explain that we are doing basic antenatal care. We then are taking care of women who don’t have any high risks, or just a normal pregnancy. If one is found to have sugar that is, glucose actually, that is evident in the urine, then we refer them, because we don’t even do them, the fasting stuff, so we will refer them to Gugulethu MOU, that’s where all the screening gets done. So, we take care of just the normal without any risk antenatal patients”. HCP 1.
The process of diabetes screening during pregnancy based on current guidelines in the local facilities in Cape Town is summarized in Figure 2. Referral starts from BANC, to Midwife and Obstetrics Units (MOU), to secondary level specialised maternity hospitals in case of impaired glucose tolerance (IGT – in which plasma glucose levels were above normal but below those defined as diabetes) [42, 43], to tertiary hospitals (GSH or Tygerberg hospital depending on jurisdiction of the MOU) for cases meeting local criteria for GDM.
“the procedure for screening, we’ve got a list of indications for doing Glucose Tolerance Test (GTT): family history of diabetes from her mother, her father or her siblings, BMI of 35 and above, history of big babies, persistent Glycosuria; for three consecutive visits. She has to come in the morning, fasting, her last meal the previous night around 10 o’clock. So, when she comes, we do the prick. If the sugar is 7 and above, we don’t continue, but if it is less than 7, we take the fasting blood and we give her 75 grams of glucose, and we take the second blood after two hours. So, they come after one week for the results. If it’s an IGT, we refer to Mowbray not Groote Schuur, but if it’s GDM, then we refer to Groote Schuur”. HCP 2.
Respondents identified several barriers to screening. First of all, socio-economic factors impede the timely access of many women to BANC and to GDM screening. Secondly, some may be diagnosed late when symptoms or consequences of GDM are already present; this becomes a reason for immediate referral to the hospital for follow-up. Thirdly, there is no way to identify and screen some women as they do not attend ANC at the clinics at all. Fourthly, as many women, like other patients, do not know or suspect that they might have diabetes, they do not proactively seek any screening during their pregnancy or clinic visits, which is why the provincial guidelines mandate that screening be initiated by the provider. Finally, lack of time due to work overload, shortage or ineffective utilisation of key equipment and other resources for GDM screening, and poor communication between facilities, were also included among other documented health system issues preventing consistent GDM screening in PHC.
“At the moment I think we have got one glucometer in the whole clinic, you understand? Sometimes we don’t know where it is and it is difficult to find it, you see…”. HCP 2.
Themes in this category were appraised in the light of BCW’s intervention functions or middle layer , regarding services offered to women diagnosed with GDM while attending a diabetic clinic at hospital for follow-up and delivery.
Upon arrival at the respective hospital to which they are referred, women with GDM benefit from hospital level integrated care under the coordination of the diabetic clinic of the maternity department. Integrated services at referral hospitals include regular blood glucose monitoring, investigations for other health problems, medical care for GDM and other health problems beyond GDM, as well as diet and lifestyle change interventions.
“We all have our specialities, so the registrar that would be looking after the patient is somebody that is rotated through the whole block, so they’ve seen cardiac, they’ve seen eclamptic patients, they’ve done diabetes; but if there is a specific problem, then we are in the fortunate position where we have the resources where we can get infectious disease people out, instead of struggling with that, or we can get the endocrinologist out, and say listen, we have now hit a wall, how do we go forward, but that is within our setting”. HCP 3.
Counselling sessions regarding lifestyle changes to deal with diabetes and its devastating consequences were said to be routinely scheduled but not integrated within the services offered in the diabetic clinic of GSH’s obstetrics unit. As noted above, respondents reported that when counselling sessions were offered, crowded clinic conditions and lack of privacy decreased the effectiveness of sessions.
Women diagnosed with GDM at primary care and referred to tertiary hospital (GSH) (N = 35) discussed barriers they faced in their long road to care from families/communities, local facilities and up to referral hospitals, with many visits both during and after pregnancy. For many women the transport costs to attend care and the extra cost of healthy food contributed to depleting their already constrained economic resource.
“…The diet food is actually very expensive compared to junk food. So, when I had to change, it was actually very hard, because I now have to spend much on my budget when it comes to my groceries, because of my diet and other food stuff for my boyfriend who is not diabetic”. Participant 3 in FGD 4.
Apart from the socio-economic issues that women have to deal with in their daily lives, many have shown confusion or limited understanding of what GDM is and the behavioural/lifestyle changes required to manage GDM and prevent or delay future T2DM for themselves and long-term metabolic problems for their babies. Some women could not explain clearly what GDM was or why a particular treatment was prescribed to them while others struggled to name GDM consequences for themselves and their babies.
