| Research Article |
Open Access |
|
| Well-Being, Diabetes Management, and Breastfeeding in Women with
Type 1 Diabetes Two and Six Months after Childbirth |
| Marie Berg* and Carina Sparud-Lundin |
| Institute of Health and Care Sciences, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden |
| *Corresponding author: |
Marie Berg
Institute of Health and Care Sciences
Sahlgrenska
Academy, University of Gothenburg
Box 457; SE-405 30 Gothenburg,
Sweden
Tel: +46317866084
Fax: +46307866120
E-mail: marie.berg@gu.se |
|
| |
| Received July 09, 2012; Accepted July 19, 2012; Published July 21, 2012 |
| |
| Citation: Berg M, Sparud-Lundin C (2012) Well-Being, Diabetes Management, and
Breastfeeding in Women with Type 1 Diabetes Two and Six Months after Childbirth.
J Women’s Health Care 1:112. doi:10.4172/2167-0420.1000112 |
| |
| Copyright: © 2012 Berg M, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited. |
| |
| Abstract |
| |
| Study background and aim: Besides adaptation to breastfeeding and to a changed lifestyle after childbirth
mothers with type 1 diabetes have to deal with erratic glycaemia. The aim in this paper was to explore patterns in and
associations between well-being, diabetes management, and breastfeeding in mothers with type 1 diabetes up to six
months after childbirth, and to compare well-being in mothers with type 1 diabetes to a reference group of mothers
without diabetes. |
| |
| Methods: In a prospective observational survey with a case-control design, 108 mothers with type 1 diabetes
were matched for parity and gestational week with 104 women in a reference group during 2007-2009. Telephone
interviews were conducted two and six months postpartum using the Psychological General Well-Being index and a
questionnaire on experience of diabetes management and breastfeeding. Associations were evaluated with a stepwise
multivariate regression model. |
| |
| Findings: Mothers with diabetes reported lower levels of general well-being and lower vitality than women in
the reference group at six months after childbirth, lower general health at two and six months. A majority reported
considerably more unstable glycaemia, especially in the first two months, and more hypoglycaemic episodes during
the breastfeeding period. Explanatory factor for better well-being at two months was the lesser extent to which
breastfeeding influenced diabetes management. At six months this factor, and longer duration of diabetes, explained
better well-being. |
| |
| Conclusion: Well-being in mothers with type 1 diabetes is negatively influenced if breastfeeding affects diabetes
management. This suggests that social support from both professionals and peers is particularly important to these
women. |
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| Keywords |
| |
| Breastfeeding; Type 1 diabetes; Support; Quality of life;
Well-being |
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| Abbreviations |
| |
| DG: Diabetes Group; RG: Reference Group |
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| Introduction |
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| Given the numerous benefits to breastfeeding it is a global
recommendation that mothers should exclusively breastfeed their
infants for the first six months of their lives [1]; also including women
with diabetes [2]. Besides adaptation to motherhood, women with type
1 diabetes after childbirth have to deal with erratic glycaemia including
increased numbers of hypoglycaemic episodes, especially during the
first weeks postpartum [3]. During lactation a glycaemic instability
related to increased insulin sensitivity has been identified in humans
[4] which have particular importance for mothers with diabetes who
show a decreased need for insulin [5] due to the increased glucose
consumption during the breastfeeding period [5,6]. It is reasonable
to assume that general well-being in these mothers might be affected
by the complexity of managing an unstable glycaemic situation at
the same time as taking care of the new-born, including establishing
breastfeeding. |
| |
| In mothers with Type 1 diabetes breastfeeding has been found to
be less frequent and of shorter duration [7,8]. However, it is not the
maternal diabetes per se that explains the lower duration of partial
or exclusive breastfeeding [8,9]. Instead, it is explained by increased
frequency of caesarean sections, lower maternal age [9], lower
education level, delivery at earlier gestational age, and delayed initiation
or non-established breastfeeding at discharge from hospital [8,9].
