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Table 1 Results of key informant interviews by categories and illustrative quotes

From: Policies and clinical practices relating to the management of gestational diabetes mellitus in the public health sector, South Africa – a qualitative study

Key findings Quotes from key informants
Theme 1: Perceived facilitators and barriers to lifestyle change
 Facilitators of lifestyle modification
  (i) Concern for the health of the unborn baby “The patients are well motivated in pregnancy, they do change because they want a live baby” - Diabetes nurse educator
“Their compliance for the very reason that they want a healthy baby is much higher. It doesn’t mean that it stays like that postpartum” – Professor, Obstetrician 1
“Pregnancy is a really good time to intervene because they are so worried about the baby and sometimes a bit shocked that something they can do or not do can harm their baby” – Professor, Obstetrician 2
 Barriers to lifestyle modification
  (i) Inadequate dietary counselling due to shortage of dieticians in the public sector “Ideally they should see a Dietician, but not everybody has access to a Dietician, and there are too many patients” – Obstetrician 3
“Actually the people that should control nutrition are nurses because there are so few dieticians. They (dieticians) are either at a hospital or at a sub-district level but day to day, it’s the nurses who are encountering patients” –Professor, Public health specialist 1
“Dieticians are a rare and scarce resource in this hospital and most of them do not have time to go into pregnancy work” - Professor, Obstetrician 4
“If the dietician is not available, we take over, but the Dietician comes to do her part as well. The Dieticians come and go, they train, qualify, work for a bit, and then they usually go into private practice, I guess.” – Professor, Obstetrician 1
“In discussions with the Department of Health around this, I think there is a sense that it was slightly ambitious to expect the nursing staff to do a full, kind of, dietary counselling intervention, and that actually the Dietician needs to be doing that...” – General practitioner, Medical Anthropology Researcher
“It’s group counselling because we are limited, which is unfortunate because,” Obstetrician 5
“We give them general advice but of course that probably isn’t enough” –Professor, Obstetrician 1
  (ii) Lack of full understanding of healthy diet requirements “A lot of the patients I don’t think actually understand what needs to be done in terms of the diet to be able to deal with this” – Obstetrician 5
  (iii) Lack of interventions for physical activity “I don’t think there is enough spoken about exercise actually, I think it could be useful” – Professor, Obstetrician 2
  (iv) Affordability of healthy food “We’ve got two groups of women, one who has resources and can try to follow the advice, most of those women do, they’ve really taken up the idea that vegetables are important, you shouldn’t drink alcohol and you should avoid sugar but the rest of the women, cost is the main factor in what they can do” – General practitioner, Medical Anthropology Researcher
“I think also it’s just the reality of going home to limited financial resources” – Obstetrician 5
“It’s really expensive to eat healthy; you can’t do it, because all the cheap food you can afford is junk food” – Professor, Public health specialist 1
“I am just quite pessimistic about how much people can acquire a healthy diet, if they are below a certain income” –Professor, Public health specialist 2
Theme 2: Challenges with postpartum follow-up for GDM women
 Health system barriers
  (i) Absence of a standardized postnatal care approach for GDM women “You are probably going to find that the policy (management of diabetes during pregnancy and postpartum) is not being implemented at primary care level. Part of the problem is that the diabetes policy is aimed at the doctors at the hospitals and the health care providers at the primary care clinic don’t read the diabetes policy” – Obstetrician 6, Policy maker 1
  (ii) Lack of communication between tertiary and primary care levels of care “The gap in the communication between a delivery unit and where the patient has to go to is one of our main concerns. So, this was meant to be the communication between the Delivery Unit and the primary healthcare facility where the mum and the baby are followed up” – Health services manager, Policy maker 2
“They get a discharge summary in which we advise them to go to their local clinic in 6 weeks’ time to have their sugars checked but we don’t have any way of checking that it’s happened” – Professor, Obstetrician 2
  (iii) Inconsistencies in completion of referral letter “What we’ve discovered was that A it [the referral letter] doesn’t get completed very well and B for one or other reason, it doesn’t reach the primary healthcare clinics” – Health services manager, Policy maker 2
  (iv) Fragmentation of care “The key obstacle is that there’s such a divide between maternal and child care in the clinic setting, and the sisters are so habituated to that. They are either working on the maternal side, or they are working in the baby side” - Health Services manager, Policy maker 2
“So certainly not all MOUs are going to be accessible to the patient, the community health centres might be the best place to do it [postpartum OGTT], but you’ve got to find out, can they cope?” – Professor, Obstetrician 4
“To my knowledge, the Community Health Centre’s are not set up for it [postpartum OGTT]. The patient has to arrive early in the morning fasting. She’s then supposed to have a fasting blood sugar, and then 2 h afterwards, she’s supposed to have the 2 h blood sugar” Professor, Obstetrician 3
  (v) A foetal – centred approach to antenatal care “So the understanding that this is more of a lifestyle thing for the long-term future maybe isn’t there enough. It’s been very much geared around the pregnancy. I would say, our focus is the pregnancy, keep the sugar down, try and have a healthy baby and a mother that’s not injured during the birth. And we don’t think too much to the afterwards” – Professor, Obstetrician 2
