“We are more than diabetes”: a qualitative study of maternity and postnatal care experiences of mothers in England with type 1, type 2 and gestational diabetes

“We are more than diabetes”: a qualitative study of maternity and postnatal care experiences of mothers in England with type 1, type 2 and gestational diabetes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “We are more than diabetes”: a qualitative study of maternity and postnatal care experiences of mothers in England with type 1, type 2 and gestational diabetes Jenny McLeish, Fiona Alderdice This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6855141/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Diabetes is a significant health issue during and after pregnancy, with increased risks of adverse outcomes for mothers and babies if maternal blood glucose is not controlled. National guidelines in England cover maternity care for women with pre-existing (type 1 or type 2) and newly-diagnosed (gestational) diabetes, but as the incidence of pregnancies affected by diabetes increases, it is unclear to what extent this guidance is being followed. Methods 32 mothers in England with type 1, type 2 or gestational diabetes were interviewed about their experiences of antenatal, intrapartum and postnatal care. Interviews were analysed using thematic analysis. Results Four themes were developed: ‘The antenatal information gap’, ‘Monitoring and management’, ‘Communicating risk and choice’, and ‘The postnatal cliff edge’. There were examples of good and poor practice across all themes, and themes were similar across all types of diabetes. Mothers felt safe when care met their needs for pre-conception counselling; high quality and timely information about diet and exercise; access to personalised advice; real time communication of blood glucose results through the use of technology; non-judgemental support that recognised their expertise on their own bodies; meaningful informed choice about mode and timing of birth with risks explained clearly and without drama; well-planned intrapartum care that included management of their blood glucose; and information to prepare for the postnatal period. Inconsistent, poorly-informed and judgemental interactions made mothers feel coerced and unsafe. Most reported intensive antenatal support but a lack of postnatal support. Conclusions Maternity services should offer mothers with diabetes person-centred, non-judgmental care that respects the autonomy of the mother as a decision-maker based on sufficient information about personal risk. Mothers need high quality, consistent, evidenced-based, culturally relevant and timely information about managing diabetes, with practical tips and recipes and access to support from other mothers, and this might be achieved by services working in partnership with third sector organisations. Primary and secondary healthcare needs to be joined up, particularly to increase postnatal support. All health professionals who are involved in maternity and postnatal care need the knowledge, skills and confidence to support mothers with all types of diabetes. Type 1 diabetes type2 diabetes gestational diabetes mellitus pregnancy postnatal qualitative Figures Figure 1 Background Diabetes is a significant health issue during and after pregnancy, affecting over 5% of pregnancies in England (England, 2024; NHS Digital, 2023) although this is likely to be a significant underestimate (Jones et al., 2025). The most common type is gestational diabetes mellitus (GDM), which is high blood glucose first diagnosed in pregnancy that normally resolves after birth (National Collaborating Centre for Women's and Children's Health, 2015). Of the women with pre-existing diabetes who become pregnant, 44% have type 1 diabetes (T1D) and 56% have type 2 (T2D) (NHS Digital, 2023).The increasing prevalence of GDM and T2D in pregnancy is associated with the population rise in obesity, more women becoming pregnant at an older age, and the increasing numbers of younger women with early-onset T2D (National Collaborating Centre for Women's and Children's Health, 2015; NHS Digital, 2023). Women from some ethnic minority communities and women from more disadvantaged socio-economic groups are at increased risk of developing T2D and GDM (National Collaborating Centre for Women's and Children's Health, 2015; NHS Digital, 2023). Pregnant women who have T1D or T2D have an increased risk of complications and adverse pregnancy outcomes (Murphy et al., 2021; National Collaborating Centre for Women's and Children's Health, 2015). Adverse outcomes can be significantly improved when women are supported to monitor and manage their blood glucose effectively, usually with insulin and/or oral medication (metformin), and the recent improvement in maternal blood glucose control and pregnancy outcomes for women with T1D in the UK has been associated with the roll-out of wearable continuous glucose monitoring (CGM) systems (Murphy et al., 2021; NHS Digital, 2023). Gestational diabetes is also associated with increased risk of complications if blood glucose levels are not managed (Ye et al., 2022). Management may be through changes to diet and exercise alone, or with the addition of metformin and/or insulin (National Collaborating Centre for Women's and Children's Health, 2015), but women with GDM often face barriers to making the recommended lifestyle changes during pregnancy (Craig et al., 2020; Guo et al., 2024; He et al., 2021). Approximately 50% of women who have had GDM experience it again in subsequent pregnancies (Egan et al., 2021). Women who have had GDM are also at increased risk of future cardio-vascular disease (Kramer et al., 2019), and up to 50% will develop T2D within 10 years (Damm et al., 2016). This suggests that GDM is a marker of an underlying metabolic disorder, and therefore provides an opportunity for early intervention based on postnatal lifestyle modification, although this can also be challenging (Dennison et al., 2019; Hedeager Momsen et al., 2021; Li et al., 2021). There are substantial international qualitative literatures on mother’s reactions to diagnosis with GDM, self-management and healthcare (He et al., 2021; Pham et al., 2022), their suggestions for improvement (Feng et al., 2025), and postnatal interventions to prevent T2D following a GDM pregnancy (Dennison et al., 2019; Hedeager Momsen et al., 2021). There is a more limited international literature that explores the physical and psychological challenges of pregnancy for mothers T1D and T2D and their experiences of healthcare (Roddy & McGowan, 2024; Sushko et al., 2021; Toledo-Chavarri et al., 2024). There are as yet few studies from the UK on the maternity care experiences and needs of women with diabetes and these have been carried out at individual clinics (Draffin et al., 2016; Parsons et al., 2018; Stenhouse et al., 2013; Woolley et al., 2015). Women with diabetes, their support networks and health professionals taking part in the James Lind Alliance Priority Setting Partnership on diabetes and pregnancy have identified as two of the top ten UK research priorities, “What are the labour and birth experiences of women with diabetes, and how can their choices and shared decision making be enhanced?”, and “What are the specific postnatal care and support needs of women with diabetes and their infants?” (Ayman et al., 2021). The aim of this study was to explore the antenatal, intrapartum and postnatal care experiences of a diverse group of mothers who have TD1, TD2 or GDM and used National Health Service (NHS) maternity services England, with the intention of contributing to policy recommendations for improving maternity and postnatal care for mothers with diabetes. Methods This was a qualitative descriptive study (Sandelowski, 2000), theoretically informed by phenomenological social psychology which focuses on understanding the subjective meaning of interpersonal interactions (Landridge, 2008). This design was chosen because the purpose was to explore participants’ experiences and thus to stay close to their accounts without imposing theory, while acknowledging the role of both participants’ understandings and the researchers’ interpretations in the production of knowledge (Pidgeon & Henwood, 1997). Participants were purposively sampled for their experiences as mothers who had a baby in England in the past 12 months and had diabetes diagnosed before or during their most recent pregnancy. Participants were recruited via email networks, social media, and posters in community groups. The invitation was publicised by the Patient and Public Involvement (PPI) group (comprising representatives from national organisations and individual mothers with lived experience of GDM, T1D or T2D) and by other members of National Perinatal Epidemiology Unit’s PPI network of voluntary and community organisations. This invitation directed mothers who were interested in participating to a short online questionnaire that (1) provided a link to the participant information leaflet and (2) asked demographic questions to enable the selection of participants using maximum variation sampling according to their type of diabetes, ethnicity, location within England, and socio-economic status based on their postcode. Each participant took part in one semi-structured telephone interview in November 2023-March 2024. Participants were sent the participant information leaflet and consent form at least 24 hours before an interview and gave informed consent before the interview began. Participants were offered £25 in vouchers to thank them for their time. Data analysis was carried out in parallel with data collection and recruitment continued past the point of thematic saturation to meet the goal of maximum diversity. Interviews were audio-recorded and professionally transcribed. To protect confidentiality, each participant was allocated a participant number tagged with their type of diabetes – “T1D” for type 1 diabetes, “T2D” for type 2 diabetes, “GDM” for gestational diabetes. Interview transcripts were analysed using inductive thematic analysis (Braun & Clarke, 2006). Transcripts were checked against audio-recordings and reread for familiarity, then coded; codes were combined and developed into themes which were discussed and agreed. Transcripts from participants with each type of diabetes were initially treated as separate datasets, and then combined into an overall analysis to reflect the goal of providing evidence to improve the care of women with all types of diabetes. Results Participants There were 357 valid responses to the invitation to be interviewed. 32 mothers were interviewed, who had experienced a total of 45 pregnancies affected by diabetes. Interviews lasted 26-62 minutes (mean 41 minutes). Mothers’ demographic characteristics and the management of their diabetes in their most recent pregnancy are shown in Table 1. Four mothers who were diagnosed with T2D had had GDM in one or more previous pregnancies. 