Application of population health management will enable the GP practices within the Primary Care Network (PCN) to contact those not yet screened and to explore barriers to screening to improve access and addressing health inequalities in step with strategic priorities(19) and operational planning guidance. (20) This identified the barriers of; lack of awareness of screening and purpose; breakdown in communication between secondary and primary care; up to 30% of women moving out of the borough; poor cultural sensitivity and lack of support in the community was discovered when speaking to individual GP practices when validating the tool and to women themselves through engagement work conducted by the lead and second author.
In response to these findings, culturally appropriate recipes were co-developed and shared with dieticians, women with lived experience and specialist diabetes midwives and obstetricians. Feedback from women was the inability to cook new food with busyness of motherhood and or work. As previously stated, Black women have the lowest postnatal screening rates,(15) the population of Lewisham is 46% Black and Minority Ethnic, and women were being signposted to White European recipes. Women wanted to be able to adjust their usual diet to one that would help prevent T2DM or worsening GDM, and not have to cook two different meals for themselves and their family. The recipe book promoted the freely accessible national diabetes prevention programme, 30 culturally sensitive recipes, links to further recipes from Diabetes UK®, imagery of portion sizes, and a reminder of the timings and importance of postnatal screening for type II diabetes. The book has recently been professionally produced in two formats; a PDF with hyperlinks to local support being shared with GP and PCN’s within Lewisham, and with 2600 books that have been shared with women who book at Guys and St. Thomas’s Foundation Trust, Kings College Hospital and University Hospital Lewisham. Plan to share the PDF version nationally in the near future, due to generous funding from South East London CCG.
Studies in Canada(21) and Australia(22) showed marked improvement of screening uptake to 50–60% when postpartum reminders were used through letters and or follow-up phone call reminders. Similar positive results were found in the USA(23) when proactively using a health educator, phone call or letters. A retrospective study conducted in the UK found that giving women blood request forms antenatally could also aid with uptake.(24) Giving women the recipe book in pregnancy can help to not only prevent worsening GDM or the development of T2DM, but also work as a reminder of the importance of postnatal screening.
A learning lunch with GP’s in Lewisham was organised to coincide with the findings from the population health management system. The learning session was attended by those working with women with GDM within the maternity unit and was recorded so that it could be shared with those unable to attend. The session enabled GP’s to access the list of women needing screening, sharing the development of the recipe book and plans for dissemination, what the evidence is telling us, useful lifestyle advice and support that is freely accessible within Lewisham. A qualitative synthesis of women's views of T2DM screening (25) found similar results. Women suggested linking screening appointments for T2DM with other appointments such as cervical screening, child vaccination schedules, or other appointments. We are in discussion with GP/PCN’s about incorporating joined up clinics where women could have their blood test, see a dietician, be offered lifestyle support in a setting that ensured accessibility and was child friendly.
It is well documented that GP practices are under workload pressure due to growing complexity of health needs and retention of GP’s,(26) however all women should have access to a 6 week postnatal check with their GP. An observational cohort study looking at this postnatal appointment found that 40% of women were not being offered this structured postnatal check within the 10 weeks post birth.(27) This can prevent the opportunity to give lifestyle advice when seeing women, especially those with a history of gestational diabetes.
Midwives also play an important role in the prevention of T2DM for women with GDM. A prospective cohort study found that breastfeeding for longer than 2 months lowered the risk of T2DM by almost one half, and breastfeeding beyond 5 months lowered the risk by more than one half, at 2 years follow-up post birth.(28) Highlighting the importance of supporting breastfeeding for women with GDM and having this discussion antenatally is an important part of prevention of T2DM.
The project has proven that in using a population health management approach we can assess how well post-partum follow up is provided in primary care thereby enabling actions to ensure this is being done in line with NICE guidance. GP Practices have an important role to play. Safeguarding health after pregnancy invests in women, birthing people and their families, and prepares for any future pregnancies.(29)
Future work
Future work should seek to evaluate the impact of the activities we have carried out and examine the timing onset of the T2DM and cost effectiveness of lifestyle and pharmacological interventions.