“I think it’s a good idea because this is a particular at risk population, who get good care during pregnancy and child birth and then often just disappear from the system” -Professor, Public health specialist 1
 Patient – related barriers
  (i) Perception of future risk of developing T2DM “Because they don’t feel ill so they tend not go to the clinic or the doctor when they don’t have an issue. So I don’t know what the barriers are but the clinics are available it just that they don’t go” – Obstetrician 6, Policy maker 1
  (ii) Non-attendance for postpartum OGTT “They are not lost to the system, they lose themselves from the system I would say. Each person has a responsibility to her own health. If you get all the information and you get the appointment, then the onus in on you” – Obstetrician 3
“We do attempt to get them back for OGTTs, a small number do come back, but not all” – Professor, Obstetrician 1
  (iii) Resistance to long term dietary change “So there is quite a lot of resistance to dietary intervention and that’s probably the reason they don’t go back because they know somebody will just talk about their diet again” – Obstetrician 6, Policy maker 1
“I can tell you, it happens here in hospital already, once that baby is born you’ll find the bottles of cool drinks, and then you tell her, you are promoting yourself to Insulin” - Diabetes Nurse
  (iv) Lack of time and cost of transport for postpartum follow-up visits “It might also be pie in the sky [expecting women to attend postpartum follow-up visits], because once you have a small one (a baby) at home, it’s very difficult to give up your time” – Professor, Obstetrician 4
“It’s quite expensive when you think of what taxi fares they probably have to pay and they are all the ones that are the most at risk. The ones that haven’t got money for the transport to get back, and we invariably lose the most at risk 20, 25% of the people” – Professor, Public health specialist 2
  (v) Lack of agency to make lifestyle changes “If you’re an incredibly poor woman in a township with few choices, with a patriarchal man who takes control of your life and you have no choices, what’s your incentive to eat healthy and exercise? Really, it’s hard. So you must go home now, and don’t put sugar, don’t put salt, cut the gravy, no potatoes or whatever. They can’t do that: their husbands will have a hernia!” – Professor Public health specialist 2
Theme 3: Views on integrated postnatal care for GDM women
 Concept of ‘One-Stop-Shop’ “I think that integration in general is a really good idea. It is a no-brainer that we’ve missed for the past 100 years!” - General practitioner, Medical Anthropology Researcher
“It’s such a good example of something of the ongoing care that’s needed and maybe it could even be applied to other areas like blood pressure or heart or whatever. It’s a really good concept” – Professor, Obstetrician 2
“There isn’t a 6-week visit for the mum at the moment; it’s just for the baby. So we are trying to integrate that maternal and child health visit” – Obstetrician 6, Policy maker 1
“I think today the emphasis is on holism, and a holistic approach to everything, and not just to concentrate on a single item which really upsets you”- Professor, Obstetrician 4
 Potential of leveraging an existing health service (i.e.; WBC) “It makes a lot of sense. It’s very nice that it’s integrated into something that exists and is standard practice” - Professor, Obstetrician 1
“Excellent idea, because she will go for her baby...” – Obstetrician 3
“Currently their focus postpartum is mainly on the baby. They do a developmental screening, immunise the baby, weigh it and check on nutrition; how’s the baby feeding and things like that. They tend to forget the mom, and that is what we specifically want to do with this postnatal policy” – Health Service manager, Policy maker 2
“In my experience, the mother would rather take the baby for the 6-week visit than to go herself for anything if she is feeling well” – Professor, Obstetrician 2
“Now, whether that can be done, I don’t know, to emphasise just the baby, and to then to say, well, you know, you’re a Diabetic, we’ll do an oral GTT at the same time, I’m not quite sure whether that’s the right approach. I think the idea is at least a step in the right direction, but whether she will come fasting is another question” - Professor, Obstetrician 4
“I think it’s a good idea, if the mother didn’t have the baby, she wouldn’t go, but for the baby’s sake, she will go” – Diabetes nurse
Theme 4: Feasibility of integrated postnatal care for GDM women in the WBC
 Resource constraints given the current clinic structure in the WBC “One of the core issues is that you’ve got a resource constrained situation, community health workers, nurses and even doctors are full to the brim. I mean their job is 120%, so anything else you give them, is a problem” – Professor, Public Health specialist 2
“The OGTT is a 2 h test that involves administering glucose and that involves taking blood at those intervals. Quite simply, the primary care clinics are not going to cope with that. There are challenges in terms of staffing and costing and deficiencies need to be sorted out” – Obstetrician 5
“I think one’s going to have to be careful with this integrated visit not to give too many tasks” – Professor, Obstetrician 2
“It’s not that people are not aware that OGTTs need to be done, it is because the environment will be challenging for people to be doing OGTTs. That’s associated with human as well as financial resources” – Obstetrician 5
 Role of nurses “Ideally, to deliver the intervention, that person should be trained to do all of those things, so that it’s a kind of one-stop shop. I don’t know if it would be better to have an additional person [dietician]to do that nutrition counselling element who’s got some dietetics training but I don’t think we can have a dietician doing that, because we don’t have enough Dieticians to go around.”– General practitioner, Medical Anthropology Researcher
“The nursing staff do the OGTT in any case. So the nursing staff at the Well Baby Clinic should be able to it” – Obstetrician 3
“All nursing staff in South Africa, have been through General Nursing where they are exposed to all those things. So they are able to do it.” – Diabetes Nurse
“I think a primary care nurse should be able to do it.” - Professor, Obstetrician 2