21 mothers had experienced comorbidities including ADHD, agoraphobia, anxiety, Chiari malformation, eating disorder, high blood pressure, depression, gallstones, hyperemesis, low lying placenta, low PAPP-A, obstetric cholestasis, polycystic ovary syndrome, pneumonia, polyhydramnios, and symphysis pubis dysfunction. Mothers were not asked about their Body Mass Index (BMI) but eight mothers spontaneously described themselves as having a “high BMI” of up to 41. Table 1 Participants’ demographic characteristics and management of their diabetes during pregnancy Number of mothers Age 25-29 6 30-34 10 35-39 13 40+ 3 Ethnicity Asian 8 Black/Black Mixed 5 Other 5 White 14 Index of multiple deprivation Quintile 1 (most deprived) 5 Quintile 2 7 Quintile 3 7 Quintile 4 5 Quintile 5 (least deprived) 6 Postcode unmatched 2 Parity 1 st birth 16 2 nd birth 13 3 rd -5 th birth 3 Type of diabetes during most recent pregnancy Type 1 7 Type 2 5 Gestational 20 Monitoring of diabetes in most recent pregnancy Finger prick 24 Continuous glucose monitoring 8 Management of diabetes in most recent pregnancy Diet (or diet + exercise) 9 Diet followed by metformin later in pregnancy 8 Diet followed by insulin later in pregnancy 2 Metformin from diagnosis 2 Insulin throughout pregnancy 8 Metformin followed by insulin later in pregnancy 3 Results Four themes were developed, shown with subthemes in Figure 1. Theme 1: The antenatal information gap Diagnosis and timing of information Only one mother with T2D had received preconception diabetes advice, which she had found very helpful. Several mothers with T1D had received comprehensive preconception information, but others had not, particularly before first pregnancies. In some cases, they felt that lack of information before pregnancy and in the first trimester may have contributed to poor outcomes. “This is my third pregnancy, but I didn't have any preconception clinic ever… I felt really guilty [in the first pregnancy which ended in miscarriage] because my blood sugar was not very well controlled initially, because I did not know.” M32-T1D “Once I was [in my] early twenties it was mentioned every diabetes appointment … With both of my children, I attended a preconception clinic and they went through optimal conditions and what pregnancy as a diabetic could look like.” M09-T1D Receiving a diagnosis of GDM was a shock for most mothers, and their priority was to find out what they needed to do. While some had received prompt information from the diabetes team about managing their condition, others said that they were extremely worried during a prolonged gap between diagnosis and access to reliable information. “The nurse said the nutritionist would have a conversation and that wasn’t until two or three weeks later. So, there was two and a half weeks where I was a bit like, ‘Oh my God, I don’t know what I’m doing.’ Cos you’re scared that you’re gonna hurt the baby more… It was really overwhelming and I felt like it was almost the end of the world.” M04-GDM Mothers had generally attempted to fill this information gap by looking for information online. A few mothers who had health anxiety or a history of disordered eating said they had reacted with extreme food restriction. “If they’d gone through that information with me, I wouldn’t have thought, ’Oh my God, you need to eat nothing .’” M22-GDM Varied quality of information There was no standardisation in the scope and format of diabetes information which mothers with GDM or T2D received about recommended lifestyle changes. Some mothers were offered a group or individual session with a dietitian, others were not; some received a brief telephone call while some had a half day in-person session covering both how to use the glucose testing kit and how to manage diabetes through diet. Some were simply given a dietary advice leaflet of variable quality, while others were signposted to the NHS diabetes webpage or to non-NHS sources of information on social media, in apps or books. Some mothers were advised to increase protein intake while others were simply advised to reduce carbohydrate intake and portion sizes. Some were given detailed information about the glycaemic index of different foods, while others were given a short list of ‘good’ or ‘bad’ foods. Some were given advice on exercise (particularly walking shortly after meals to stabilise blood sugar), but many were not. A few were given information about ‘food pairing’ (eating a high fat food with a high carbohydrate food). A couple of mothers said they had received excellent information that was relevant to them as individuals, including real-time access to a member of the diabetes team if they had questions. “It was really clear information, so I made changes straight away to my diet… I could just go straight and phone [the team], ‘I’m going out for tea tonight and I was going to have this, is that ok?’ … and she was really helpful.” M23-GDM However, most mothers had received limited and generic information which they did not find useful and which became increasingly irrelevant as pregnancy progressed and their glucose tolerance changed. “And I never really got any kind of diet help. They obviously tell you to reduce your carbs, your processed stuff, blah, blah, blah, but I was never given any kind of formal training or information to help with it…[The diabetes team says] ‘ What are you eating? Oh, maybe you could just eat a bit less of that and eat more of this,’ and you’re on your way. ” M05-T2D Several mothers said that the NHS information they were given in leaflets or on the website was inaccurate, outdated or contradicted their own experience, and this had led them to lose trust in ‘official’ information. For other mothers, the main problem with the information received was that it gave suggestions that were not culturally relevant. “It was an ancient, photocopied sheet that looked like it had been made in the eighties and all the information was really wrong… Before I had gestational diabetes I was just looking on the NHS website because there is so much other bogus information out there. But this threw that all into disarray because suddenly the NHS advice was not good anymore.” M30-GDM “I didn't follow that recipe book at all because it just wasn't for me or my palette. I guess maybe in different cultures people eat different things.” M17-GDM The dearth of comprehensive practical information could lead a mother to infer that GDM could not be a serious problem, thus undermining the health behaviours that were being promoted. “I thought that I’d have a bit of a conversation with [the specialist] about things like your diet, testing. But it was quite rushed. I didn’t receive a leaflet or any written information... It made me think that maybe it’s not as serious as I’m led to believe.” M22-GDM Some mothers commented that the diabetes teams should make it clear that the advice given would not apply to every pregnant woman in the same way. A couple of mothers said that the team had talked about blood glucose targets without checking the mothers’ understanding of the information they were given. “I’d misunderstood what I was supposed to be doing with my readings. I’d been eating to make sure that they were kept at around a specific level. ‘Oh no, you’re supposed to be under that!’…You’re overloaded with information and you’re worried so you don’t take it all in, you need very clear information of ‘This is what you need to be doing and how you need to be doing it.’” M11-GDM Some mothers felt frustrated when diabetes teams were not able to give them useful suggestions when they reported particular foods spiking their glucose levels, and instead told them that they would need to find out what they could tolerate through trial and error. When asked what information they would ideally have wanted from the NHS, mothers highlighted two key things: comprehensive, practical information that included food swaps and recommended recipes, and access to personalised information, which few had received. “The dietitian said to me, ‘Just experiment and see what works for you’… She didn’t give me any suggestions. Felt like a complete waste of time because I thought, I’ve just relayed all of my story, but for what?” M06-T2 Trusting experiential knowledge Many mothers had turned to online sources to fill the NHS information gaps, citing the websites of UK-based diabetes organisations and nutritionists on social media for their practical and holistic advice (“ your bible to getting through it” M30-GDM). These online sources were, for many, the only way they learned about the benefits of exercise after meals. Some online sources included recommendations that were not part of official NHS advice, such as ‘food combining’ or eating protein and vegetables before carbohydrates in individual meals. Mothers said that these unofficial sources were both more empathetic in tone and more useful than official ones, because they addressed real-life situations and recognised that pregnant women with diabetes still wanted to enjoy food. “They had some tips of what to do, like when your nurse tells you not to snack, they have a laughing emoji and then they tell you what kind of snacks you should have before bed which could actually help with your dawn phenomenon [the increase in blood sugar levels in the early morning]… They made you not feel so bad about yourself ‘cos they’d always remind you it’s not your fault, and you can still have nice treats.” M07-GDM Many mothers particularly valued online peer support forums where they could find out how other mothers managed their diabetes during pregnancy. Some said that they found experiential evidence was more credible and more effective than theoretical information provided by the diabetes team. Across all types of diabetes, mothers were enthusiastic about how these forums had given them moral support as well as useful ideas. “I t was nice to feel like you’re not alone… other people are experiencing it too and it’s OK to have a wobble and be stressed out by it, but to feel supported too. M13-T2D “The midwife and the dietitian had both told me that maybe have two Weetabix [blocks of processed wheat] for breakfast, and … it spiked me straight away, really high. So I posted in that group…and about 15 other people commented on it, saying, ‘You’ll probably find people who have gestational diabetes can’t tolerate cereals and Weetabix, try more protein-based things.’ I felt like that was a bit disheartening, ‘cos if all of these people who have gestational diabetes know all this from trial and error, why don’t the midwives and the dietitians know that?” M20-GDM Many of the mothers who had not been signposted to external resources said that a recommendation by the diabetes team would have been influential and reassuring. However, a couple of mothers described how online peer support could have risks as well as benefits, because they felt frightened or undermined by reading other mothers’ descriptions of their maternity care. “I thought, I'll join a group. It was actually probably one of the worst things I could have done for my mental health. Because it becomes an echo chamber, doesn’t it? …People share their horror stories. I know people need a place to share, but it was really triggering and people in the group were very anti-induction. So I felt crap for my choice [to have a planned induction].” M28-GDM Theme 2: Monitoring and management Technology: convenience, clarity and accountability There was no consistency in what was offered to mothers to test their blood glucose and to communicate the results to the diabetes team. All of the mothers with GDM, three mothers with T2D, and one mother with T1D used finger prick testing, with the results given to the diabetes team by telephone, text message, showing them the results in a notebook, or through an app. Eight mothers with T1D or T2D had used continuous glucose monitoring. Many of the mothers who had monitored their blood glucose through finger prick testing commented that this was unpleasant, burdensome and difficult to fit into working life. All mothers who had used continuous glucose monitoring said that this had improved their diabetes control, in part because the diabetes team could give real time feedback without waiting for the next appointment. “I've got phobia of needles, so… it was traumatic for me to do that testing. And then they were saying to me, the more stressed that you're getting, you're probably spiking your sugars before you are testing because you're working yourself up.” M19-GDM “My diabetic midwife could look at my [CGM] sensor, look at my blood sugars without having to contact me. She could review them and say, ‘We’ll tweak your insulin down’, things like that. She would check them at least once a week.” M18-T2D Mothers who were given an app to record and communicate their glucose readings said that this was more convenient, helped them to notice patterns of highs or lows, and enabled the team to be proactive in following up high readings. Where the app synchronised automatically with the glucose monitor, several mothers said that this helped by making them more accountable. Without this, there was a temptation to manipulate the results to avoid being “told off” . “[The app synchronising] meant that obviously I couldn't lie… They actually were really monitoring me. And while that feels a bit big brothery, it makes you take accountability.” M24-GDM “If I knew I was going to have a cheat day, I would put a different reading, because I knew I was going to get told off…I did tell my nurse afterwards, ‘I had a naughty reading and I might have lied on it. But only because I didn't want you having a go at me.’ " M19-GDM Contrasting attitudes to medication Whereas the mothers with T1D and T2D were used to taking metformin and/or insulin, many of the mothers with GDM said they wanted to avoid taking medication, citing concerns about side effects, the potential impact on the baby, and unwillingness to inject insulin: “That's going to feel like one failure too many” (M28-GDM). This had inspired some to strictly observe a restricted diet, but they then found it upsetting when even this was not enough as their pregnancy progressed: “I was on a militant diet… but I had to go on metformin towards the end, it just made me feel horrible.” M10-GDM A few mothers were critical of what they felt was an over-hasty decision by the diabetes team to move them to medication instead of giving them support to manage their blood glucose through diet. By contrast, a couple of mothers accepted the offer of medication with relief when they felt unable to cope with the dietary restrictions. “I wasn’t given any help in finding out what to eat instead. It felt very dismissive, ’We’ll just put you on medication rather than anything else.’” M11-GDM “I had a one-year-old toddler, I was shattered. I developed [a health condition] and I decided, ‘Diabetes and what the hell I'm eating is another thing I just don't want to deal with…Yeah, put me on medication then.’” M19-GDM Feeling safe: personalised care and positive feedback Some mothers said that they had experienced excellent care from individuals or the team. The key positive aspects of care were that it was non-judgemental, empathetic, responsive, and individualised to their needs. “I did speak to a number of exceedingly patient, kind individuals who talked me off ledges … and were very empathetic in their ‘I can understand it must be very difficult’ and gave me a lot of grace. …I never felt like they were pushing me off the phone. Even with them being under-resourced and under-staffed, I didn’t feel like I was being an idiot for asking questions.” M02-GDM This sense of safety was particularly reported by some mothers with T1D or T2D who experienced continuity of care from a diabetes specialist who made them feel known as an individual, and by mothers who appreciated the increased medical surveillance: “The [specialist] midwifery care was what set my pregnancy up for success… because I had that longitudinal support from one person who knew me. She was the constant.” M14-T1D “That was very, very lucky that we have so much regular contact made with us, it’s classed as specialist care... So the midwife checks up on you. You have extra scans and you have the consultant checking in with you.” M06-T1D Mothers with T1D also described good care as being listened to and recognised as the expert on their own body within a robust diabetes maternity care pathway: “They had a clear system in place that they followed for their diabetic mums … And the thing that I really valued with [the diabetic nurse] was she would acknowledge that she was not necessarily the expert in my diabetes. And she would listen to me and take on board what I was saying was working well and not working well.” M25-T1D Some mothers with T2 or GDM said they judged themselves for having developed diabetes, particularly if they described themselves as overweight. They appreciated healthcare professionals who encouraged self-kindness and were tolerant of occasional deviations from dietary advice. “It was always ‘This is your hormones, it’s nothing to do with the size or the weight of you, it’s simply because your body can’t manage the insulin’ … When they said, ‘It’s not your fault’, that’s the best thing to hear, because you do think it’s your fault.” M23-GDM “The guilt comes into it…They were always really supportive about having a lifestyle, saying that it’s OK to go out and have a bit of birthday cake if it’s your birthday, and normalising that you are human.” M13-T2D Some mothers said they found it motivating to have regular positive feedback about how they were controlling their glucose. “I liked the fact that they’d always say that I was doing really well; they always used to be encouraging, even though I thought I wasn’t doing really well.” M05-T2D However, where praise was given without personalised care, this could lead to harm for a mother with a history of disordered eating who managed her glucose through extreme restriction, and contrasted her experiences of professional support in her two pregnancies: “I had no carbs in my first pregnancy from about week 29 when I was diagnosed … I got so much praise for being diet controlled, but nobody was looking at what I was eating. They just kept saying, ‘Oh, your numbers are great. Keep doing what you're doing.’…The second time they picked up that I had problems with food. [The dietitian] went, ‘What's your relationship with food like?’ So she opened the door for me to make the confession… It was very individual-centred.” M28-GDM Feeling unsafe: rushed, inconsistent, judgemental care Most mothers reported interactions which they experienced as poor care with some (or most) of the health professionals they encountered. Although many mentioned that they knew the quality of care was affected by short staffing, they described impersonal encounters where they felt they were processed hastily and without having a genuine chance to ask questions or to check they had understood. “T hey were rushing and so you felt kind of dismissed: ‘Do you have any questions - no - OK, bye!’”. M10-GDM “When the people that you see haven't read what the last person said, there's nothing linked together…They need to talk to you like you're a person. Because we came home with words written down that we then googled because we didn't know what they meant … [The staff] were putting a coat on. They would get you out the door before you had a chance to think.” M26-T2D Many mothers also described being treated in ways which alienated them: they were disbelieved, reprimanded, accused of eating against medical advice, and treated patronisingly by staff. This made them feel judged, humiliated, and infantalised. “They were shaming. I was trying my very best with what I had. My basals had gone from 18 units a day to 280 units a day… [They told me] this was all my fault because I should be doing things differently… They were saying, ‘We don't believe you're following our advice.’ And I was.” M14-T1D “I'd only been testing for two days [and] I was being interrogated [by the nurse], ‘You're not taking this seriously. You've got all these red [high glucose] readings. Do you not understand the need to be green [low glucose]?’ And I was like, ‘I do understand. But when I was given the kit by the midwife, she explained it will take me a few days to understand what is a trigger for me.’ And the nurse was like, ‘Nope, you do not understand! This is going to harm your baby. If your sugar levels don't get controlled, it could be fatal.’… I was literally being told off like a child as though I'm doing something on purpose. And they made me feel, excuse my language, like shit. I literally came out of that crying.” M19-GDM In particular a few mothers felt explicitly stigmatised by health professionals because of the association between diabetes, overweight and poor diet, and the moral overtone to professionals’ language when they talked about eating, which reinforced mothers’ wider sense of shame and guilt. “People assume if you’ve got diabetes, you tend to be more on the obese side. And then all of a sudden, you’re labelled as part of it. I t’s got connotations…The nurse said, ‘You’ve been good , you haven’t had any reds [high glucose readings].’” M12-GDM “My high readings were always because I knew I had eaten something bad… It's one of those situations like if your teacher or your parents tell you off and you know what you've done anyway, it's more annoying than when you don't know what you've done… So there could be a way that they speak where they talk with you rather than to you.” M24-GDM Stigmatising encounters were also reported by some mothers who described themselves as slim or who had T1D, particularly when health professionals showed a limited understanding of the different types of diabetes. “It was a very brusque person on the phone, who just wanted to bark the diagnosis at you … And I was saying, ‘Hang on, what should I do?’ and she said to me, ‘You should try and be healthier’. It makes you feel extraordinarily guilty and your fault for this happening…[ On meeting the diabetes team later] It feels like they’ve taken you into the ‘fatty room’ because there’s an absolutely enormous chair for the patient but then everyone else is in normal chairs… I just wanted to get out as quickly as possible. I didn’t ask half the stuff I wanted to.” M30-GDM “Some people don’t know the difference between type 1 and type 2 diabetes, which happened a few times in hospital with midwives. If I'd ordered my food and there was a pudding with it, they'd be like, ‘Are you allowed that, you shouldn't be eating that.’ … I kept trying to say ‘No, I'm type 1 diabetic,” and it gets draining having to explain to them. And it's that sense of judgment, they're trying to say that I'm doing stuff wrong, and you think about what they're thinking.” M15-T1D Some of the Asian mothers felt that they had been unfairly targeted for GDM testing (as national guidance is to offer testing for GDM to mothers with risk factors, including an ethnicity with a high prevalence of diabetes). Some also said that staff had then applied stereotyped generalisations. “What's hard is that you only go for the test if you're in a certain group … When you're in the waiting room, it's just a room full of ethnic minorities. ” M16-GDM “T he midwife I spoke to [by telephone] made some assumptions about me and it really upset me: ‘I can see your sugars are still very high... clearly, you must be eating this [type of food],’ and it was very judgemental. And in my opinion they saw my name, I’m Asian … I don’t actually have a typical Asian diet because I actually eat more Englishy food than I do traditional Indian food.’” M07-GDM For some mothers, feelings of safety were undermined when they received contradictory information about how to manage their diabetes safely. This made them uncertain who to trust. “One person that I’d speak to would be like, ‘You can have ice cream here and there, and you don’t need to contact us every time you have a high [glucose reading] that’s explained.’ And then another one would be textbook, ‘The minute you have another high, contact us!’ …When some things conflict, it makes it really difficult to understand what’s the right way.” M02-GDM For other mothers, a key problem was being treated as the condition rather than as a pregnant women who had the condition: “My time in hospital, I was constantly referred to as ‘the diabetic’” (M09-T1D).This could lead to an apparent reduction in normal maternity care when all the attention was placed on diabetes. Likewise women who had other medical issues in their pregnancies as well as diabetes said that a lack of joined-up working between the different teams left them unclear if anyone had an overview of their care and who to turn to when there were complications. “From the minute I was diagnosed with diabetes, it was all about the diabetes and not about the pregnancy. It’s a whistlestop tour of ‘Let’s quickly listen to baby …[now] let’s talk about the diabetes!’ ” M07-GDM “It was starting to get confusing with all the teams... I wanted to know who was the team that was really on top of everything … If someone had to take a decision, who was going to?” M27-GDM A final issue that undermined feelings of safety was when the food that mothers were offered in hospital contradicted all the dietary advice they had been told was essential. Although some mothers had been offered choices that included diabetic-friendly options, others had not; they had resorted to asking family to bring in food for them, or ate the unsuitable food. This could be a particular problem for Asian mothers when the only vegetarian or halal options were carbohydrate-heavy, so mothers faced a choice between going hungry or undoing their own dietary glucose control. “The night I was in before the c-section they gave me a triple carb meal. I inherited the person’s meal selection that was there before. So, obviously I had to eat it because I had nothing else. I think that is why my levels went high… The midwife told me she was type 1 herself, but still, plonking a triple carb meal in front of me! She was really blasé. She said, ‘You’ll be fine. Just take some insulin.’” M05-T2D “[Pakistani women] are given a label of either you’re a vegetarian or halal. [For vegetarians] all you’re given is a cheese sandwich… [And] they just assume that anything that’s halal basically must mean that you want a curry, naan and rice!” M06-T2D Inconsistent management during birth Mothers’ experiences of diabetes management during induction and labour or in preparation for elective caesarean birth were very varied. Some mothers were asked to monitor their own blood glucose during this time, some had this done for them by the midwives, and some were not tested. “I asked my midwife, ‘Do I need to bring my monitor?’ And they were like, ‘No, no. The midwives will check.’ But they didn't check my sugar during labour at all. M24-GDM Several mothers experienced difficulties in managing their blood sugar when they were told to fast before an elective caesarean birth, but the operation was then delayed. “[The midwife] told me that I would be the first in. Because of the fasting, it can send your blood sugar levels haywire. In the end I was the last in; I didn’t get seen until the afternoon. I was having a hypo, quite a big one.” M30-GDM Some mothers who were using an insulin pump were told they could to keep it on, while others were told that the policy was to use a sliding scale during birth. One mother found herself in an unsafe situation when maternity staff did not appear to understand how to care for a mother who needed insulin. In response to frequent hypoglycaemic episodes in late pregnancy, the diabetes team had documented a plan for her to go on a sliding scale the evening before her caesarean birth to protect the baby by achieving 24 hours of stable blood sugar. When the mother had taken off her insulin pump and taken long-acting insulin, maternity professionals on a new shift refused to put her on the sliding scale, but she was unable to go back to the insulin pump because of the long-acting insulin. “[They said] that I would have to just monitor myself and shout to them if I had any problems. I challenged them a lot on that and they absolutely refused… I had to stay up all night and keep monitoring my blood sugars. But the stress of that was absolutely horrific. Because my consultant had been really honest about the risks if my blood sugars was deranged before having baby. So to know that they had increased my risk of it going wrong, I was frustrated, really angry, really scared… They didn't have that knowledge to understand what I was saying. It was one of them times where I thought, ‘I don't trust these people to actually look after me.’ ” M15-T1 Theme 3: Communicating risk and choice Supporting informed choice or gaining compliance through fear Mothers accepted that healthcare professionals had a duty to give them information about the potential risks of diabetes for pregnancy outcome, and felt that these facts could potentially motivate behaviour change and enable them to make informed choices. They were, however, very critical when the risks were communicated in ways which they experienced as hysterical and frightening. “I was trying so bloody hard and my sugars were not getting better and I was just having to up and up that insulin. And I then felt like I wasn’t doing good enough and the person on the phone was like, ‘Oh my God, this is so bad for your baby, this is so dangerous!’ The way she was saying it made me worry even more.” M07-GDM Mothers were adamant that information about mitigating risk should always be communicated at the same time as information about the risk itself (see subtheme Diagnosis and timing of information ). Without this they felt intensely vulnerable: “I felt like I was being left to my own devices…If the repercussions is that bad then I felt like there wasn’t enough emphasis on how to manage it properly .” M10-GDM For some mothers, the way that health professionals talked about risk had felt as if it was actively intended to coerce them to accept an intervention, rather than to offer informed choice. “We'd had a scan and they'd said, ‘You're carrying a big baby, so we're going to induce you.’ And if there'd have stopped there, that would've been fine. But the diabetic lady, she put the fear of God in me by saying, ‘You've got a HUGE baby. And if it's a vaginal delivery, we might have to break arms and limbs to get her out. And it might get stuck.’ It was horrific. Tuesday, Wednesday, I think I cried every minute of every day. And then on the Thursday we had a normal midwife appointment, and she said the exact opposite. She said, ‘They say that to frighten you into having an elective caesarean’… And [the baby] wasn't big. She was seven and a half pounds.” M26-T2D Mothers said that it was frustrating when guidelines about birth were applied without any personalisation relating to their actual glucose control or predicted size of the baby, and some had pushed for specific information about the scientific basis for particular recommendations and policies. “Just because I am diabetic, doesn’t mean that I fall into that broad spectrum of other diabetics. We’re all individuals. So, yes, I understand their recommendations and procedures that have worked, but don’t forget that we are more than diabetes .” M09-T1D In particular, it was impossible for mothers to evaluate the magnitude of their personal risk and make a genuinely informed choice if they were told only relative and not absolute risks of adverse outcomes. “It was almost like a threatened choice because I wasn't sure that I was actually at high risk. How bad was my levels compared with other people?…There's another fear in you [when] the doctor says you’re ‘choosing stillbirth’, basically…I didn't know how small the risk really was. Still today, I don't know.” M17-GDM Birth options: choice offered or doctor decides The issues of explaining risk and offering choice were most graphically reflected in the discussions mothers described about where, when and how they would give birth. All of the mothers had been told their only option for place of birth was a consultant-led obstetric unit. A quarter of the mothers, across all types of diabetes, said that they felt they were offered genuine choice in their options for mode and timing of birth, with enough information to make this choice confidently. Some had opted to wait for labour to start spontaneously, some had chosen early induction and some had chosen elective caesarean section. “They weren’t favouring one [type of birth] over the other in trying to encourage me to pick one. It was all what I wanted to do; I had plenty of time to decide and they gave me all the information that I needed... I was really happy with my decisions.” M08-T1D However, the majority of mothers had not experienced discussions about the timing or mode of birth that respected their autonomy as decision makers. Across all types of diabetes, many described being told at the outset that they were “not allowed” to continue the pregnancy past a particular gestation. If they tried to negotiate, the health professionals implied that slightly delaying intervention was a favour they could grant. Mothers said these encounters were unnecessarily stressful. “As soon as I got diagnosed with diabetes, my community midwife said, “They’re not going to let you carry to 40 weeks. We will get you induced from 38-39 weeks” … It’s like ‘Go and prepare for an induction!’ ” M31-GDM “I said that I would think about it, when they were forcing me to have an induction … The doctor said, ‘But I have given you an extra few days compared to women who would be taking tablets!’ I got an extra few days.” M03-GDM Theme 4: The postnatal cliff edge Lack of preparation for the postnatal period Most mothers reported receiving minimal information during pregnancy about how their diabetes and its consequences would be handled postnatally. For example, mothers mentioned that they were not told about the risk of jaundice, or about expressing colostrum antenatally in case their newborn baby experienced hypoglycaemia. Some with GDM were also not told that they could stop testing their blood glucose after birth, and some with T1D had not been prepared for the complexity of managing insulin while breastfeeding. “Nobody had that conversation [about insulin while breastfeeding]’ with me. So I had no idea about that… That would have been useful… A nice little leaflet saying, ‘Diabetes after birth; if you’re breastfeeding, try this. If you’re not breastfeeding, try this.’” M09-T1D By contrast, a couple of mothers with T1D had received clear information about postnatal blood glucose and insulin in advance, which helped them to cope better. “Quite a bit of time before my c-section was due, I sat down with the consultant and we wrote out a proper plan … It really reassured me that’s going to give me the best control, and that helped me prepare. ” M08-T1D Diabetes care is cut off Just one mother with GDM described a specific local policy for the diabetes team to follow up mothers after birth with comprehensive information about self-care and an opportunity to ask questions. “When I was leaving the hospital, the diabetes midwives came and saw me. They made it a policy that every woman that had been under their care, they would check in on your baby, answer any questions about post-pregnancy …I was given information on leaving the hospital that was really useful…She was, hand on heart, the best healthcare professional I've ever dealt with.” M28-GDM Most mothers said they were shocked by the total withdrawal of care from the pregnancy diabetes team from the moment of birth: “The only thing they focused on was getting you to 37 weeks. And then it seems like you drop off the edge of a cliff after that in terms of the support ” (M15-T1D). In hospital, this loss of care manifested immediately in postnatal staff who were unaware or did not remember that the baby’s and mother’s blood glucose should be tested after birth: “We had to ask them should the baby be tested, because they forgot .” (M10-GDM) The abrupt loss of care after intensive antenatal support also left many mothers with all types of diabetes feeling vulnerable and neglected in the community. This loss of care was unsettling for many mothers but was particularly problematic for mothers with T1D who experienced significant difficulties in managing their blood glucose after birth. “I felt confident when I was pregnant that the gestational diabetes team would keep me safe…I do not have any confidence that my GP practice knows that I had gestational diabetes or what to do in terms of long-term monitoring.” M11-GDM “There was absolutely no diabetic care after delivery whatsoever…I had to manage myself with my blood sugars after and they were everywhere…I was fluctuating between hypo and high constantly [while breastfeeding]. … I was worried because I was just guessing [how many units of insulin to use] every single time .” M32-T1D Mothers said that it did not make sense for all the resources to be allocated to pregnancy and nothing at all to the postnatal period, and suggested that the diabetes team’s care should extend into the immediate weeks after birth. They said it was not realistic to put the onus on mothers with a newborn baby to proactively try to get help when they were exhausted and worried about being seen as a nuisance or being criticised, especially if they were also experiencing mental health challenges. “When I was pregnant, it felt like everyone really cared. As soon as she came out, it was like I didn't matter anymore. They just said that if I had any questions, to give them a ring... I think it's really difficult when you're struggling [with postnatal depression and anxiety] to reach out to people… And if you've been struggling for say three weeks and you think, ‘I’ll get into trouble because my blood sugars have been running really high all this time and I’ve not done anything about it,’ then you're even less likely to reach out.” M15-T1D Unsystematic follow up by GPs Mothers with GDM described inconsistent experiences of having their blood sugar checked by the general practitioner (GP) in the community, using the recommended fasting plasma glucose test at 6–13 weeks after birth. A few mothers said they were proactively told by the GP that this test was needed, and one mother described a local process where her hospital team had alerted the GP to make this appointment. “When I got the original prescription from the hospital to get the pipettes to do the [finger prick] test, I had to take it to my doctors so they could write the prescription and in it was also a note for them to arrange an appointment after I’d had the baby. And so that was actually arranged before I’d even had the baby. My doctors were really, really good .” M12-GDM Most mothers said that there appeared to be no communication between the hospital and the GP to flag that the mother had had GDM, even if the GP had issued prescriptions for metformin. It was left to the individual mother to remember to book the appointment, but in some cases the mother was unaware that she was supposed to do it this: “No one ever told me about a follow-up or to book in a follow-up” (M19-GDM). Mothers pointed out that this was a flawed system because it was easily forgotten in the chaos of postnatal life, and a mother might not take the initiative if she was worried about the result. “Truthfully, I forgot… I’ve got a new baby, my priority went down the list. It was like, I’ve been cleared, I don’t need to worry anymore.” M01-GDM Where mothers had booked to have the test, they frequently encountered perplexity at the GP surgery about what was needed, differing policies over whether or not this could be combined with their own postnatal check at 6-8 weeks, and confusion over whether or not it should be a fasting test. Many women said they took the test but were not given the result. They commented that this process was particularly unsafe for women who did not speak English. “They didn’t know what to do for the blood test either. It was supposed to be fasted blood test, they hadn’t told me to fast in the morning for it…And when I turned up for it they had to ring the other GPs and ask questions about, ‘Well she’s saying she needs it ‘cos she had gestational diabetes, is this right?’ And I feel like there’s going to be a lot of people here [who don’t speak English] that slip through the gaps of connective care afterwards.” M11-GDM Likewise the onus was on the mothers to arrange annual blood sugar testing follow-ups, but not all mothers were confident they would remember to do this. “They did mention that we will probably have to have yearly checks, to check sugar levels … We have to remember, amongst everything else in life!” M03-GDM Inconsistent advice about reducing future risk For mothers with GDM, there were inconsistent messages about whether or not they should maintain the diet and exercise regime that had been recommended for pregnancy. Some mothers remembered being given clear and specific information, either in hospital or following a 6-13 week blood glucose test, about their future risk of developing T2D and how to avoid this, and said they were motivated to maintain lifestyle changes to minimise their risk. “They did say, ‘You're 50% more likely now to develop type 2 diabetes in the next five years after you've had your baby.’ That wasn't nice to hear because I've got diabetes in my family anyway. I did go back to my better diets again... I really don't want to develop diabetes.” M21-GDM However, most mothers said that they were not advised to maintain a risk-reducing lifestyle, but were told they could resume their pre-pregnancy diet without the health professional having established the suitability of that diet. The message that there was no need to pay attention to diet was reinforced in hospital when women were offered sweet biscuits or white bread and jam straight after giving birth. “They said maybe in your second pregnancy, you could get [gestational diabetes] again and you are obviously more at risk of type two in the future. They didn't say anything about taking care of it. They were like, ‘After giving birth, just eat as you want.’ That's it.” M24-GDM Mothers pointed out that even when they were given advice to continue a diabetes prevention lifestyle, this was intrinsically difficult while looking after a newborn baby, when it was hard to prioritise their own needs. After the stress of following dietary restrictions during pregnancy, they were relieved to return to pre-pregnancy eating and exercise patterns if health professionals appeared to encourage this, or did not give them clear advice on what they should do to reduce their risk. This had direct negative consequences for a mother who had lost weight during pregnancy and a mother who was diagnosed as pre-diabetic after her first baby and developed T2D before the second. “I got really good feedback from the practice nurse: ‘Your risk is really low now [after losing weight], so we don’t need to do anything. Just go home and eat and catch up on everything you’ve missed.’ …Then I kind of went the other way, because I was emotionally deprived of food as well…So, obviously what’s ended up happening over the course of this year is I put all the weight back on.” M06-T2D “I didn’t realise the severity of having pre-diabetes. I received a text message from my GP after having [baby 1] to say I was pre-diabetic and I didn’t think anything of it. I didn’t realise how important it would have been to change my diet back then, and I probably could have prevented having type 2 diabetes.” M13-T2D Discussion This study found that antenatal, birth and postnatal care experiences for mothers with all types of diabetes were mixed, with wide variation in practice, despite standardised national guidelines on diabetes in pregnancy being available for the National Health Service in England (National Collaborating Centre for Women's and Children's Health, 2015 ). The themes identified were similar across all types of diabetes. Some mothers with T1D diabetes had received comprehensive pre-conception counselling; antenatal care from an expert team who followed a clear care pathway, respected their own expertise on their bodies, and offered meaningful informed choice about mode and timing of birth; well-planned intrapartum care that included management of their blood glucose before and during birth; and detailed planning for postnatal care that enabled them to prepare for the challenges of managing blood glucose after birth, especially when breastfeeding. Other mothers with T1D in different parts of England had received none of these things, and consequently felt unsafe at every stage. Some mothers with GDM and T2D had received care that made them feel safe, understood and respected. They received clear, high quality and timely information about diet and exercise to manage the condition, and signposting to recommended resources; access to personalised advice from the diabetes team or a dietitian; real time communication of blood sugar test results to the diabetes team through the use of technology; clarity about the management of blood glucose during birth; choice about mode and timing of birth; and information to prepare for the postnatal period. Again, many had not received this support. Only a few mothers had received a proactive invitation from their GP for blood glucose testing at 6–13 weeks after birth. Only one out of the five mothers with T2D had received any preconception advice. The patchy provision of preconception care for women with pre-existing diabetes has been attributed to the lack of a standardised care pathway (Dyer et al., 2025 ). Across all types of diabetes, mothers said