Factors Influencing Non-Adherence to Postpartum Diabetes Screening

This systematic review examines the factors contributing to non-adherence to postpartum diabetes screening among women with a history of gestational diabetes mellitus (GDM). The review analyzes four cohort studies conducted between 2008 and 2018, which employed the IADPSG criteria for GDM diagnosis and ADA criteria for type 2 diabetes mellitus. The findings reveal that a significant majority of women demonstrate non-adherence to postpartum screening guidelines. Key factors influencing this non-adherence include patient perceptions regarding postpartum follow-up, obstetric considerations, and socio-demographic variables, such as lack of awareness, difficulties in accessing healthcare, and concerns about the risks associated with GDM. The review highlights the importance of interventions, such as promoting patient-nurse contact and proactive screening strategies, to improve adherence rates and ultimately prevent the development of type 2 diabetes mellitus in this high-risk population. The report underscores the need for targeted interventions to improve screening rates.

Running head: SYSTEMATIC REVIEW 1
Factors Associated with Non-Adherence to Postpartum Diabetes Screening
Name:
Institutional Affiliation:

SYSTEMATIC REVIEW 2
Articles Chosen for Review
Hunt, K. J., & Conway, D. L. (2008). Who returns for postpartum glucose screening following
gestational diabetes mellitus?. American Journal of Obstetrics & Gynecology, 198(4),
404-e1.
Lawrence, J. M., Black, M. H., Hsu, J. W., Chen, W., & Sacks, D. A. (2010). Prevalence and
timing of postpartum glucose testing and sustained glucose dysregulation after gestational
diabetes mellitus. Diabetes Care, 33(3), 569-576.
McCloskey, L., Bernstein, J., Winter, M., Iverson, R., & Lee-Parritz, A. (2014). Follow-up of
gestational diabetes mellitus in an urban safety net hospital: missed opportunities to
launch preventive care for women. Journal of Women's Health, 23(4), 327-334.
McGovern, A., Butler, L., Jones, S., van Vlymen, J., Sadek, K., Munro, N., ... & de Lusignan, S.
(2014). Diabetes screening after gestational diabetes in England: a quantitative
retrospective cohort study. Br J Gen Pract, 64(618), e17-e23.
Abstract
Gestational Diabetes Mellitus (GDM) for a very long period has been perceived as a
complication during pregnancy that resolves itself after childbirth. On the contrary, studies have
established that the disease can affect lifetime health complications if not diagnosed and treated
during its early stages of development. More specifically, women who have been diagnosed with
GMD have a potential risk of developing type 2 diabetes mellitus. As a result, type 2 diabetes
mellitus should be screened to provide the diabetic status of the patient. Particularly, the
screening is important since type 2 diabetes mellitus has a long symptomatic period in which the
condition can be detected. Despite the international availability of international guidelines

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available for postpartum diabetes screening, the adherence to these guidelines is still very poor.
The objective of this review was to synthesize the factors associated with non-adherence to
postpartum diabetes screening. A retrospective study was performed on a cohort of patients with
gestational diabetes mellitus from January 2008 to January 2018. The diagnosis was based on the
IADPSG criteria. On the other hand, the diagnosis of type 2 diabetes mellitus was based on
ADA’s criteria designed in 2016. The women selected for this cohort were given appointments,
which were scheduled between 6 and 12 weeks postpartum. Of the 148 of the women studied,
only 20 returned for postpartum screening. The results indicated that 45% of those who came
back for postpartum screening had history of diabetes. There is no significance for clinical and
demographic variables such as ethnicity, smoking, and age. A significant majority of women
showed non-adherence to postpartum screening guidelines. The factors that contributed to this
non-adherence were patient’s views relating to postpartum follow-up, obstetric, and socio-
demographic factors.
Keywords: Gestational Diabetes Mellitus, postpartum, type 2 diabetes, screening, variables.
Background
Gestational Diabetes Mellitus is diagnosed during the late second or early third trimester
of pregnancy that is associated with type 2 diabetes mellitus. The condition is caused by
dysglycemia as articulated by American Diabetes Association Standards of Diabetes Care
(2017).Gestational Diabetes Mellitus is a potential risk factor for the development of type 2
diabetes mellitus during the postpartum period. In particular, patients with Gestational Diabetes
Mellitus normally develop the type 2 diabetes mellitus after a period of 5 to 16 years. The time
taken for the patients diagnosed with Gestational Diabetes Mellitus to show type 2 diabetes

