Original article| Volume 24, ISSUE 4, e373-e379, July 2014

Understanding Why Some Women with a History of Gestational Diabetes Do Not Get Tested for Diabetes



      The proportion of women with previous gestational diabetes mellitus (GDM) receiving postpartum diabetes testing is far less than desired. Even in health care systems with high testing rates, some women remain untested. We explored what helps and what hinders women to obtain recommended testing.


      In this mixed methods study, we recruited 139 patients with a history of GDM in their most recent pregnancy (6 months to 4.5 years before study enrollment) from a delivery system that had instituted a quality improvement program to increase postpartum diabetes testing rates. We determined whether they had received a postpartum diabetes test according to American Diabetes Association guidelines. Using survey data, we ran logistic regression models to assess correlates of testing status, and we conducted in-depth interviews with 22 women to provide greater context to their survey responses.


      Of the 139 women, 21 women (15%) did not complete recommended diabetes testing. From the survey data, women who visited a primary care provider had 72% (95% CI, 0.09–0.83) lesser odds of not having been tested. From the qualitative interviews, difficulty fitting testing around work and caregiver demands were the most common reasons for not testing. Untested women interpreted providers' reassurances that diabetes would resolve after delivery and lack of reminders to reschedule missed appointments and to complete diabetes testing as indicators that their physicians were not concerned about their diabetes risk.


      Among hard-to-reach women, multiple demands on their time were common explanations for not receiving a postpartum diabetes test. Consistent messages regarding long-term diabetes risk during pregnancy, access to postpartum primary care and convenient lab appointments, and systematic reminders to providers and patients are approaches that, in combination, may influence more resistant women to test.
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        • American Diabetes Association (ADA)
        Standards of medical care in diabetes-2012.
        Diabetes Care. 2010; 35: s11-s63
        • Bellamy L.
        • Casas J.P.
        • Hingorani A.D.
        • Williams D.
        Type 2 diabetes mellitus after gestational diabetes: A systematic review and meta-analysis.
        Lancet. 2009; 373: 1773-1779
        • Bennett W.L.
        • Ennen C.S.
        • Carrese J.A.
        • Hill-Briggs F.
        • Levine D.
        • Nicholson W.K.
        • et al.
        Barriers to and facilitators of postpartum follow-up care in women with recent gestational diabetes mellitus: A qualitative study.
        Journal of Women's Health. 2011; 20: 239-245
        • Bentley-Lewis R.
        • Levkoff S.
        • Stuebe A.
        • Seely E.W.
        Gestational diabetes mellitus: Postpartum opportunities for the of type 2 diabetes mellitus.
        Endocrinology & Metabolism. 2008; 4: 552-558
        • Carson M.P.
        • Frank M.I.
        • Keely E.
        Postpartum testing rates among women with a history of gestational diabetes: Systematic review.
        Primary Care Diabetes. 2013; 7: 177-186
        • Casey B.M.
        • Lucas M.J.
        • Mcintire D.D.
        • Leveno K.J.
        Pregnancy outcomes in women with gestational diabetes compared with the general obstetric population.
        Obstetrics & Gynecology. 1997; 90: 869-873
        • Clark H.D.
        • Graham I.D.
        • Karovitch A.
        • Keely E.
        Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized clinical trial.
        American Journal of Obstetrics and Gynecology. 2009; 200 (634): e631-e637
        • Cox J.L.
        • Holden J.M.
        • Sagovsky R.
        Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale.
        British Journal of Psychiatry. 1987; 150: 782-786
        • Ekelund M.
        • Shaat N.
        • Almgren P.
        • Groop L.
        • Berntorp K.
        Prediction of postpartum diabetes in women with gestational diabetes mellitus.
        Diabetologia. 2010; 53: 452-457
        • Ferrara A.
        • Peng T.
        • Kim C.
        Trend in postpartum diabetes screening and subsequent diabetes and impaired fasting glucose among women with histories of gestational diabetes mellitus.
        Diabetes Care. 2009; 32: 2269-2274
        • Hale N.L.
        • Probst J.C.
        • Liu J.
        • Martin A.B.
        • Bennett K.J.
        • Glover S.
        Postpartum screening for diabetes among Medicaid-eligible South Carolina women with gestational diabetes.
        Women's Health Issues. 2012; 22: e163-e169
        • Henderson C.E.
        • Kavookjian J.
        • Leitstein H.
        • McKoy J.M.
        • Murage W.J.
        • Lipman R.D.
        Window of opportunity: Postpartum screening of women with gestational diabetes for early detection of prediabetes and type 2 diabetes.
        Open Diabetes Journal. 2012; 5: 25-28
        • Hunsberger M.L.
        • Donatella R.J.
        • Lindsay K.
        • Rosenberg K.D.
        Physician care patterns and adherence to postpartum glucose testing after gestational diabetes mellitus in Oregon.
        PLOS One. 2012; 7: e47052
        • Johns K.
        • Olynik C.
        • Mase R.
        • Kreisman S.
        • Tildesley H.
        Gestational diabetes mellitus outcome in 394 patients.
        Journal of Obstetrics and Gynaecology Canada. 2006; 2: 122-127
        • Keely E.
        • Clark H.
        • Karovitch A.
        • Graham I.
        Screening for type 2 diabetes after gestational diabetes.
        Canadian Family Physician. 2010; 56: 558-563
      1. Michigan Diabetes Research and Training Center. (2014). Risk Perception Survey for Developing Diabetes (RPS-DD), adapted for women with histories of gestational diabetes. Available at:

        • Ratner R.E.
        • Christophi C.A.
        • Metzger B.E.
        • Dabelea D.
        • Bennett P.H.
        • Pi-Sunyer X.
        • et al.
        Diabetes Prevention Program Research Group. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions.
        Journal of Clinical Endocrinology Metabolism. 2008; 93: 4774-4779
        • Regnault N.
        • Gillman M.W.
        • Rifas-Shiman S.L.
        • Eggleston E.
        • Oken E.
        Sex-specific associations of gestational glucose tolerance with childhood body composition.
        Diabetes Care. 2013; 36: 3045-3053
        • Shea A.K.
        • Shah B.R.
        • Clark H.D.
        • Malcolm J.
        • Walker M.
        • Karovitch A.
        • et al.
        The effectiveness of implementing a reminder system into routine clinical practice: Does it increase postpartum screening in women with gestational diabetes?.
        Chronic Disease in Canada. 2011; 331: 58-62
      2. U.S. Census. (2012). State and county quick facts. Available at:

        • Vesco K.K.
        • Dietz P.M.
        • Bulkey J.
        • Bruce F.C.
        • Callaghan W.M.
        • England L.
        • et al.
        A system-based intervention to improve postpartum diabetes screening among women with gestational diabetes.
        American Journal of Obstetric Gynecology. 2012; 207: 283.e1-283.e6


      Kathryn A. Paez, RN, PhD, is a principal researcher in Health Policy and Research at the American Institutes for Research. Her research interests concern improving quality of care and access to care to improve population health.


      Emma M. Eggleston, MD, MPH, is an instructor in the Department of Population Medicine at Harvard Medical School and the Harvard Pilgrim Health Care Institute. Her clinical and research interests are in diabetes, pregnancy, and vascular disease.


      Susan J. Griffey, DrPH, BSN, directs the Evaluation Center at Social & Scientific Systems. She researches public health interventions and programs in the US and in global development settings in primary and reproductive health care, HIV/AIDS, and chronic diseases.


      Brandy Farrar, PhD, is a researcher in Health Policy and Research at the American Institutes for Research. The majority of Ms. Farrar's research involves evaluating the effectiveness, viability, and impact of innovative programs designed to improve quality, access, and capacity of health care services.


      Jacquelyn Smith, MA, is a senior survey manager at Social & Scientific Systems. She applies her 20 years of experience in survey methodology and survey operational management to numerous public health studies in both acute and chronic disease topics.


      Jennifer Thompson, MPP, is a project manager in the Obesity Prevention Program in the Department of Population Medicine at the Harvard Pilgrim Health Care institute and Harvard Medical School. Her projects focus on diabetes, early childhood nutrition, and obesity.


      Matthew Gillman, MD, SM, is a Professor and Director of the Obesity Prevention Program, which seeks to lessen the burden of obesity and its consequences, in the Department of Population Medicine at the Harvard Pilgrim Health Care Institute and Harvard Medical School.