that having a pregnancy complicated by diabetes had created additional stress, anxiety, feeling out of control, guilt and shame. This in line with previous findings about the psychological impact of a diagnosis of GDM or of becoming pregnant with pre-existing diabetes (Craig et al., 2020 ; Pham et al., 2022 ; Roddy & McGowan, 2024 ; Sushko et al., 2021 ), which may be categorised as ‘diabetes distress’ (Tschirhart et al., 2024 ). This study found that good maternity and postnatal care could decrease mothers’ diabetes distress, while poor care increased it, with the potential to create a vicious circle since increasing stress may in itself increase blood glucose instability and reduce self-care (Lloyd et al., 2005 ). One of the key ways in which distress could be decreased was through the provision of high quality information about self-management of diabetes, given at the time of diagnosis (for GDM) or before or early in pregnancy (for pre-existing diabetes). There were highly inconsistent approaches (between different hospitals and within the same hospital) to the content and format of information about diet and exercise that was made available to mothers, an endemic problem highlighted in previous reviews (Craig et al., 2020 ; Van Ryswyk et al., 2015 ). Mothers were very critical of services that had not given them enough specific and up-to-date information to make the recommended lifestyle changes, had delayed giving them this information, or had not offered a referral to a dietitian or advice about regularly exercising after meals, contrary to national guidance (National Collaborating Centre for Women's and Children's Health, 2015 ). Many mothers had turned to online sources of information to fill the gap, and in some cases diabetes teams had signposted mothers directly to these external sources. Mothers particularly valued receiving practical and empathetic advice, recipes and food swaps from other mothers with diabetes, although some were cautious of other aspects of peer support. Pham et al. ( 2024 ) have drawn attention to the important role that peer-led online communities can have in meeting information and support needs in the context of resource-constrained formal healthcare. However, some of the advice that mothers described receiving from online sources differed significantly from the NHS advice – for example, standard NHS advice for mothers with GDM is to eat a diet based on starchy and low glycaemic index foods with plenty of fruit and vegetables (National Health Service, 2022 ), whereas a popular user-led website recommends a diet high in protein, natural fats and green vegetables and low in carbohydrates, with carbohydrates only eaten ‘paired’ with natural fat or protein to slow down the release of glucose (Gestational Diabetes UK, 2023 ). There is currently insufficient evidence about the optimal dietary and exercise strategies that will improve outcomes for women with GDM (Dingena et al., 2023 ; Han et al., 2017 ; Yamamoto et al., 2018 ), and a review by Dingena et al. ( 2023 ) found that there were also no randomised controlled studies or crossover trials on diet or exercise interventions for pregnant women with pre-existing diabetes. Given the variation even between national guidelines in different countries on diet and exercise for mothers with diabetes in pregnancy (Rasmussen et al., 2020 ), this is an important topic for future research. Previous studies in the UK have reported paternalistic and judgemental encounters with health professionals (Parsons et al., 2018 ; Stenhouse et al., 2013 ). NHS guidance specifically cautions health professionals against using value-laden language such as ‘good’, ‘bad’ or ‘failing’ when talking to people with diabetes, as this can increase shame and “imply that following instructions will result in perfect glucose levels, even though it is known that the tools to manage diabetes are far from perfect ”(NHS England, 2018 , p. 8). This may be particularly relevant for those mothers with GDM and T2D who have previously felt stigma in the context of their weight (Duarte et al., 2017 ), which may be inadvertently reinforced by health professionals’ choice of words. Contemporary dieting culture both creates feelings of moral transgression for food choices and engenders resistance (Madden & Chamberlain, 2010 ), and this culture was reflected in this study with some mothers describing themselves as “naughty” and expecting to be “told off” by an authority figure, while others asserted a right to “treats” or a “lifestyle” which went against strict dietary advice. This framing led to mistrust on both sides, with some mothers occasionally falsifying blood glucose results (as also found by Draffin et al. ( 2016 )), and in other cases health professionals refusing to believe that a mother was could be following their advice if she was unable to control her blood glucose. Simplistic praise for ‘good’ glucose control could also have a malign impact on women with a history of eating disorder who used extreme food restriction, a coping strategy also identified by Draffin et al. ( 2016 ). Although mothers with T1D have been reported to have mixed feelings about using technology for diabetes management (Roddy & McGowan, 2024 ), in this study mothers with all types of diabetes welcomed the use of technology as convenient, supporting honest communication and increasing their control over their diabetes. Previous research has found that some mothers with diabetes simply do not want to hear about the risks of negative outcomes for their babies (Parsons et al., 2018 ), but it is a more common finding that mothers feel health professionals use the risks to pressurise them into compliance with interventions (Parsons et al., 2018 ; Roddy & McGowan, 2024 ). All the mothers in this research accepted the importance of knowing about the potential risks, which could motivate them to make the sometimes difficult behaviour changes, but they were critical of health professionals who communicated these risks in ways that were alarmist, not personalised and lacked detail about absolute rather than relative risk. The challenges of communicating pregnancy risks in a way that is effective but not alarmist has been highlighted in other contexts such as maternal obesity (Duarte et al., 2017 ). Parsons et al. ( 2018 ) suggest that health professionals’ behaviour may be influenced by their own anxiety if mothers’ blood glucose is not controlled and the baby’s health is at risk, but by contrast this study also found examples of health professionals who talked in a balanced and empathetic way about the causes of diabetes, food choices, and risk, and fully supported mothers’ autonomy as experts on their own bodies and decision makers. A couple of mothers in this study were uncomfortable that they had been offered GDM testing on the grounds of ethnicity, interpreting this as unfair targeting rather than being prioritised for an enhanced service. This suggests the need for more careful messaging about why the test may be offered, and echoes a finding, in a report about stillbirth, that Black and Asian parents may decline diabetes testing if ethnicity is cited as a risk factor without the reasons being well explained (Sands, 2023 ). Some mothers also experienced stereotyping about the foods they were assumed to eat based on their ethnicity, and a lack of culturally relevant dietary information, as previously reported for women from minority ethnic and migrant groups (Bandyopadhyay, 2021 ; Draffin et al., 2016 ; Kirkham et al., 2021 ). Where culturally inclusive resources have been developed locally (Bridle, undated), there is no mechanism for sharing them to other parts of the NHS. Previous research has found that mothers with diabetes may be unhappy about the medicalisation of their pregnancies, or reassured by it (Edwards et al., 2016 ; Parsons et al., 2014 ; Parsons et al., 2018 ). The mothers in this study generally appreciated the additional monitoring they received provided it was meaningful, while being in some cases critical if they were told to take medication before they had a chance to try glucose control through dietary changes and exercise. Some were also frustrated at being seen only through the lens of diabetes so that normal maternity care was reduced or rushed (Edwards et al., 2016 ; Parsons et al., 2018 ). Being classed as a ‘high risk’ pregnancy was directly linked to a reduction in the birth choices offered to the mothers, so that none were offered the option of a birth outside an obstetric unit, although it has recently been found that women with well controlled GDM may safely plan birth in a midwifery unit on the same site as obstetric and neonatal services (Morelli et al., 2024 ). Many mothers reported that they were told, as soon as they were pregnant (for T1D and T2D) or as soon as they were diagnosed (for GDM), that they were “not allowed” to continue their pregnancy past gestations of 37–39 weeks. While national guidance supports advising to mothers with pre-existing diabetes and no other complications to give birth between 37 weeks and 38 weeks plus 6 days, it specifies that women with GDM should be advised to give birth before 40 weeks plus 6 days (National Collaborating Centre for Women's and Children's Health, 2015 ). The evidence of this study is that in some hospitals, early induction was being applied to women with uncomplicated GDM as a matter of policy, and was not communicated as a recommendation but as the doctor’s decision. Whereas mothers received an intensive level of specialist care during pregnancy, this did not continue during and after birth when they were handed over to non-specialist teams who did not necessarily have any understanding of diabetes management, putting mothers and babies at avoidable risk of harm. Mothers with T1D who were used to autonomy in managing their blood glucose found it disempowering when they were “not allowed” to control their own insulin during labour and birth, and frightening when maternity teams did not demonstrate understanding of how to keep their blood glucose stable. Some mothers reported that during in-patient stays in hospital they were given food that undermined the dietary guidance they had been given for diabetes, and that this was a particular problem for Asian mothers. In line with earlier findings (Craig et al., 2020 ; Parsons et al., 2018 ; Roddy & McGowan, 2024 ), mothers with all types of diabetes felt vulnerable and unsafe when their specialist diabetes care was suddenly cut off from birth, and they suggested that it should ideally be continued into the immediate postnatal period. This postnatal ‘cliff edge’ had immediate consequences for mothers with T1D who had great difficulty in managing their fluctuating blood glucose while breastfeeding (Sparud-Lundin & Berg, 2011 ). Most mothers had not been prepared for this loss of care, and nor had their diabetes team tried to fill this gap by giving them information in advance about how diabetes might affect mother and baby postnatally. The absence of continuity of care between the antenatal diabetes team and the staff on labour suites and postnatal wards was mirrored in many cases by the lack of joined-up working between the hospital and community health services, with some women and some GPs unaware of follow up testing for mothers with GDM. There is a substantial literature on prevention of