“I also think GDM is when you are diabetic, they find out when you are pregnant, and then it’s not going to be seen after birth, but I was thinking like that before, but I have never actually known…that’s an impression, but I’m just assuming, I’m not sure”. Participant 1 in FGD 4.
Women’s understanding about GDM as discussed in the FGDs was compared to the results from exit interview questionnaires. Despite the time they spent throughout the diagnosis and referral process at lower levels of health care, and after attending the diabetic clinic at GSH for their GDM care many times, only 43% reported having received advice about all four recommended actions (improve diet, reduce sugar intake, physical exercise and regularly take prescribed medication) to improve their GDM and prevent T2DM. However, women reported being satisfied with the information they had received, despite this lack of alignment with recommendations. Only half (51%) of the respondents were aware of the importance of reducing sugar intake, while 69% recalled being advised to exercise, 86% to improve their diet and 83% to take pills regularly. The contrast of improving diet (86%) and reducing sugar intake (51%) suggests incomplete and/or ineffective lifestyle change education.
Table 5 shows that, in contrast to the barriers reported by respondents regarding selective and late screening practices at primary care level, 94% kept their appointments at the referral hospital (GSH), 49% had already been tested in the morning before the FGDs were conducted, and 77% felt that nurses were interested or concerned about their health. Women who felt that nurses have empathy and time for them easily engaged with the nurses to ask about their GDM and general health, trusting their advice to change their lifestyle during pregnancy and postpartum to prevent or delay T2DM onset. Most women had their appointments every week (43%) or every 2 weeks (34%) with 86% reporting having received all their medications and not facing any stock-out. The multiple correlations between the advice that women with GDM received and their view on whether nurses were interested or concerned about their health, generally established a negligible, weak or moderate association as none reached 0.5. (Figure 3).
|N (sample size)||35|
|Age (in years)||mean (SD)||33.7 (4.6)|
|median (IQR)||34.0 (30.0, 37.0)|
|How long have you been attending diabetic clinic for your GDM care? (in days)||mean (SD)||106.9 (52.3)|
|median (IQR)||120.0 (90.0, 120.0)|
|OGTT or blood glucose measured today?||Yes||17 (49%)|
|Missing value||9 (26%)|
|Receive a SMS or a phone call to come to clinic?||Yes||1 (3%)|
|Missing value||1 (3%)|
|Advices to reduce sugar intake?||Yes||18 (51%)|
|Advices to exercise?||Yes||24 (69%)|
|Advices to take my pills regularly?||Yes||29 (83%)|
|Advices to improve my diet?||Yes||30 (86%)|
|Number of advices received||One||8 (23%)|
|The nurse was interested/concerned about your health?||No concerned||2 (6%)|
|Somewhat concerned||6 (17%)|
|Appropriately concerned||27 (77%)|
|Is there any medication that the nurse should have given you, but it is out of stock?||Yes||4 (11%)|
|Missing value||1 (3%)|
|When is your return date?||1 Week||15 (43%)|
|2 Weeks||12 (34%)|
|1 Month||5 (14%)|
|2 Months||1 (3%)|
Even though integrated services including ANC and GDM were generally appreciated at referral hospitals, there was no follow-up for women and their babies after delivery. When women and their babies were back in their community after delivery, it was reported that they were seen at their local facilities exclusively for babies’ check-up and immunisation and that women did not have access to any specific programme that provided follow-up. Upon discharge, the details about their health were written up in their antenatal record (Road to Health booklet), but according to women and HCPs, the hospital does not consistently give or send a referral letter, nor call or communicate in other ways with local clinics regarding postnatal care. This is despite the guidelines indicating that a referral letter recommending a 6 week postpartum OGTT and follow up at a local clinic should always be handed to women at discharge. Both KIs and HCPs reported that, once back at the clinics, the women who did receive follow-up letters and medication from hospital tend to focus on their babies and forget or ignore to look after their own health. The few women who had approached the nurses at the primary care clinic regarding their postnatal check-up reported that they had not been successful in getting screened for diabetes.
“The maternity sisters do not communicate with the local clinic sister for follow-up on these clients about medication after delivery and then we don’t know. So, maybe they got letters from hospital that you must follow up at this clinic to get your medication that is going to control you but mothers don’t follow up, as I have noted, they don’t follow up, they only focus on the baby after delivery,…… But if there is a problem, then the doctor prescribes when discharging them but they will never mention it to us at the clinic…And then, if they are with the person who didn’t see them when pregnant, you won’t know if the client had a problem with the glucose”. HCP 3.