During the breastfeeding period, mothers with diabetes have described
how they have felt that they were “in the grip” of blood glucose levels
and increased fear of hypoglycaemic episodes [10]. The challenge of
becoming a mother as a woman with type 1 diabetes most likely requires professional and peer support beyond that required by mothers in
general after childbirth. The need for breastfeeding counselling and
psychosocial support has been highlighted in a few studies [7,11], hence
only a few have focused on support for diabetes management. These
studies indicate that the extensive professional care provided during
pregnancy and childbirth is often interrupted suddenly, and there is a
gap in the continuity of care before reestablishment of contact with the
ordinary diabetes clinic [12,13]. |
| |
| To summarize, breastfeeding appears to be more complex for
mothers with diabetes than for mothers in general and few studies have
explored the experiences of the experience of well-being in relation
to diabetes management, breastfeeding [3,5] and support in early
motherhood. |
| |
| As part of a research project in Sweden on diabetes and early
motherhood, the aim in this paper was to explore patterns in
and associations between well-being, diabetes management, and
breastfeeding in mothers with type 1 diabetes up to six months after
childbirth. A further aim was to compare well-being in mothers with
type 1 diabetes to a reference group of mothers without diabetes. |
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| Materials and Methods |
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| This is a prospective observational survey with a case-control
design, comprising women with type 1 diabetes (diabetes group, DG)
and a reference group (RG). |
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| Setting and sample |
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| Swedish-speaking mothers with type 1 diabetes in a Swedish region
with four hospitals were invited to participate during a two-year period
in 2007–2009. The routines of antenatal care for the target group varied
between the four different settings, however in all settings, care was
provided by a multidisciplinary team to prevent, detect, and treat
potential maternal and foetal complications. After childbirth clinical
practice focused on the new-born child, and included monitoring of
blood glucose and supplemental feeding during the first and sometimes
subsequent days of life in order to avoid neonatal hypoglycaemia. All
women were encouraged to initiate breastfeeding early if possible,
depending on maternal and neonatal conditions. Routines for
postpartum diabetes care differed between the hospitals; in most cases
mothers were expected to take the responsibility for reconnecting with
their regular diabetes clinic. A facilitating condition for breastfeeding
in Sweden is the long paid parental leave, a cost shared by the state
and the employer; 480 days of parental leave per child of which two
months are dedicated to each parent. This condition supports mother’s
possibility to breastfeed. |
| |
| Mothers were included consecutively after childbirth. For every
included woman with type 1 diabetes the next mother giving birth at
the same hospital was invited as a reference if she fulfilled the matching
criteria; gestational week and parity (primiparity vs. multiparity). The
exclusion criteria were occurrence of any kind of diabetes, and the
inability to understand and speak Swedish. All women were given
verbal and written information about the study, and informed consent
was collected prior to participation. The project was approved by the
Regional Ethics Board (Dnr: 351-07). |
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| Data collection |
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| Data were collected via telephone interviews at two and six months
postpartum, using the Psychological General Well-Being index (PGWB)
to measure well-being [14] and a new questionnaire developed by the
research group as no valid instrument was available focusing issues on
diabetes management, glycaemic control, breastfeeding and support in
early motherhood. To assure face validity, the questionnaire was tested
for comprehensibility and relevance by 20 women; 10 women in each
group (DG and RG). Only minor revisions were made and thus data
from these women were included in the final analysis. |
| |
| In the present article, the RG was used to compare the Psychological
General Well-Being index including 22 items divided into six subscales:
anxiety, depressed mood, positive well-being, self-control, general
health, and vitality. The items are rated on a six-point Likert scale
where 0 reflects the most distress and 5 the highest level of well-being;
