Perceptions of mothers with gestational diabetes and their healthcare workers on postpartum physical activity to attenuate progression of gestational diabetes to diabetes mellitus: A qualitative study

INTRODUCTION

The prevalence of gestational diabetes mellitus (GDM) has increased dramatically within the past decade with high values observed in the Asian continent.¹ Compared to normoglycaemics, women with GDM have a higher risk of developing type 2 diabetes mellitus (T2DM),² metabolic syndrome³ and recurrence of GDM in subsequent pregnancies.⁴

Lifestyle interventions delay or prevent the development of T2DM by one-sixth in women with prior GDM⁵ and early, effective interventions are considered essential.⁶ Physical activity improves insulin sensitivity and glucose homeostasis as a whole⁷ and is deemed safe for postpartum women as these do not negatively affect lactation.⁸ However, postpartum women often face issues such as maternal fatigue, overwhelming childcare demands, lack of assistance with childcare and insufficient time^9,10 as only some women receive adequate social support.⁹ Understanding the barriers specific to these women and ways to overcome them are important when suggesting lifestyle intervention strategies to this distinct group.

South Asians have a unique culture, which may not be comparable with other regions of the world. Therefore, we explored the perceptions of women with GDM and their healthcare workers regarding postpartum physical activity to attenuate the progression to T2DM.

METHODS

RESULTS

Thirty-six subjects (30 antenatal mothers for FGDs and 6 healthcare workers for IDIs) participated in the study. Most mothers (80%) were aged below 35 years. Eight mothers had completed secondary education while only 2 had tertiary educational qualifications. All mothers were either in their second or third pregnancy and had a past history of GDM.

DISCUSSION

Physical activity plays an important role in attenuating the development of T2DM in mothers with a history of GDM. This qualitative phenomenological study was carried out to explore the views and past experiences of antenatal mothers with a history of GDM and of a selected group of primary healthcare workers caring for mothers regarding postpartum physical activity patterns, their attitudes, and beliefs and barriers related to physical activity during the postpartum period.

Sri Lanka is an island in South Asia, which has a unique culture with traditional beliefs and practices. The cultural beliefs seem to influence the activity patterns and behaviour of mothers during the postpartum period. As reported in a previous study, a majority of women in the South Asian region do not have the authority to take decisions regarding their lives and in some circumstances their health is not considered important by their family members.¹² As shown in the results, a majority of postpartum mothers do not get an opportunity to engage in any type of physical activity including physical exercises as they are considered to be weak, fragile and vulnerable to health issues. The focus is on imposing restrictions on the movements of a woman after giving birth to a child. It appears that cultural beliefs influencing the behaviour of postpartum women are not confined to the Asian continent. A qualitative study conducted in Britain¹⁰ has reported physical activity restrictions to postpartum women due to cultural norms. Nevertheless, as reported in the literature, the purpose of this repression is mostly to help the mother in building back her strength.¹³

Though it is reported that the support from the partner and the society are important to direct them towards healthy physical activity behaviour,^9,10 unfortunately due to this undue reliance on social and cultural norms, women do not get much support to engage in physical exercises as per the recommendations.

Similar to previous studies,^14,15 women in our study also showed a keen interest to know about the future risk of diabetes and preventive strategies. It is reported that perception of risk promotes behaviour change of postpartum mothers after GDM.¹⁶ Hence, this interest could be used to introduce new lifestyle intervention programmes. Nevertheless, Saligheh and co-researchers⁹ have reported that though mothers are aware about the benefits of physical activity, they give low priority to it due to responsibilities of motherhood, lack of energy, feeling of exhaustion and time restrictions. Therefore, to increase the compliance of mothers to achieve optimal outcomes from lifestyle modification programmes, it is important that these barriers are studied thoroughly and addressed appropriately.

Healthcare workers in the present study believed that they lack the necessary knowledge regarding postpartum physical activities for mothers with GDM to provide them with sound professional advice. Since healthcare workers play a crucial role in assisting and educating women regarding perinatal care, insufficient knowledge in the area of physical activity recommendations could be the root cause for the lack of reinforcement by them. As reported earlier, healthcare workers not only in Sri Lanka,¹⁷ but in other countries such as India¹⁸ and Bangladesh¹⁴ do not have optimum knowledge about the prevention and control of diabetes, in general.

As perceived by the mothers, stigma is another major inhibitory factor for physical exercises during the postpartum period. Though some mothers were willing to engage in physical exercises, they expressed their concerns about criticism from the family and the community. Most felt uncomfortable to engage in exercises due to this social stigma. Since lack of awareness of the wider society may be the prime factor for this stigma, it is important to address this matter by a holistic approach. Lack of motivation is another theme which emerged from IDIs. Although mothers have several reasons to motivate them to follow healthy behaviours during pregnancy, they do not have both intrinsic and extrinsic motivations after the delivery of the baby. One reason for decreased motivation may be the lack of awareness of both GDM mothers and their family members regarding the future risk of diabetes. Thus, as Tewari et al.¹⁴ suggested, better knowledge about GDM and T2DM may motivate the mothers to maintain healthy lifestyles.

Time pressure is a universal barrier for being physically active during the postpartum period. According to the ideas of mothers, time is a limited resource especially due to childcare responsibilities.¹³ Based on FGDs, the present study also identified childcare demands as a major barrier for healthy behaviour of mothers.

Exploration of barriers for physical activity suggested that traditional and cultural beliefs are major inhibitors to change current practices. Women, especially in Asia, adhere to societal norms and are unwilling to give up traditional beliefs and practices. In a previous investigation, we reported how cultural norms affect the diet of postpartum mothers¹⁹ highlighting the importance of considering these factors when designing lifestyle intervention programmes. The beliefs of mothers on traditional practices cannot be ignored when designing interventions, if optimum compliance is targeted.

Motherhood is a challenge and a novel experience for women. Therefore, with new responsibilities, a unique set of barriers have emerged. Home-based intervention programmes were suggested by previous studies²⁰ due to lack of time and transportation difficulties.^10,11 High social support, especially from the husband,^11,12 self-efficacy and regular follow up¹¹ were identified as facilitating factors that enhance the woman’s capacity to maintain a healthy lifestyle.

Community nurses play an important role in facilitating health behaviours in mothers with GDM to prevent complications, especially the progression of GDM to T2DM. Promoting physical exercises in postpartum women is a challenge for healthcare workers as the postpartum period is a unique phase of a woman’s life. Our findings are expected to create a platform to plan and implement a culturally accepted, scientifically sound and user-friendly exercise protocol for postpartum mothers.