The BCW’s sources of behaviour or inner layer  was used to map and interpret failures in postnatal follow-up for mothers with previous GDM and their babies, a problem identified by all KI and HCPs approached for this research. This reported gap in postnatal care for women with GDM was also seen as an implementation vacuum that the newly approved WC postnatal policy aimed to solve  but respondents considered that the policy fell short in terms of follow-up for women who had GDM. The ongoing IINDIAGO study that aims to integrate post-partum follow up for women post-GDM into PHC was presented to respondents at the end of the interview, in order to explore the perceived relevance and feasibility of such an intervention. The idea was welcomed and seen as feasible by all respondents including women.
Well, the issue about IINDIAGO is that you are actually addressing the exact problem. I think it’s feasible, given the right funding. I have no doubt, you know, things like weight reduction and proper dietary counselling etc. can prevent the development of Type 2. KI 3.
The BCW’s sources of behaviour or inner layer  was applied to help understand the changes that need to take place in the community in order to prevent or delay T2DM. Since the overwhelmed clinics do not intervene much, if at all, in T2DM prevention efforts, CHWs were considered to be the best-placed health workers to successfully contribute to implementation of activities in the family and community. CHWs in South Africa have greatly assisted [45, 46] in other community-based interventions to improve health, principally in the areas of maternal and child health and HIV care. Existing policy also gives them a role to play in non-communicable diseases (NCDs) . All participants (KIs, HCPs, Women) commended CHWs and suggested that they get involved in T2DM prevention once trained and working under clinic supervision. KIs suggested that their involvement could bring some clinical services like NCDs screening, counselling, health education, and implementation of specific preventive measures to the patients and family members within communities.
Reflecting on their experiences with HIV and tuberculosis, the CHWs who participated in this study responded positively to the idea of getting involved in such innovative and integrated approach towards T2DM prevention for women who had GDM. CHWs explained how their visits to the families within community are more inclusive and go beyond the single patient they are scheduled to visit, covering a range of health problems of all present family members. Equipped with their household charts, they reported that they conduct a complete surveillance of the family and refer family members with particular health problems to the right health facility for further diagnosis and care. CHWs emphasised their visiting and educating roles would align well with the tasks they would handle in T2DM prevention efforts. These positive comments were made despite reporting challenges they face in their daily activities like limited training; low and irregular payments; very busy clinics that sometimes fail to follow up the patients they refer to them. CHWs expressed commitment to their cause and engagement in their mission within the community.
“Me, I love the job that I am doing because I don’t have a problem with people, and I can convince them but if someone is not doing well, I report her to the supervisor who will then intervene”. CHW participant 3, FGD 1.
In the face of increasing GDM prevalence in Africa  and despite calls for universal screening, the guidelines in most countries recommend selective screening to diagnose and manage GDM and its sequelae [49, 50]. Risk factor-based screening has been the main approach adopted in South Africa. Even though the current GDM screening guidelines in South Africa now meet international standards, respecting the value thresholds as recently discussed by Adam S. and Rheeder , they are still ineffectively applied. The “Basic antenatal care (BANC) protocol” was identified as the main tool used for antenatal service provision in most of Cape Town clinics but is a complex guideline with many components . Ultimately the decision to screen GDM or not lies with the nurses, in line with the facility plan rather than this complex protocol itself.
Documented challenges in GDM testing at primary care level were a sign but also a cause of poor screening practice. Universal screening of GDM cannot be successful if concurrent barriers are not addressed. These challenges to GDM screening in PHC include but are not limited to shortages of well-trained HCPs and ill-equipped clinics to test and deal with NCDs based on the available guidelines . Multiple barriers impeding proper GDM screening and follow up post-GDM have been documented in other studies and this study’s findings corroborate many, including: weaknesses at different health system levels; poor understanding of postpartum GDM risks of T2DM development for both women and their babies; and various patient, community and health service level barriers for women when they are referred back into PHC for follow-up after delivery [15, 52, 53]. Our findings further suggest that the expertise and knowledge required of both nurses and women are insufficient to make a risk factor-based approach effective in South Africa.
It has never been easy for women to navigate health systems to access obstetric care in sub-Saharan Africa due to multiple individual and family socio-economic barriers such as low household income, illiteracy, lack of transport means and its cost, and cultural beliefs/practices, among others as reported in recent studies [54, 55]. Despite these issues, women receive integrated and highly appreciated antenatal and perinatal care at the tertiary level. Women with GDM who participated in this study confirmed this. However, women who strived to protect their babies from the adverse effects of GDM feel relieved after delivery and this is reinforced after their glucose levels return to the normal range. Additionally, the lack of structured postnatal care for these women does not foster the implementation of T2DM prevention initiatives.
