Elsevier

Midwifery

Volume 25, Issue 2, April 2009, Pages 126-133
Midwifery

Juggling type 1 diabetes and pregnancy in rural Australia

https://doi.org/10.1016/j.midw.2007.01.016Get rights and content

Abstract

Objective

to explore the experiences of women with type 1 diabetes, living in rural Australia, while preparing for pregnancy and childbirth. Additionally, we aimed to describe the women's engagement with, and expectations of, health-care providers during this period, and subsequently highlight potential service and informational gaps.

Design

qualitative research using a collective case-study design; seven women with type 1 diabetes who had given birth within the previous 12 months participated in in-depth interviews about their experiences of pregnancy and birth. Data were analysed thematically.

Setting

The experience of type 1 diabetes, preconception preparation and pregnancy among rural Australian women was explored, including interactions with health professionals.

Participants

seven women aged between 26 and 35 years agreed to be interviewed. The woman had one or two children and had given birth within the past 12 months.

Findings

rigid narrow control of blood glucose levels before conception and during pregnancy created unfamiliar body responses for women, with hypoglycaemic symptoms disappearing or changing. For example, some women mentioned developing tunnel vision or numbness and tingling around their lips and tongue as different symptoms of hypoglycaemia. Women needed information and support to differentiate between what might be normal or abnormal bodily processes associated with pregnancy, diabetes, or both. The women's preparation for conception and pregnancy was reliant on the level of available expertise and advice. Participants’ experiences were coloured by their limited access and interactions with expert health professionals.

Conclusion

women with type 1 diabetes experienced significant hardship during their pregnancy, including a higher incidence of hypoglycaemic episodes, a loss of hypoglycaemic symptom recognition and weight gain. These difficulties were compounded by a scarcity of available information to support the management of their pregnancy and a lack of availability of experienced health professionals.

Implications for practice

national and international consensus guidelines emphasise the importance of preconception and pregnancy care for women with type 1 diabetes. Close clinical supervision and the development of closer co-operation and partnership between the women and health-care providers before conception and during pregnancy may improve outcomes for these women and their babies. Building confidence in professional care requires increased access to specialist services, increased levels of demonstrated knowledge and expertise and better general community access to information about preparation for pregnancy and birth among women who have type 1 diabetes.

Introduction

Type 1 diabetes is the most common chronic illness that complicates pregnancy (Burrow et al., 2004), and presents significant risks to the woman and her baby. These risks include higher rates of congenital malformations and stillbirth compared with women who do not have diabetes (Ray et al., 2001; Temple et al., 2002). Additionally, as a result of the pregnancy, women with type 1 diabetes may experience accelerated progression of diabetes-related complications, including nephropathy, retinopathy and hypertension. There is also an increased incidence of pre-eclampsia and pre-term births among these women (Jensen et al., 2004). These risks can be markedly reduced with optimal glycaemic control (Temple et al., 2002).

Much has been published on type 1 diabetes and pregnancy; however, it is biomedical in focus, emphasising medical management, with current research and guidelines for practice to optimise clinical outcomes for women and their fetus (Hod et al., 2003; Reece et al., 2004). There is still a lack of consensus in international guidelines for the care of women with diabetes during pregnancy (Cutchie et al., 2006), with only minimal improvements in the outcomes for women and babies (Confidential Enquiry into Maternal and Child Health [CEMACH], 2005). The experience and effect of pregnancy for women with type 1 diabetes, and women's interactions with health-care providers has received less attention.

Care for women with diabetes once pregnant involves earlier monitoring, often resulting in time away from work, more likelihood of hospitalisation during pregnancy and juggling leave and other family commitments (Kay, 1996; Hod et al., 2003). Women who carry a ‘high-risk pregnancy’ require frequent consultations with specialist obstetricians and doctors in addition to specialist diabetic nurses, and dieticians (Hutcherson, 2003). However, the level of specialist maternity services available for women with diabetes is limited (Platt et al., 2002).

Living in rural communities is well accepted as leading to poorer health outcomes and having reduced access to health services (Australian Institute of Health and Welfare, 1998; Ricketts, 2000). Globally, there is a clearly documented imbalance in the geographical distribution of health-care specialists, with greater access to specialist care in urban settings (Zun et al., 2006). Therefore, women with type 1 diabetes living in rural communities are likely to face additional challenges when they plan for conception and pregnancy. We were unable to locate any published work exploring this. This project investigated the pregnancy and maternity-care experiences of women with type 1 diabetes who live in regional and rural communities in Australia. The qualitative study design uses in-depth interviews (Patton, 1990) and thematic analysis (Thorne et al., 1997) to explore the women's experience of their preconception preparation and pregnancy, and to describe women's engagement with health-care providers during this period.

Section snippets

Setting

This is an Australian-wide study, and women responded from many areas of rural and regional Australia. In Australia, in 2003, a total of 252,584 women gave birth, with a crude birth rate of 127 per 1000. The average age of first-time mothers is 29.5 years. Some 30% of Australians live in rural or remote areas. Provision of services to these areas is often problematic owing to a shortage of appropriately qualified health professionals prepared to work in rural and remote areas and because of the

Findings

During the interviews, the women talked about the discipline, stress, and sheer hard work involved in reducing and maintaining blood glucose levels to a level that signified minimal risk to both their fetus and themselves. Blood glucose management was a dominant feature in their conversations. It was linked to their preparation for pregnancy, their experience of pregnancy, and the quality of, and access to, specialist health services. Women also reported difficulties in access to appropriate

Discussion

The women resided in five separate states of Australia and, although a small qualitative study, the findings highlight common themes related to the management of blood glucose levels, women's informational needs and health-service provision. Some of these findings are consistent with previous studies and women's stories. Women with pre-existing diabetes understand that they will experience a different trajectory of obstetric care to other women (Kay, 1996; Nankervis and Costa, 2000). The normal

Conclusion

Internationally, the management of pregnancy among women with type 1 and type 2 diabetes remains less than optimal (Australasian Diabetes in Pregnancy Society, 2002; Diabetes and Pregnancy group, France, 2003; CEMACH, 2005; McElduff et al., 2005), despite evidence that better outcomes are achievable. The recognised benefits of professionals working in partnership with women (CEMACH, 2005) were absent in many of the stories of women in this study. In principle, medical consensus guidelines and

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