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mellitus is influenced by the population studied (Nabuko et al, 2016) and the screening methods
employed for a particular study (Grant, 2016). The level of glucose tolerance varies from 11% to
42% for type 2 diabetes mellitus patients and impaired fasting glycemia respectively (Carson,
Frank, & Keely, 2013).
According to Association of Brazil (2017), the increase in the number of case of women
reported to have Gestational Diabetes Mellitus is attributed to increase in cases of obesity.
Specifically, the cases of obese women have increased by over 11% since 2003 particularly for
women aged 20 and above. This increase has proven to be a risk factor for Gestational Diabetes
Mellitus. Further, International Association of Diabetes and Pregnancy Study shows Gestational
Diabetes Mellitus women aged over 20 years have a prevalence of 18% (Trujillo, 2015). As
highlighted by National Collaborating Centre for Women’s and Children’s Health (2015), the
risk factors of Gestational Diabetes Mellitus include advanced age of maternity, history of
diabetes among family members, obesity, and history of polycystic ovary syndrome.
Additionally, Parlea & Feig (2014) indicates that in vitro fertilization as well as low levels of
vitamin D is also potential risk factors for the development of Gestational Diabetes Mellitus.
The increase in the number of cases of obese women negatively affects the diagnosis of
type 2 diabetes. Studies indicate that the number of women who are not diagnosed with type 2
diabetes mellitus is related to obesity (Lawrence & Contresas, 2015). For this reason, it is
recommended that all women be tested for type 2 diabetes mellitus during their first pregnancy
visits (International Diabetes Federation, 2015). Postpartum diagnosis is a vital process that all
women should consider participate in such programs. As highlighted earlier, Gestational
Diabetes Mellitus is a risk factor for type 2 diabetes mellitus (Buchanan & Xiang’, 2015). The
postpartum screening provides a route for assessing the women who could benefit when

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subjected to preventive measures (American Diabetes Association Standards of Medical Care in
Diabetes, 2017). Despite the benefits of postpartum screening of offering a chance to avert the
development of type 2 diabetes mellitus, studies show that the adherence to the stipulated
guidelines is very low. Studies indicate that old age, Gestational Diabetes Mellitus in previous
pregnancies, high standards of education, and high-income levels are likely indicators of women
more likely to exhibit non-adherence (Weinert et al, 2014). It is in this view that a study was
conducted to synthesize the factors associated with non-adherence to postpartum diabetes
screening
Methods
The study design employed for this systematic review was retrospective cohort study
conducted in Asia from January 2008 to January 2018. The diagnosis of Gestational Diabetes
Mellitus was based on theInternational Association of Diabetes and Pregnancy Study
Groups(IADPSG) criteria while type 2 diabetes mellitus diagnosis applied the ADA’s criteria of
2016. The results were based on the 2-hour OGTT value in which values between 126 and 200
mg/dl indicated type 2 diabetes mellitus. All the women under investigation were made to fill in
questionnaires to provide information about their socio-demographic information such as history
of Gestational Diabetes Mellitus, age, ethnicity, and marital status. The patients were then
instructed to carry out postpartum screening with 6-12 weeks after delivery by returning to the
clinic for evaluation.
The electronic searches for this review consisted mainly of databases. These databases
included Database of Abstract Reviews such as MEDLINE In-Process and Medline daily from
2011 to present, Science Direct from 2013 to date, and CINAHL from 2008 to 2010. However,