T2D after GDM, including the reasons why mothers may not take up testing (Dennison et al., 2020 ; Dennison et al., 2019 ); this study highlights a key barrier from within the healthcare system itself, with lack of communication and awareness meaning that considerable persistence was needed to get tested at some GP practices. The absence of joined-up care carried a real risk of future harm when GPs and postnatal staff in hospital and the community had a limited understanding of diabetes and reassured mothers with GDM that they could go back their pre-pregnancy lifestyle, instead of recommending that they continue a diabetes prevention lifestyle in line with national guidance (National Collaborating Centre for Women's and Children's Health, 2015 ). However, on most of these postnatal issues there were also some examples of good practice – where mothers were given full information about likely postnatal challenges and how to manage them, were followed up by the antenatal diabetes team before leaving hospital, were given comprehensive information about future risk and how to avoid it, or were automatically invited for follow up testing with liaison between hospital and GP. The fact that following guidance and providing person-centred care was achievable in some NHS services in England suggests that it should be achievable for all. Strengths and limitations This study included mothers with all three types of diabetes, and from diverse backgrounds and diverse parts of England, and explored their experiences across the whole maternity and postnatal care continuum. While this has enabled their experiences to be thematically analysed and compared, it also meant that more limited numbers of mothers with the less common T1D and T2D were included. Conclusions There were examples of both good and poor practice. Mothers’ experiences of care during a diabetic pregnancy could be improved if all NHS services followed existing national guidelines and offered person-centred, non-judgmental care that respects the autonomy of the mother as a decision-maker based on sufficient information about personal risk. Mothers need high quality, consistent, evidenced-based, culturally relevant and timely information about managing diabetes, with specific practical tips and recipes and access to support from other mothers, and this might be achieved by services working in partnership with third sector organisations. Primary and secondary healthcare needs to be joined up so that women with diabetes receive pre-conception counselling, support in pregnancy and for a transitional period after birth, and intrapartum and postnatal care that addresses their needs as mothers who have or have had diabetes and may be at future risk. The continuing increase in pregnancies affected by diabetes means that all health professionals who are involved in maternity and postnatal care need the knowledge, skills and confidence to support mothers with all types of diabetes. Declarations Ethical approval and consent The University of Oxford Medical Sciences Interdivisional Research Ethics Committee approved the study (R85996/RE001). Informed consent was obtained from all participants and all methods were carried out in accordance with the Declaration of Helsinki and relevant guidelines and regulations. Consent to publish Not applicable Availability of data and materials The datasets generated during the current study are not publicly available due to the consent process but are available from the corresponding author on reasonable request. Conflict of interest The authors declare they have no competing interests. Funding This research is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-1217-21202. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Authors’ contrib u tions JM and FA designed the study. JM conducted the interviews and analysed the data, and FA analysed a subset of the data. JM wrote the first draft, and FA reviewed and agreed the final version of the manuscript. Acknowledgements Thank you to the mothers who took part in this study, and to our PPI contributors who reviewed the study documents, advised on the interview topic guide, publicised the study to recruit participants, and commented on the findings: Niki Beslin, Sarah Dunkley, Amber Marshall (Big Birthas), Anna Morris (Diabetes UK), Vanathy Nathan, Joanne Paterson (Gestational Diabetes UK). Authors’ information JM & FA: NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Public Health, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK. 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(2024). Outcomes for women with diabetes admitted for labour care to midwifery units in the UK: a national prospective cohort study and survey of practice using the UK Midwifery Study System (UKMidSS). BMJ Open, 14 (12), e087161. doi: 10.1136/bmjopen-2024-087161 Murphy, H. R., Howgate, C., O'Keefe, J., Myers, J., Morgan, M., Coleman, M. A., Jolly, M., Valabhji, J., Scott, E. M., Knighton, P., et al. (2021). Characteristics and outcomes of pregnant women with type 1 or type 2 diabetes: a 5-year national population-based cohort study. Lancet Diabetes Endocrinol, 9 (3), 153-164. doi: 10.1016/s2213-8587(20)30406-x National Collaborating Centre for Women's and Children's Health. (2015). Clinical Guidelines Diabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the Postnatal Period Diabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the Postnatal Period . London: National Institute for Health and Care Excellence (UK). National Health Service. (2022). Gestational Diabetes - Treatment. Retrieved 25 March 2025, from https://www.nhs.uk/conditions/gestational-diabetes/treatment/ NHS Digital. (2023). National Pregnancy in Diabetes Audit 2021 and 2022 (01 January 2021 to 31 December 2022). NHS England. (2018). Language Matters: Language and diabetes . NHS England. Parsons, J., Ismail, K., Amiel, S., & Forbes, A. (2014). Perceptions Among Women With Gestational Diabetes. Qualitative Health Research, 24 (4), 575-585. doi: 10.1177/1049732314524636 Parsons, J., Sparrow, K., Ismail, K., Hunt, K., Rogers, H., & Forbes, A. (2018). Experiences of gestational diabetes and gestational diabetes care: A focus group and interview study. BMC Pregnancy and Childbirth, 18 (1), 25-25. doi: 10.1186/s12884-018-1657-9 Pham, S., Churruca, K., Ellis, L. A., & Braithwaite, J. (2022). A scoping review of gestational diabetes mellitus healthcare: experiences of care reported by pregnant women internationally. BMC Pregnancy and Childbirth, 22 (1), 627. doi: 10.1186/s12884-022-04931-5 Pham, S., Churruca, K., Ellis, L. A., & Braithwaite, J. (2024). Help-Seeking, Support, and Engagement in Gestational Diabetes Mellitus Online Communities on Facebook: Content Analysis. JMIR Form Res, 8 , e49494. doi: 10.2196/49494 Pidgeon, N., & Henwood, K. (1997). Using grounded theory in psychological research. In N. Hayes (Ed.), Doing qualitative analysis in psychology . Hove: Psychology Press. Rasmussen, L., Poulsen, C. W., Kampmann, U., Smedegaard, S. B., Ovesen, P. G., & Fuglsang, J. (2020). Diet and Healthy Lifestyle in the Management of Gestational Diabetes Mellitus. Nutrients, 12 (10). doi: 10.3390/nu12103050 Roddy, J., & McGowan, L. (2024). What are the childbearing experiences of women with type 1 diabetes? A scoping review of qualitative literature. Midwifery, 128 , 103884. doi: 10.1016/j.midw.2023.103884 Sandelowski, M. (2000). Whatever Happened to Qualitative Description? Research in Nursing and Health, 23 , 334-340. doi: 10.1002/1098-240X(200008)23:43.0.CO;2-G Sands. (2023). The Sands Listening Project: Leraning from the experiences of Black and Asian bereaved parents. London: Sands (Stillbirth and Neonatal Death Society). Sparud-Lundin, C., & Berg, M. (2011). Extraordinary exposed in early motherhood - a qualitative study exploring experiences of mothers with type 1 diabetes. BMC Women's Health, 11 (1), 10-10. doi: 10.1186/1472-6874-11-10 Stenhouse, E., Letherby, G., & Stephen, N. (2013). Women with pre-existing diabetes and their experiences of maternity care services. Midwifery, 29 (2), 148-153. doi: 10.1016/j.midw.2011.12.007 Sushko, K., Menezes, H. T., Strachan, P., Butt, M., & Sherifali, D. (2021). Self-management education among women with pre-existing diabetes in pregnancy: A scoping review. International Journal of Nursing Studies, 117 , 103883. doi: 10.1016/j.ijnurstu.2021.103883 Toledo-Chavarri, A., Delgado, J., & Rodríguez-Martín, B. (2024). Perspectives of women living with type 1 diabetes regarding preconception and antenatal care: A qualitative evidence synthesis. Health Expectations, 27 (1), e13876. doi: 10.1111/hex.13876 Tschirhart, H., Landeen, J., Yost, J., Nerenberg, K. A., & Sherifali, D. (2024). Perceptions of diabetes distress during pregnancy in women with type 1 and type 2 diabetes: a qualitative interpretive description study. BMC Pregnancy and Childbirth, 24 (1), 232. doi: 10.1186/s12884-024-06370-w Van Ryswyk, E., Middleton, P., Shute, E., Hague, W., & Crowther, C. (2015). Women's views and knowledge regarding healthcare seeking for gestational diabetes in the postpartum period: A systematic review of qualitative/survey studies. Diabetes Research and Clinical Practice, 110 (2), 109-122. doi: 10.1016/j.diabres.2015.09.010 Woolley, M., Jones, C., Davies, J., Rao, U., Ewins, D., Nair, S., & Joseph, F. (2015). Type 1 diabetes and pregnancy: a phenomenological study of women's first experiences. Practical Diabetes, 32 (1), 13-18. doi: https://doi.org/10.1002/pdi.1914 Yamamoto, J. M., Kellett, J. E., Balsells, M., García-Patterson, A., Hadar, E., Solà, I., Gich, I., van der Beek, E. M., Castañeda-Gutiérrez, E., Heinonen, S., et al. (2018). Gestational Diabetes Mellitus and Diet: A Systematic Review and Meta-analysis of Randomized Controlled Trials Examining the Impact of Modified Dietary Interventions on Maternal Glucose Control and Neonatal Birth Weight. Diabetes Care, 41 (7), 1346-1361. doi: 10.2337/dc18-0102 Ye, W., Luo, C., Huang, J., Li, C., Liu, Z., & Liu, F. (2022). Gestational diabetes mellitus and adverse pregnancy outcomes: systematic review and meta-analysis. BMJ, 377 , e067946. doi: 10.1136/bmj-2021-067946 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 14 May, 2026 Reviews received at journal 13 Feb, 2026 Reviewers agreed at journal 20 Jul, 2025 Reviewers agreed at journal 13 Jul, 2025 Reviewers invited by journal 11 Jul, 2025 Editor invited by journal 13 Jun, 2025 Editor assigned by journal 10 Jun, 2025 Submission checks completed at journal 10 Jun, 2025 First submitted to journal 09 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6855141","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":484766261,"identity":"678aeaec-c8a1-4ecd-8ffc-b396cced1ce7","order_by":0,"name":"Jenny McLeish","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIiWNgGAWjYBACxgYogw/IZGaoQJFkw6+FDazlDBFaUKSZGduI0MLc3nvsMQ/DNnk29ubmz4Xz7uTxSyQwAkXs5Bkk0hKwOqznXLoxD8Ntwzaeg23SM7c9K5ackcBsOIMh2bBBIu0AVi0zcsykgVoS2CQS25h5tx1O3HADyP7AwJzAIJHegFXL/DdQLfIPmz/zzjmcuB+kJYGhHreWGTwwWxgbpHkbgLZIgG05DNSCw2E9OWaScwxAfklsk+Y5drhY4szDZsMZBseBIs+wet+w/YyZxJuK2/L87Mcff+apOZzH35588DFPRTVQJM0Aqxagc5l4kKQSINFrgDsi5UGO+4EkgNUto2AUjIJRMLIBAMDmVsAbL8dwAAAAAElFTkSuQmCC","orcid":"","institution":"University of Oxford","correspondingAuthor":true,"prefix":"","firstName":"Jenny","middleName":"","lastName":"McLeish","suffix":""},{"id":484766262,"identity":"542b1aad-aa1e-440b-8746-32438ed373d7","order_by":1,"name":"Fiona