Confusion and concern about the diagnosis of GDM
Prior to undergoing testing for GDM, women stated they had understood little about the reasons for the testing. Once diagnosed with GDM the most common expressed feeling they stated they felt was anxiety. Several participants used the (translated) words ‘worry’ and ‘fear’ to describe their feelings at the time of diagnosis. There was confusion about the aetiology of GDM.Women gave different explanations about why they had acquired GDM, ranging from a family predisposition to modern dietary habits. Most women were unsure of the aetiology. Several women blamed themselves for not controlling their diet.
"“My doctor did not explain much about this condition. She only noted this condition was resulted partly from gene and partly the food we consume nowadays. Our food contains many kinds of chemicals that may cause diabetes. I could not understand the disease”"
"“I was so hungry I kept eating as usual. That must the reason I’m here today”"
Fear of adverse effects from GDM
Women were very concerned about the potential adverse effects of GDM on their baby. The major concerns were premature delivery, growth restriction and stillbirth. Common themes expressed were:
"“It may slow baby’s growth, sudden death…babies easily have low blood sugar levels or more likely be born with abnormalities”"
"“..my baby might die if I’m not on diet”"
Several women were uncertain about the risks that GDM posed for themselves during the pregnancy and after the birth, with other unrelated symptoms being attributed to the GDM.
"“Some nights I felt it hard to breathe, I guess it’s resulted from high sugar in my blood”"
Some women were aware of the increased risk of type 2 diabetes after the pregnancy, although many women attributed this to luck. Knowledge around need for testing for type 2 diabetes after the pregnancy was low. Women felt that testing would likely be necessary but were not aware when this should occur.
Dietary changes “I think it’s so tough for us”
The major area of concern and the topic around which most discussion occurred was around changes in diet. Women reported fear of high blood glucose levels (BGL). There was confusion over exactly what dietary changes were recommended, with exclusion of food groups and drastic restrictions of intake reported by some.
"“I knew it (consuming rice) was wrong, but I didn’t have any means to quantify”"
"“I am not sure which food should be taken and which should not be”"
The solution to maintaining low BGL for many women was to restrict their dietary intake, resulting in feelings of hunger.
"“I always feel starved but I dare not eat”"
"“I was asked to take only half a bowl each meal, but I am so hungry I eat as usual”"
Participants in all groups reported feelings of hunger or starvation. Most women felt that they had to bear this for the sake of the baby, although there were several cases of women reporting their babies were growth restricted. Women felt that they had to trust their doctor, yet they were concerned about the effects of the recommendations.
"“I’m afraid this diet won’t provide enough nutrients for the baby, but the doctor told me to do that”"
"“…I was too tired to be hungry, or even thinking about eating. As a result I could not gain weight and the baby became malnutritious (sic)”"
The advice that most women reported being given was to ‘reduce starch’ intake in their diet. For Vietnamese women this advice was understood as reducing rice, the dietary staple in Vietnam.
"“We Vietnamese are used to eating rice. We are thus not comfortable to have alternatives to rice.”"
With a lack of counselling and advice about appropriate food substitutions, women experimented with alternate food sources.
"“ (I thought) sticky rice could make me full longer, I thus took it. My blood sugar then rose up to 200 (mg/dL, 11.1mmol/L) and I had to admit to hospital”"
"“I change my food everyday to see which one is best for me”"
Another food repeatedly mentioned in the groups was milk, with sweetened milk and pregnancy formula for mothers being very popular in Vietnam. Several women commented they had changed to sugar free milk, although were concerned about the nutrient value of this.
"“I had to drink milk because I felt hungry, and I want to feed my baby”"
"“No sugar milk seems not to make me full. Rice makes me full, but starch is prohibited. It’s really hard for us.”"
Blood glucose monitoring: access and understanding barriers
Women expressed concern about blood glucose monitoring, with the majority being uncertain of the rationale behind testing and the interpretation of results. Some expressed concern about the effects of blood loss from repeated tests.
"“I guess … I would be fatigued because of blood loss if I keep getting blood for checking every day until delivery”"
Monitoring of blood glucose amongst women who were out patients ranged from 4 times a day using a personal meter, to twice weekly, weekly or second weekly monitoring in the high-risk pregnancy unit. For women with unstable diabetes admitted to the hospital, monitoring occurred up to 6 times per day. The hospital has a scheme whereby women can have a loan of a glucose meter free of charge. Several of the women in the focus groups were unaware of this scheme. Others did not feel confident in performing and interpreting the tests themselves. Thus most women preferred to come to the hospital for BGL monitoring. Several women stated this was inconvenient, however they felt they must do this for the wellbeing of the baby.
"“Of course it is time consuming and affects my work a lot.”"
Weekly blood glucose monitoring was not limited to women with mild diet controlled GDM. One woman reported being commenced on insulin and waiting 7 days before being asked to come back to the hospital for a BGL check. At that time her BGL was 8.8mmol/L fasting (recommended < 5.1 mmol/L).
One woman had had two previous pregnancies, the first resulting in a stillbirth and the second a macrosomic 5.1kg infant. These are both conditions associated with poorly controlled GDM. She stated that this pregnancy she preferred to have blood glucose monitoring once a week, as she disliked needles.
Information on what the optimal blood glucose ranges for fasting, pre- and post-prandial should be was also unclear to most of the participants. One woman stated that she knew the normal range by reading the leaflet in the blood glucose meter pack, a range likely to have been written for type 2 diabetes.
Breast-feeding: balancing conflicting information about benefits for baby
There was a wide variation in opinions amongst women with GDM about the best way to feed their babies. Some women expressed a fear of breastfeeding as it could pass diabetes through to the child.
"“If the mother breastfeeds her baby the ‘diabetes factor’ may transmit to the baby and it’s no good. It may make the baby have the same disease afterwards”"
Other women were aware of health benefits associated with breast-feeding and stated that despite the perceived risk of transmission, they would still prefer to breast-feed:
"“I’m concerned about that (transmission of diabetes to the infant) of course. However to my understanding breast milk has antibodies which might be good for my baby because they would protect it from infection”"
The desire for more information about GDM
The majority of women who participated in the focus groups expressed a strong desire to obtain more information. Women felt it would be particularly helpful to have more detailed information on the recommended dietary modifications and the risks of GDM for the baby. They felt the doctors provided useful information, however were too busy to answer all their questions:
"“…Doctors have to consult for many patients. In fact they may have so much work to do and this disease lasts for quite a long time during your pregnancy, so you may sometimes (have) lack of consultation”"
"“We have many questions but dare not keep asking”"
"“There is just a small sheet concerning the risk of GDM distributed by the hospital staff at the antenatal care department. No other information on GDM is available”"
When they could not get sufficient information from doctors, the women stated they found other sources of information.
"“We read magazines, books or ask friends.”"
"“I asked other patients”"
Another source of information used was a phone health support service, which is run by non-medical personnel and is not specifically for diabetes or pregnancy. Other participants stated they visited Government Nutrition centres, which have been established to prevent childhood under nutrition.
When women were asked about how they would like to receive information on GDM,women felt that facilitated small group sessions with medical practitioners as well as more detailed leaflets specifically describing dietary changes would be useful.