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additional information was retrieved from a number of sources and methods. Firstly,
observational studies were extensively used to gather primary data from clinical facilities. Such
information included the procedure for diagnosis of both type 2 diabetes mellitus and Gestational
Diabetes Mellitus. On the other hand, studies involving postpartum diabetes screening were also
considered for review. The reviews were particularly important in the obtaining information on
the primary indicators of non-adherence to postpartum screening. Further, the articles on
postpartum diabetes screening were carefully studied to provide further insight on the factors
associated with non-adherence to postpartum diabetes screening. The articles were selected
through random sampling. Additionally, cohort studies were taken into consideration to obtain
information regarding how follow-up activities were conducted and the results obtained. To
gather information about the socio-demographic factors associated with non-adherence to
postpartum diabetes screening, questionnaire filled in by the patients were considered for review.
The articles, which were excluded for review, included systematic reviews, review articles,
technical reports, and meta-analysis.
Criteria for Considering Studies for Review
This review included observational studies, follow-ups especially cohort studies, and
studies that involve postpartum diabetes screening. In addition, articles obtained through random
sampling were also included. Other studies included exposures and free excess articles.
Types of Participants
This review included female participants above 32 years from high, middle, and low-income
family backgrounds.
Types of Interventions

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Postpartum diabetes screening is a crucial medical requirement for detection and treating of type
2 diabetes for women with gestational diabetes mellitus. The review was aimed at studying the
factors associated with non-adherence to postpartum visits with a view of recommending
intervention measures, which can be put in place to address the issue of low adherence. More
importantly, the review would offer an insight on the factors that would encourage postpartum
visits so that the level of adherence is significantly increased. The review excluded studies on
meta-analysis, systematic reviews, technical reports, and review articles.
Search Methods for Identification of Studies
The electronic sources reviewed in this study-included Database of Abstract Reviews such as
MEDLINE In-Process and Medline daily from 2011 to present, Science Direct from 2013 to
date, and CINAHL from 2008 to 2010. Other sources considered for review were reference lists
of the relevant studies and reviews under consideration. In addition, cited reference searches
were conducted for the relevant studies and reviews.

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Figure 1: PRISMA Flow Diagram for the Review
Statistical Analysis
The data obtained in this systematic review were reported as means ± standard deviation
for continuous variables with the discrete variables were represented with relative frequencies.
The analysis of women who adhered to postpartum diabetes screening and those showed non-
adherence was done using the t-test. Further, the analysis of the rate at which the patients who
96 records identified though
database searches
90 records after removal of
duplicates
60 records excluded90 records subjected to screening
26 articles excluded:
Review articles (n=4)
Systematic review (n=7)
Meta-analysis (n=3)
Guidelines (n=3)
Technical reports (n=9)
30 full-text articles considered for
assessment
4 (final articles) cohort studies
included

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adhered to the screening guidelines returned to the clinic was also conducted. The socio-
demographic factors were included in the analysis as independent variables. A confidence
Interval of 95% was applied in all the analysis with a p-value less than 0.05 considered
significant.
Results
The four final articles that were reviewed showed a significant majority of women
show non-adherence to postpartum screening. The factors that contributed to this non-adherence
were patient’s views relating to postpartum follow-up, obstetric, and socio-demographic factors.
However, the results indicate that non-adherence decreases when interventions are put in place to
promote patient-nurse contact. In addition non-adherence to postpartum visits was established to
decrease for patients who began the screening in comparison to those who failed to attend the
visits initially. The results are summarized in Table 1.
Table 1: Socio-Demographic Factors Associated with Non-Adherence to Postpartum
Screening
Author/Year Study Design Results (factors) Remarks
McCloskey, Bernstein, Winter,
Iverson, & Lee-Parritz (2014).
McGoven et al (2014)
Hunt, K. J., & Conway, D. L.
(2008).
Cohort Study
Cohort Study
Cohort Study
Lack of awareness,
difficulties in accessing
health care centers
Concern only for risks of
Gestational Diabetes
Mellitus
Obesity
Patient’s views
Home screening
decreased non-
adherence