hence, the total score range is 0-110 [14]. The Psychological General
Well-Being index (PGWB) has been developed according to evidence
based routines for instrument development and has a high internal
consistency reliability (Chronbach´s alpha: 0.92) [15]. PGWB has been
used in several studies on chronic conditions but has not earlier been
used on this population group. A Swedish version of PGWB has been
psychometrically evaluated, and shows similar satisfying results with
respect to internal consistency [16]. |
| |
| Study variables in the questionnaire developed by the research
group included socio-demographic data, breastfeeding pattern, diabetes management support from health care professionals and
significant others during childbirth and postpartum care, experience
of diabetes management in relation to breastfeeding including
occurrence of low and unstable blood glucose levels, insulin dose, and
self-reported glycaemic control in terms of HbA1C. Items concerning
professional and peer support were based on findings from earlier
research [13,17,18]. Documentation of the women’s blood glucose
patterns one week before each telephone interview was requested in
order to capture fluctuations in relation to breastfeeding and daily life
postpartum. Unfortunately very few women managed to document
their blood glucose pattern due to the demanding life situation in early
motherhood which made analysis impossible. |
| |
| The following additional data were collected from medical
records: mode of delivery; maternal outcomes including preeclampsia,
interventions in relation to foetal asphyxia, and haemorrhage; length
of stay in maternal and neonatal care unit interventions; and diabetesrelated
data including insulin doses (in early and late pregnancy),
insulin administration (pen/pump), diabetes classification according
to White [19], and HbA1C in early and late pregnancy. In Sweden,
HbA1C is analysed by the Mono-S method, which produces values
around 1% lower than the standard values of the Diabetes Control
and Complications Trial (DCCT)/National Glycohemoglobin
Standardization Program (NGSP) [20]. Before analyses the Mono-S
values were converted to IFCC units (mmol/mol) [21]. |
| |
| Data analysis |
| |
| Continuous variables were analysed using descriptive statistics:
mean (standard deviation/SD), median, and range (min-max); while n
(%) was used for categorical and dichotomous variables. Analyses were
conducted using two software packages: version 18.0 of SPSS (Chicago,
IL) and version 9.2 of SAS (Cary, NC). All tests were two-tailed and
conducted at the 5% significance level. Student’s t-test was used to
compare continuous variables (insulin doses, HbA1C) when roughly
estimated to be normally distributed. The Mann-Whitney U-test was
used to analyse differences between DG and RG in the total score and
six subscales of Psychological General Well-Being index, and a change
from two to six months postpartum was analysed with the Wilcoxon
signed-rank test. Associations between the study variables and
Psychological General Well-Being index in DG at two and six months
after childbirth were investigated with the Mann-Whitney U-test for
dichotomous variables, and Spearman’s correlation for continuous or
ordered categorical variables. Variables showing statistically significant
associations with Psychological General Well-Being index were
entered into a stepwise multivariate regression model with the total
score as dependent variable, in order to obtain the best explanatory
model. The presented parameter estimates, SE, p-values, and R2 were
taken from the multivariate regression models which included the best
independent explanatory factors. |
| |
| To discover a difference of at least 10% in well-being score (PGWB)
where the Reference group have a mean value of 101 versus 91 in the
Diabetes Group, standard deviation 0.25, we needed to include a
minimum of 100 mothers in each group. Power: 80%, alpha=0.05, twosided
test. This goes for using t-test for comparison. Using the nonparametric
Mann-Whitney U-test instead, 104 mothers are needed to
be included in each group. |
| |
| Results |
| |
| Study group characteristics |
| |
| Of 128 possible women with type 1 diabetes, 108 participated in the study. The remaining 20 women were either not identified at time
for inclusion or declined to participate, and did not differ from the
included women in terms of age, gestational week, mode of delivery,
and birth weight. In the RG, 104 mothers participated in the two-month
interviews and 99 in the six-month interviews. Gestational week and
parity were similar between the groups, as a consequence of the casecontrol
research design. In the total groups of participants (DG+RG, n
= 212), mean gestational week at childbirth was 37.9 (SD 1.8, median
