Juggling type 1 diabetes and pregnancy in rural Australia
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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