Lewisham Health and Care Partners

Creating sustainable and equitable change for women with gestational diabetes

Promotion of good health and disease prevention during pregnancy and after delivery

Gestational diabetes

Gestational diabetes mellitus (GDM) is the onset of elevated blood sugar levels during pregnancy and falls under the umbrella of hyperglycaemia in pregnancy. GDM is associated with the leading causes of maternal deaths and disabilities, increased health complications in newborns, and increased post-partum risk for obesity, high blood pressure and Type 2 diabetes mellitus (T2DM) for the woman, child and future generations.

In the UK, T2DM following the development of GDM in pregnancy is on the rise¹, and Black African/Caribbean and Asian women face an increased risk. Women with GDM have a 50% chance of developing T2DM within the first five years following birth² and a recent systematic review found women with GDM were 10 times more likely to develop T2DM than those without.³

A report from the London School of Economics indicates that diabetes treatment costs the UK £13.75bn a year, with £11.72bn being spent on Type 2 alone.⁴

NICE guidance⁵ recommends that women diagnosed with GDM should be offered a HbA1c blood test to check for diabetes between six and 13 weeks after giving birth, and once every year after that if the result is within normal limits.

Lewisham data

The 2021/22 NHS priorities and operational planning guidance encourages services to use real-time data to improve outcomes through population health management. The Cerner population health platform, HealtheIntent^®, allows data from primary, secondary care and other datasets to come together, where historically there has been no failsafe of communication.

Postnatal screening for T2DM in women with GDM has been poor in the UK, with only 18.5% of women in the UK having a postnatal follow-up before six months⁶. A systematic review found that Black women had the lowest postnatal screening rates despite the higher risk for T2DM⁷ . This has highlighted need for targeted screening and prevention, especially for the population of Lewisham where 46% are from Black, Asian and ethnically diverse groups.

Laura Bridle, trainee consultant midwife in Public Health and Lewisham’s 2020/21 Population Health Fellow, explains that although developing GDM in pregnancy can’t be prevented, the awareness around increased risk factors for T2DM can be greatly improved. By thoughtfully co-designing interventions to accommodate and support these women, their ongoing health and wellbeing can be maintained.

“When I first ran an extract of the data from our population health platform, I was quite taken aback to realise that over a three-year period, 66% of eligible women had not had their initial post-birth HbA1c check and a further 99% of all women who had GDM during pregnancy had not been screened annually. This showed that the majority of women who were not being offered a routine blood test to check their ongoing risk of developing T2DM. Often it was because the GPs were not even aware of the GDM diagnosis, so didn’t know that they needed to offer the blood test. I also realised that this was not only a problem in the Lewisham area – if it was happening here, it was also happening across South East London and nationally.”

Laura led a team to develop a series of interventions to not only ensure women were receiving the necessary post-birth screening, but also the relevant support was in place to promote health and wellbeing, reducing the risk of developing T2DM and the associated cost impact on the health service. As Laura says, “If people are made aware of the risks and are also empowered to keep themselves well and healthy, they are more likely to take control of their own situation. We needed a way to improve awareness to make a difference.”

Interventions

The project worked with multi-professional groups to co-produce and introduce a number of changes to improve awareness of GDM, post-birth monitoring and to help prevent the development of T2DM in women diagnosed with GDM. These included:

• Improved communication between hospital teams and primary care about a woman’s GDM diagnosis through clearer documentation and coding on discharge letters. This was driven by diabetes midwives in Lewisham as well as SE London.
• A GDM analytics dashboard providing system, primary care (PCN and practice) and patient-level views, enabling improved monitoring of pathway points and case finding.
• The project lead working with a multi-ethnicity group of women with lived experience and to co-produce a culturally inclusive and relevant recipe book. Feedback from women has been positive. The recipes suitable for women diagnosed with GDM were from the Diabetes UK website, the women themselves and colleagues. Recipes including favourite foods were adapted for GDM and checked with dieticians. The book featured visual portion sizes as well as information for women about the importance of ongoing screening. The book has been funded and will be available in PDF or printed format. The plan is for all maternity Trusts and PCNs in SE London to trial the book, allowing for feedback from women and birthing people. If successful, the PDF version will be shared with all maternity services and PCNs nationally.
• Emphasising the importance of exercise and movement in reducing risk and preventing T2DM. There are a range of support services available In Lewisham. Women diagnosed with GDM can now access the NHS National Diabetes Prevention Programme (NDPP) and/or 12 weeks of structured weight-loss programmes (new format SW and WW) via GP referrals for free. Some of these programmes and social media platforms feature influential Black women in their promotional activities and material encouraging relevance for this group of women. Maternity Voice partnership on Instagram is another example, encouraging being active and talking to other women. There are also locally established ‘Walk and Talk’ groups that women can join.
• A borough-wide education event being held to raise awareness of the GDM-recommended practice, supportive resources, sharing information with GPs as they have an important role to play. The Lewisham Clinical Effectiveness Group (CEG) developed a guide to GDM in primary care covering how to access the dashboards, what the dashboards show, example text messages, coding, setting up alerts in source EPRs, case finding views, exporting patient lists and the relevant referral pathways. Reminding women to have their screening and reminding providers that the NHS NDPP is now open to GDM women.

The plan is to review progress every three months/quarterly, monitoring the uptake of HbA1c screenings and looking at ways to improve through targeting if necessary. Targeted intervention can prevent, reverse or delay the development of T2DM, supporting better health after pregnancy for women and their families, and preparing them for any future pregnancies.

^{1 Benhalima K, Damm P, Van Assche A, Mathieu C, Devlieger R, Mahmood T, Dunne F (2016) Screening for gestational diabetes in Europe: where do we stand and how to move forward?: A scientific paper commissioned by the European Board & College of Obstetrics and Gynaecology (EBCOG). Eur J Obstet Gynecol Reprod Biol. 201():192-6.}

^{2 https://www.nice.org.uk/guidance/ng3/chapter/Recommendations-for-research}

^{3 Vounzoulaki E., Khunti K., Tan B. and Gillies C. (2020) Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis. British Medical Journal. 369.}

^{4 Kanavos P, Aardweg Svd, Schurer W. Diabetes expenditure, burden of disease and management in 5 EU countries. London School of Economics; 2012.}

^{5 National Institute for Health and Care Excellence (NICE) (2015) Diabetes in pregnancy: management from preconception to the postnatal period. (NG3) NICE, London.}

^{6 McGovern A., Butler L., Jones S., van Vlymen J., Sadek K., Munro N., Carr H. and de Lusignan S. (2014) Diabetes screening after gestational diabetes in England: a quantitative retrospective cohort study. British Journal of General Practice. 64 (618), pp. 17-23.}

^{7 Herrick CJ, Puri R, Rahaman R, Hardi A, Stewart K, Colditz GA. Maternal Race/Ethnicity and Postpartum Diabetes Screening: A Systematic Review and Meta-Analysis. J Womens Health (Larchmt). 2020 May;29(5):609-621. doi: 10.1089/jwh.2019.8081. Epub 2020 Feb 19. PMID: 32074479; PMCID: PMC7247031.}