Psychosocial factors associated with early booking and frequency of antenatal care (ANC) visits in a rural and urban setting in south Africa

Late antenatal care (ANC) booking remains the trend in most countries in sub- Saharan Africa despite the known benefits of early booking. Infrequent, poor and no antenatal care are among the most frequent patient-related avoidable factors and missed opportunities identified for many cases of maternal death in South Africa. Whilst most country guidelines recommend that a woman initiates antenatal care (ANC) within the first 16 weeks of pregnancy and the Basic Antenatal Care (BANC) approach recommends at least 4 visits during pregnancy, this has not translated into practice amongst women in South Africa. Disparities in timing of initiation of antenatal care and frequency of attendance exist between countries and between rural and urban settings within a country. Previous studies have identified demographic factors, physical access to health facilities, parity, lack of health education, relationships with health care providers and misconceptions of antenatal care (ANC) as factors influencing timing of ANC booking. Psychosocial factors have been found to also play an important role in timing and frequency of attendance to antenatal care. Strong social capital and social support were identified as protective factors against late ANC initiation and inadequate attendance whilst substance use, experiencing negative feelings about the pregnancy, misconceptions about antenatal care, poor mental health were mostly associated with poor ANC attendance. In the literature, partner characteristics and cultural and religious beliefs were associated with both early and late ANC initiation depending on the specific factors investigated. Research on the associations between psychosocial factors and antenatal care attendance is currently quite limited and fairly new and in addition, some psychosocial factors may not be associated with timing of initiation but may have an effect on the frequency of attendance of follow-up visits. The aim of the study was to examine the association between psychosocial factors and ANC booking to determine whether psychosocial factors (particularly substance use, feelings about pregnancy, social capital, social support, cultural beliefs, mental health perceptions, self-esteem and partner characteristics) were associated with not only timing of initiation of antenatal care but also frequency of attendance of antenatal care visits during a previous pregnancy among women in an urban and rural location in South Africa

Experiences of lifestyle change among women with gestational diabetes mellitus (GDM): A behavioural diagnosis using the COM-B model in a low-income setting

Lifestyle change can reduce the risk of developing type 2 diabetes among women with prior gestational diabetes mellitus (GDM). While understanding women’s lived experiences and views around GDM is critical to the development of behaviour change interventions to reduce this risk, few studies have addressed this issue in low- and middle- income countries. The aim of the study was to explore women’s lived experiences of GDM and the feasibility of sustained lifestyle modification after GDM in a low-income setting

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

BACKGROUND: Women with a prior gestational diabetes have an increased lifetime risk of developing type 2 diabetes. Although post-partum follow-up for GDM women is essential to prevent progression to type 2 diabetes, it is poorly attended. The need for health systems interventions to support postpartum follow-up for GDM women is evident, but there is little knowledge of actual current practice. The aim of this study was to explore current policies and clinical practices relating to antenatal and post-natal care for women with GDM in South Africa, as well as health sector stakeholders’ perspectives on the barriers to – and opportunities for – delivering an integrated mother - baby health service that extends beyond the first week post-partum, to the infant’s first year of life. METHODS: Following a document review of policy and clinical practice guidelines, in-depth interviews were conducted with 11 key informants who were key policy makers, health service managers and clinicians working in the public health services in South Africa’s two major cities (Johannesburg and Cape Town). Data were analysed using qualitative content analysis procedures. RESULTS: The document review and interviews established that it is policy that health services adhere to international guidelines for GDM diagnosis and management, in addition to locally developed guidelines and protocols for clinical practice. All key informants confirmed that lack of postpartum follow-up for GDM women is a significant problem. Health systems barriers include fragmentation of care and the absence of standardised postnatal care for post-GDM women. Key informants also raised patient - related challenges including lack of perceived future risk of developing type 2 diabetes and non-attendance for postpartum follow up, as barriers to postnatal care for GDM women. All participants supported integrated primary health services but cautioned against overloading health workers. CONCLUSION: Although there is alignment between international guidelines, local policy and reported clinical practice in the management of GDM, there is a gap in continuation of care in the postpartum period. Health systems interventions that support and facilitate active follow-up for women with prior GDM are needed if high rates of progression to type 2 diabetes are to be avoided

Integrated health system intervention aimed at reducing type 2 diabetes risk in women after gestational diabetes in South Africa (IINDIAGO): a randomised controlled trial protocol

Introduction South Africa has a high prevalence of gestational diabetes mellitus (GDM; 15%) and many of these women (48%) progress to type 2 diabetes mellitus (T2DM) within 5 years post partum. A significant proportion (47%) of the women are not aware of their diabetes status after the index pregnancy, which may be in part to low postnatal diabetes screening rates. Therefore, we aim to evaluate a intervention that reduces the subsequent risk of developing T2DM among women with recent GDM. Our objectives are fourfold: (1) compare the completion of the nationally recommended 6-week postpartum oral glucose tolerance test (OGTT) between intervention and control groups; (2) compare the diabetes risk reduction between control and intervention groups at 12 months’ post partum; (3) assess the process of implementation; and (4) assess the cost-effectiveness of the proposed intervention package.Methods and analyses Convergent parallel mixed-methods study with the main component being a pragmatic, 2-arm individually randomised controlled trial, which will be carried out at five major referral centres and up to 26 well-baby clinics in the Western Cape and Gauteng provinces of South Africa. Participants (n=370) with GDM (with no prior history of either type 1 or type 2 diabetes) will be recruited into the study at 24–36 weeks’ gestational age, at which stage first data collection will take place. Subsequent data collection will take place at 6–8 weeks after delivery and again at 12 months. The primary outcome for the trial is twofold: first, the completion of the recommended 2-hour OGTT at the well-baby clinics 6–8 weeks post partum, and second, a composite diabetes risk reduction indicator at 12 months. Process evaluation will assess fidelity, acceptability, and dose of the intervention.Ethics and dissemination Ethics approval has been granted from University of Cape Town (829/2016), University of the Witwatersrand, Johannesburg (M170228), University of Stellenbosch (N17/04/032) and the University of Montreal (2019-794). The results of the trial will be disseminated through publication in peer-reviewed journals and presentations to key South African Government stakeholders and health service providers.Protocol version 1 December 2022 (version #2). Any protocol amendments will be communicated to investigators, Human Ethics Research Committees, trial participants, and trial registries.Trial registration number PAN African Clinical Trials Registry (https://pactr.samrc.ac.za) on 11 June 2018 (identifier PACTR201805003336174)