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Lawrence, J. M., Black, M. H., Hsu,
J. W., Chen, W., & Sacks, D. A.
(2010).
Cohort Study Inadequate follow-up
strategies visits
Non-adherence
decreased with
assigning a nurse
Discussion
Summary of Main Results
This review was aimed at synthesizing the factors associated with non-adherence to
postpartum diabetes screening. Generally, a significant majority of women showed non-
adherence to postpartum screening. Different factors were established to cause non-adherence.
For instance, a study by McCloskey, Bernstein, Winter, Iverson, & Lee-Parritz (2014)
established that non-adherence was attributed to lack of awareness and difficulties in accessing
health care centers. On the other hand, results conducted in England associated non-adherence to
concern only for risks of Gestational Diabetes Mellitus (McGovern et al, 2014). These results
generally show that the adherence to postpartum diabetes screening is very low despite having
guidelines in place in clinical settings. However, studies showed that non-adherence decreases
when an active search is conducted. To illustrate this, women who began postpartum visits
showed an increased adherence compared to those who completely do not attend the visits
(Lawrence, Black, Hsu, Chen, & Sacks, 2010). Similarly, Hunt & Conway (2008) illustrates that
non-adherence decreased after a nurse was hired to contact the patients and even conduct
screening in the patients’ homes.
Changes in the structure of the health system also significantly increase the rate of
adherence to postpartum diabetes screening. To begin with, the implementation of programs
aimed at caring for patients contributes to increasing the rate of adherence to postpartum

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screening. Such programs include initiation of programs that care for the patients (Aroda et al,
2015). For example, a nurse could be assigned specific number of patients to care for. In so
doing, the nurse can send telephone messages to remind the patients of postpartum screening
schedules. As a result of constant follow-up, the adherence of the patients is significantly
increased as highlighted by Dietz et al (2008). Similarly, the patients could be divided into
groups and a group leader assigned to each group. The creation of groups promotes sharing of
information and encouragement. In addition, collaboration between the patients and the nurses
improves the rate of patient visits for postpartum screening (Bernstein, McCloskey, Gebel,
Iverson, & Lee-Parritz, 2016). Therefore, the low adherence obtained in this study can be
attributed to inadequate follow-up strategies. For instance, failure to send reminders to the
patients could have contributed to the low rate of adherence obtained.
Overall Completeness and Applicability of Evidence
The development of strategies to address the issue of low rates of adherence to
postpartum screening guidelines does not seem to be satisfactory in practice. The study of the
questionnaires filled by the patients reveals varying reasons why a majority of patients fails to
conduct postpartum screening. These reasons include difficulty in caring for the newborn, lack of
awareness, difficulties in accessing health care centers, and concern only for risks of Gestational
Diabetes Mellitus to the fetus (Clark, Graham, Karovitch, & Keely, 2009). In addition, the
factors that are associated with non-adherence to postpartum diabetes screening were found to be
different for different studies. For instance, age, level of income, and level of education are
reported by one of the studies (Tovar, Chasan-Taber, & Eggleston, 2015). On the contrary, other
studies report association between non-adherence and obesity (Hunt& Conway, 2008). These
variations mean that the results for a particular study must be treated with care. The results of an

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investigation depend on the sample size and therefore the interpretation must be based on this
consideration. A study in which the sample size is significantly small limits the number of
variables that can be studied and hence influences the factors that are associated with the
adherence to postpartum screening. It is therefore difficult to exclude certain factors from a list
of factors, which influence the rate of adherence to postpartum screening guidelines. As a result
applying a single result in practice would not yield the expected results.
Regardless of the sample size, follow-up of the patients is established to influence the
rate of adherence to postpartum screening. All the studies reviewed indicated that the rate of
postpartum adherence significantly increased whenever a follow-up program was put in place.
Particularly, diabetes prevention program resulted in a change of the lifestyle of the patient,
which minimized the risk factors for development of type 2 diabetes mellitus. With increased
sensitization of the patients, an increase in the postpartum visits is realized (Van Ryswyk,
Middleton, Hague, & Crowther, 2016). Therefore, postpartum visits are not only important for
detection of type 2 diabetes mellitus but also targets interventions measures aimed at reducing
that risk factors associated with diabetes. It is therefore crucial that patients carry out postpartum
screening as spelt out in the screening guidelines in order to detect and treat type 2 diabetes
during the early stages of diagnosis. As well, postpartum visits presents an opportunity for the
patients to be enlightened on the preventive measures such as change I lifestyle that can be
undertaken to minimize chances of developing diabetes during subsequent pregnancies.
Certainty of the Evidence
Based on the Grading Recommendations Assessment, Development, and Evaluation
(GRADE) approach, the certainty of the evidenced was rated as low. In the first place, the