Our findings suggest that this could be at least partially mitigated with clear and consistent discussions about GDM and its long-term consequences for both women and their babies throughout ANC, perinatal and post-partum services. Health education may encourage these women to follow-up with postnatal testing and lifestyle change measures at the clinic and in the community. Referral hospitals must first communicate with the local facilities regarding follow-up for these women and, in return, the clinics need to continue surveillance and initiate integrated postnatal behavioural change interventions for T2DM prevention. Such interventions would be useful for other NCDs and broader health care needs beyond the immediate aim of dealing with IGT, T2DM or diabetes related health issues but to achieve this, nurses need appropriate training and more resources in the facilities.
The IINDIAGO project is exploring whether such postnatal follow-up could be linked to the babies’ immunisation, which normally starts soon after delivery and discharge from hospital. HCPs showed willingness to add this programme to their workload after receiving proper guidelines and adequate training on their side. Women also expressed support for this kind of intervention after discussing its dual benefits, for them and for their babies. Engaging policy makers to change guidelines on the one hand and appropriately train frontline healthcare workers including CHWs on the other has succeeded in other trials and interventions in PHC for the same populations. Here, Prevention of Mother-to-Child Transmission of HIV (PMTCT) which continues from ANC into postnatal care with lifelong services within the facility and in the community [56, 57, 58] could serve as a case study.
Effective care of GDM and prevention or delay of T2DM requires a continuum of care from screening and diagnosis of GDM, to antenatal and intrapartum management, to post-partum follow up and prevention interventions. Despite policy support and guidelines promoting integrated care, implementation of GDM screening, delivery of counselling about GDM and T2DM, and post-partum follow up are suboptimal in Western Cape. Many women are diagnosed late in their pregnancy and postnatal follow-up is almost non-existent. An innovative strategy of integrating universal GDM screening in local health facilities with postnatal follow-up of these women and their babies in the community based PHC services is considered desirable and feasible by all participants in this study. Women, health providers, and experts added that this integration would work well if the resource and training constraints facing PHC as well as socio-economic barriers to women are addressed.
The datasets analysed during the current study are not publicly available to preserve participant anonymity.
|ADA||American Diabetes Association|
|BANC||Basic ANtenatal Care|
|BCW||Behaviour Change Wheel|
|CHWs||Community Health Workers|
|DPSG||Diabetes Pregnancy Study Group|
|EASD||European Association for the Study of Diabetes|
|GDM||Gestational Diabetes Mellitus|
|GSH||Groote Schuur Hospital|
|HCPs||Health Care Providers|
|HIV||Human Immunodeficiency Virus|
|IADPSG||International Association of Diabetes and Pregnancy Study Groups|
|IGT||Impaired Glucose Tolerance|
|IINDIAGO||Integrated Intervention for Diabetes risk after Gestational diabetes|
|LMICs||Low and Middle-Income Countries|
|MMAT||Mixed Methods Appraisal Tool|
|MOU||Midwife and Obstetrics Unit|
|NDDG||National Diabetes Data Group|
|NIMART||Nurse -Initiated Management of AntiRetroviral Therapy|
|OGTT||Oral Glucose Tolerance Test|
|PHC||Primary Health Care|
|PICT||Provider-initiated counselling and testing|
|PMTCT||Prevention of Mother-To-Child Transmission|
|PNC||Post Natal Care|
|T2DM||Type 2 Diabetes Mellitus|
The study was approved by the Human Research Ethics Committee at the Faculty of Health Sciences, University of Cape Town (HREC REF: 946/2014) and the Centre de Recherche du Centre Hospitalier de l’Université de Montréal (2018-6690, 17.044 – ID). Written informed consent was obtained from all participants.
We would like to thank the participants for their contribution to this study.
Ozayr Mahomed, Public Health Medicine Specialist, Senior Lecturer- Discipline of Public Health Medicine, University of KwaZulu Natal, South Africa.
One anonymous reviewer.
No funding has been received for the study but it was part of a PhD project. The first author, JCM held a PhD scholarship of her supervisor Christina Zarowsky from the Canadian Institutes of Health Research (CIHR) under the “Team Grant – Implementation Research in the Prevention and Treatment of Type II Diabetes in Low- and Middle-Income Countries” competition. This funding is for the following randomized trial: integrated health system intervention aimed at reducing type 2 diabetes risk in women after gestational diabetes in South Africa (IINDIAGO). HT holds a salary award (chercheur-boursier) from the “Fond de la recherche en santé- du Québec (FRQ-S)” and a salary award (New Investigator Salary Award) from Canadian Institutes of Health Research (CIHR).
The authors have no competing interests to declare.
JCM, CZ, and HT designed the study. JCM conducted interviews, data analysis and wrote the first manuscript under the supervision of CZ and HT. PREB, LM, LJW, SN, KM, NL, HT and CZ critically revised versions of the manuscript. All authors read and approved the final manuscript for publication.
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