38, range 30-41), and 53% were primiparas. Details on demographics
and maternal and neonatal outcomes are described elsewhere [8]. In
brief, mean age and education level did not differ between the DG
and the RG. In the DG there were more inductions of labour, more
caesarean sections, more frequent separation of mother and child early
postpartum and longer postpartum stay. The rate of partial or exclusive
breastfeeding differed significantly between the groups; at two months
it was 81% in the DG and 95% in the RG, and at six months it was 62%
in the DG and 79% in the RG [8]. |
| |
| Descriptive diabetes-related data for the mothers with type 1
diabetes are shown in Table 1. The insulin dose (IU/24 h) was not
significantly lower at two months postpartum compared to prepregnancy/
early pregnancy dose (P=0.06). Furthermore the insulin
dose was lower at two months compared to six months postpartum
(P=0.018). Insulin dose did not differ between breastfeeding and nonbreastfeeding
mothers at two months postpartum (mean 37.0, SD 13.6,
vs. mean 45.3, SD 21.6; P=0.115), but at six months breastfeeding was
associated with a lower insulin dose (mean 37.3, SD 14.3, vs. mean
45.7, SD 18.6; P= 0.016). Glycaemic control in terms of self-reported
HbA1C was worse at six months compared to two months postpartum
(P < 0.001). However, there was no difference in HbA1C between
breastfeeding and non-breastfeeding mothers either at two months
(P=0.935) or at six months (P=0.137). |
|
| |
|
Table 1: Diabetes-related data for the study population. |
|
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| Experience of diabetes management, breastfeeding, and
support |
| |
| The women’s experience of diabetes management in relation to
breastfeeding is reported in Table 2. Two-thirds stated that breastfeeding
had affected their diabetes management “quite a lot” or “very much”
between birth and two months postpartum, and almost half that this was the case between two and six months postpartum. Just over one
tenth of the mothers reported that breastfeeding had not affected their
diabetes management at all between birth and two months, and just over
one fifth reported that this was the case between two and six months.
At two months postpartum, around 70% of the group had experienced
quite unstable or very unstable blood glucose levels, compared to 55%
at the six-month interview. Experience of hypoglycaemia was more
frequently reported at the two-month interview than at the six-month
interview. About half of the breastfeeding mothers reported that their
diabetes management was affected during the whole period (Table 2). |
| |
|
Table 2: Experiences of diabetes management in relation to breastfeeding 0-2 and 2-6 months postpartum. |
|
| |
| Table 3 presents the extent of diabetes management support
received from professionals and significant others. Almost a third of
the women reported no received support at all during labour and a
quarter no received support at the postpartum maternity care unit. At
the two-month interview, one fifth of the women reported receiving
no support from the specialist antenatal care, and one fifth received no
support from their regular diabetes clinic. The mean time for the first
postpartum visit to the regular diabetes clinic was four months (SD
3.1). At six months, 83.3% (90 of 108 women) had visited the diabetes
clinic. Almost two thirds of the women had experienced a great deal of
support from their partner, and only a few no supports at all (Table 3). |
| |
|
Table 3: Diabetes management support from professionals and significant others, 0-2 and 2-6 months postpartum. |
|
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| Comparison of well-being in mothers with and without
diabetes |
| |
| Table 4 presents the mother’s experience of well-being in terms of
PGWB. At six months, the DG expressed worse self-reported general
well-being than did the RG. Subscale analyses indicated that general
health was lower in the DG both at two and at six months, without any
improvement between two and six months. Vitality was also lower at
six months in the DG compared to the RG. Both groups had improved
their self-control at six months compared to two months postpartum
(Table 4). |
| |
|
Table 4: Well-being evaluated with the Psychological General Well-Being index (PGWB) in the diabetes group (DG) and the reference group (RG). |
|
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| Association between well-being and independent variables in
mothers with type 1 diabetes |
| |
| In the bivariate analysis (Table 5), three independent variables
were associated with well-being at two months in mothers with type 1 diabetes: breastfeeding affecting diabetes management, more unstable
blood glucose, and more difficulties in handling diabetes during
breastfeeding. At six months, four independent variables were associated
with well-being: diabetes duration, HbA1C, breastfeeding affecting
diabetes management, and more difficulties in handling diabetes. The
influence of breastfeeding on diabetes management was coded as 1
(very much) to 4 (not at all) (Table 5). In the multivariate regression
analysis, the only independent factor remaining as explanatory for
better well-being at two months after childbirth was the lesser extent
to which breastfeeding influenced diabetes management (= variable
1) (βint = 69.43, SEint = 3.06; βvar1= 5.58, SE var1 = 1.30, p = <0.0001; R2
= 0.14). At six months two independent factors explained better wellbeing;
lesser influence of breastfeeding on diabetes management1, and
longer duration of diabetes (= variable2) (βint = 65.63, SEint = 4.15; βvar1=
3.35, SEvar1 = 1.21, p = 0.0067; βvar2= 0.47, SE var2= 0.16, p = 0.0034; R2 =
0.14). |
| |
|
Table 5: Associations between independent variables and the outcome variable; total score of Psychological Well-Being (PGWB) at 2 and 6 months postpartum in women
with type 1 diabetes. |
|
| |
| Discussion |
| |
| The main findings in this study are that mothers with type 1 diabetes
during the first six months after childbirth experience a growing
exhaustion. A majority experienced considerably more unstable and
lower glycaemia and increased numbers of hypoglycaemic episodes
especially during the first two months. This echoes earlier studies
[3,5]. It is clear that insulin requirements change considerably during pregnancy and early motherhood. Stage et al. [6] found a lower daily
insulin dose in lactating women four months after childbirth compared
to pre-pregnancy doses, and a higher insulin dose in non-breastfeeding
mothers. In our study, we only found differences between lactating and
non-lactating mothers at six months; this might be explained by the
high proportion of women breastfeeding at two months postpartum. |
| |
| The multivariate regression analyses revealed that breastfeeding
could negatively influence diabetes management in the mothers with
type 1 diabetes. Breastfeeding has been shown to affect the response
of the maternal autonomic nervous system to stressors [22], and has
been associated with reduced perceived stress and negative moods in
mothers in general [23]. Although we did not examine the association
with stress and negative moods, breastfeeding did not seem to have
such a positive effect on perceived stress and moods (measured as
psychological well-being). |
| |
| In this case-control study we matched for gestational week
and parity. Many other factors can influence on well-being and
breastfeeding in mothers with diabetes, among others the level of
disease severity. The study included data on both diabetes duration
and diabetes classification (Table 1) and both these variables were
investigated regarding association to well-being (PGWB). Only
diabetes duration was associated with well-being. Neither was
occurrence of maternal complication associated with well-being (Table 5). Surprisingly, longer duration of diabetes was found to explain
better well-being at six months. Given that longer duration positively
improves the degree of acceptance of the disease, a possible explanation
could be that this in turn may promote women’s ability to manage the
transition to motherhood. A previous study on pregnant women with
type 1 diabetes indicates that acceptance of one’s life conditions during
pregnancy is of vital importance for mastering challenges in daily life
[17]. However, this needs to be further investigated in future studies. |
| |
| Much has been written about the contrarious feelings that are
connected with breastfeeding. It is both a deeply personal experience
and a social phenomenon with embedded contradictoriness between
expectations and reality. In our study it was evident that self-control
in all mothers was affected during the early motherhood period (both
DG and RG), and that there was an improvement over time in their
mastering of daily life expressed as perceived self-control. Many
women experience a sense of disillusionment and failure in relation
to breastfeeding. A metasynthesis highlight that existing sociocultural
discourses contributes to these feelings, and conclude that health
professionals´ language and practice have the potential to enhance
maternal self-esteem in relation to breastfeeding [24]. Breastfeeding
rates are known to be promoted by professional support, and this
support should include sensitivity to individual needs and self-efficacy
[25,26]. A high proportion of the mothers with type 1 diabetes in our
study had experienced insufficient professional support for diabetes
management after discharge from maternity care. Early initiation
of breastfeeding and breastfeeding at discharge from hospital have
been shown to be predictive for breastfeeding in mothers with type 1
diabetes [8], indicating that professional support in maternity care can
influence breastfeeding rates in this group; just as it can for mothers in
general [24-26]. The struggle of manage fluctuating glycaemic control
while simultaneously establishing breastfeeding is in line with findings
from previous studies in women with type 1 diabetes [13,27]. The
majority of women reported that their partners had provided a great
deal of support with respect to diabetes management. This indicates that the family members of mothers with type 1 diabetes also might
benefit from complementary support from diabetes care providers. |
| |
| In this study, current clinical practice were in accordance with
international recommendations [2]; a follow-up in maternity care
within six weeks after birth. The mean time in this population for
reconnecting visit at the diabetes clinic was about four months after
childbirth. It is obvious that there is need for increased professional
support during the first months after childbirth; including advice to
adapt insulin doses. |
| |
| Limitation for the Study |
| |
| This explorative study has several limitations. The first is the lack
of data of glycaemic control (i.e. HbA1c), with a lot of missing data,
especially at the two-month follow-up. This limited data probably
resulted in insufficient statistical power to detect differences. The
reason for this lack of data was the limited contact with health care
professionals. Another limitation is that we did not collect any data on
the mothers’ body weight, making it impossible to report insulin doses
in terms of IU/kg/24 hrs. Body weight often undergoes a fast reduction
during early motherhood, which can be assumed to influence insulin
requirements. Blood glucose patterns were requested in the study
design but few women completed this documentation, indicating that
it was not reasonable to place such demands on these already loaded
women. Th is might explain why diabetes management during the
postnatal period in women with type 1 diabetes is so poorly researched.
Asking for the subjective experience of how breastfeeding had affected
diabetes management was one way to explore this issue. However, the
association with well-being need to be further investigated in studies
with different design. |
| |
| Another limitation is that the independent variables in the
multivariate analyses explained only 14% of well-being at two and six
months indicating that other not evaluated variables might influence
well-being. |
| |
| Strength of this study is its holistic perspective, examining the
experience of both diabetes management and well-being during
breastfeeding. Objective data in terms of HbA1c alone do not provide
information about the subjective meaning of living with type 1 diabetes
in early motherhood. Moreover, the case-control design allowed the
evaluation of general psychological health and well-being in this group
of women via comparison with healthy women without diabetes. |
| |
| Conclusion |
| |
| The findings of this study show that well-being during the first
months after childbirth was associated with difficulties with diabetes
management, probably due to higher degree of glycaemic instability.
Diabetes management is more difficult for the mother occupied in
taking care of the new-born. These conditions influence well-being in
terms of general health and vitality, and there is a negative effect on
well-being the more breastfeeding affects diabetes management. The
findings highlight the importance of increased awareness in healthcare
professionals, relatives and peers for the exhausting condition for
women with diabetes in early motherhood. We suggest that the
provision of professional support, including strategies to handle
unstable glycaemia in relation to breastfeeding to these women, is even
more important and might reduce the negative association between diabetes management and well-being. Further research need to
confirm the findings of this explorative study and evaluate supportive
interventions to mothers with diabetes in this vulnerable phase of life. |
| |
| Acknowledgements |
| |
| The study was designed by MB and CSL. Data was collected by CSL.
Statistical analysis was done by CSL and the statistical consultant Aldina Pivodic.
MB and CSL performed the interpretation of the result and drafted the manuscript.
Gratitude goes to Margareta Wennergren, obstetrician and associate professor
who participated in the study until her death in 2011. The study was funded by the
Swedish Diabetes Association (DIA2007-016), Capio Research Foundation (2007-
1405), and The Goljes Foundation. |
| |
|
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