Alderdice","email":"","orcid":"","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"Fiona","middleName":"","lastName":"Alderdice","suffix":""}],"badges":[],"createdAt":"2025-06-09 13:53:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6855141/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6855141/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86759358,"identity":"7880f659-5eb6-4649-bc29-0685dc50c398","added_by":"auto","created_at":"2025-07-15 10:01:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":433119,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThemes and subthemes\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6855141/v1/9aa339a01028f91ff4322010.png"},{"id":86760549,"identity":"dd18f377-a7ba-4a98-994b-6c9b26699fcc","added_by":"auto","created_at":"2025-07-15 10:17:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1483919,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6855141/v1/b9d78bed-8e0b-42c2-a84d-bdc7893ee0e8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“We are more than diabetes”: a qualitative study of maternity and postnatal care experiences of mothers in England with type 1, type 2 and gestational diabetes","fulltext":[{"header":"Background","content":"\u003cp\u003eDiabetes is a significant health issue during and after pregnancy, affecting over 5% of pregnancies in England (England, 2024; NHS Digital, 2023) although this is likely to be a significant underestimate (Jones et al., 2025). The most common type is gestational diabetes mellitus (GDM), which is high blood glucose first diagnosed in pregnancy that normally resolves after birth (National Collaborating Centre for Women's and Children's Health, 2015). Of the women with pre-existing diabetes who become pregnant, 44% have type 1 diabetes (T1D) and 56% have type 2 (T2D) (NHS Digital, 2023).The increasing prevalence of GDM and T2D in pregnancy is associated with the population rise in obesity, more women becoming pregnant at an older age, and the increasing numbers of younger women with early-onset T2D (National Collaborating Centre for Women's and Children's Health, 2015; NHS Digital, 2023). Women from some ethnic minority communities and women from more disadvantaged socio-economic groups are at increased risk of developing T2D and GDM (National Collaborating Centre for Women's and Children's Health, 2015; NHS Digital, 2023).\u003c/p\u003e\n\u003cp\u003ePregnant women who have T1D or T2D have an increased risk of complications and adverse pregnancy outcomes (Murphy et al., 2021; National Collaborating Centre for Women's and Children's Health, 2015). Adverse outcomes can be significantly improved when women are supported to monitor and manage their blood glucose effectively, usually with insulin and/or oral medication (metformin), and the recent improvement in maternal blood glucose control and pregnancy outcomes for women with T1D in the UK has been associated with the roll-out of wearable continuous glucose monitoring (CGM) systems (Murphy et al., 2021; NHS Digital, 2023).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGestational diabetes is also associated with increased risk of complications if blood glucose levels are not managed (Ye et al., 2022). Management may be through changes to diet and exercise alone, or with the addition of metformin and/or insulin (National Collaborating Centre for Women's and Children's Health, 2015), but women with GDM often face barriers to making the recommended lifestyle changes during pregnancy (Craig et al., 2020; Guo et al., 2024; He et al., 2021). Approximately 50% of women who have had GDM experience it again in subsequent pregnancies (Egan et al., 2021). Women who have had GDM are also at increased risk of future cardio-vascular disease (Kramer et al., 2019), and up to 50% will develop T2D within 10 years (Damm et al., 2016). This suggests that GDM is a marker of an underlying metabolic disorder, and therefore provides an opportunity for early intervention based on postnatal lifestyle modification, although this can also be challenging (Dennison et al., 2019; Hedeager Momsen et al., 2021; Li et al., 2021).\u003c/p\u003e\n\u003cp\u003eThere are substantial international qualitative literatures on mother’s reactions to diagnosis with GDM, self-management and healthcare (He et al., 2021; Pham et al., 2022), their suggestions for improvement (Feng et al., 2025), and postnatal interventions to prevent T2D following a GDM pregnancy (Dennison et al., 2019; Hedeager Momsen et al., 2021). There is a more limited international literature that explores the physical and psychological challenges of pregnancy for mothers T1D and T2D and their experiences of healthcare (Roddy \u0026amp; McGowan, 2024; Sushko et al., 2021; Toledo-Chavarri et al., 2024). There are as yet few studies from the UK on the maternity care experiences and needs of women with diabetes and these have been carried out at individual clinics (Draffin et al., 2016; Parsons et al., 2018; Stenhouse et al., 2013; Woolley et al., 2015).\u003c/p\u003e\n\u003cp\u003eWomen with diabetes, their support networks and health professionals taking part in the James Lind Alliance Priority Setting Partnership on diabetes and pregnancy have identified as two of the top ten UK research priorities, \u003cem\u003e“What are the labour and birth experiences of women with diabetes, and how can their choices and shared decision making be enhanced?”,\u003c/em\u003e and \u003cem\u003e“What are the specific postnatal care and support needs of women with diabetes and their infants?”\u003c/em\u003e (Ayman et al., 2021). The aim of this study was to explore the antenatal, intrapartum and postnatal care experiences of a diverse group of mothers who have TD1, TD2 or GDM and used National Health Service (NHS) maternity services England, with the intention of contributing to policy recommendations for improving maternity and postnatal care for mothers with diabetes.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was a qualitative descriptive study (Sandelowski, 2000), theoretically informed by phenomenological social psychology which focuses on understanding the subjective meaning of interpersonal interactions \u0026nbsp;(Landridge, 2008). This design was chosen because the purpose was to explore participants’ experiences and thus to stay close to their accounts without imposing theory, while acknowledging the role of both participants’ understandings and the researchers’ interpretations in the production of knowledge (Pidgeon \u0026amp; Henwood, 1997).\u003c/p\u003e\n\u003cp\u003eParticipants were purposively sampled for their experiences as mothers who had a baby in England in the past 12 months and had diabetes diagnosed before or during their most recent pregnancy.\u0026nbsp;Participants were recruited via email networks, social media, and posters in community groups. The invitation was publicised by the Patient and Public Involvement (PPI) group (comprising representatives from national organisations and individual mothers with lived experience of GDM, T1D or T2D) and by other members of National Perinatal Epidemiology Unit’s PPI network of voluntary and community organisations. This invitation directed mothers who were interested in participating to a short online questionnaire that (1) provided a link to the participant information leaflet and (2) asked demographic questions to enable the selection of participants using maximum variation sampling according to their type of diabetes, ethnicity, location within England, and socio-economic status based on their postcode.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEach participant took part in one semi-structured telephone interview in November 2023-March 2024.\u0026nbsp;Participants were sent the participant information leaflet and consent form at least 24 hours before an interview and gave informed consent before the interview began. Participants were offered £25 in vouchers to thank them for their time. Data analysis was carried out in parallel with data collection and recruitment continued past the point of thematic saturation to meet the goal of maximum diversity.\u003c/p\u003e\n\u003cp\u003eInterviews were audio-recorded and professionally transcribed. To protect confidentiality, each participant was allocated a participant number tagged with their type of diabetes – “T1D” for type 1 diabetes, “T2D” for type 2 diabetes, “GDM” for gestational diabetes. Interview transcripts were analysed using inductive thematic analysis (Braun \u0026amp; Clarke, 2006). \u0026nbsp;Transcripts were checked against audio-recordings and reread for familiarity, then coded; codes were combined and developed into themes which were discussed and agreed. Transcripts from participants with each type of diabetes were initially treated as separate datasets, and then combined into an overall analysis to reflect the goal of providing evidence to improve the care of women with all types of diabetes.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were 357 valid responses to the invitation to be interviewed. 32 mothers were interviewed, who had experienced a total of 45 pregnancies affected by diabetes. Interviews lasted 26-62 minutes (mean 41 minutes). Mothers\u0026rsquo; demographic characteristics and the management of their diabetes in their most recent pregnancy are shown in Table 1. Four mothers who were diagnosed with T2D had had GDM in one or more previous pregnancies. 21 mothers had experienced comorbidities including ADHD, agoraphobia, anxiety, Chiari malformation, eating disorder, high blood pressure, depression, gallstones, hyperemesis, low lying placenta, low PAPP-A, obstetric cholestasis, polycystic ovary syndrome, pneumonia, polyhydramnios, and symphysis pubis dysfunction. Mothers were not asked about their Body Mass Index (BMI) but eight mothers spontaneously described themselves as having a\u003cem\u003e\u0026nbsp;\u0026ldquo;high BMI\u0026rdquo;\u0026nbsp;\u003c/em\u003eof up to 41.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 Participants\u0026rsquo; demographic characteristics and management of their diabetes during pregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of mothers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e25-29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e30-34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e35-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e40+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eAsian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eBlack/Black Mixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndex of multiple deprivation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eQuintile 1 (most deprived)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eQuintile 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eQuintile 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eQuintile 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eQuintile 5 (least deprived)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003ePostcode unmatched\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e -5\u003csup\u003eth\u003c/sup\u003e birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of diabetes during most recent pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eType 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eType 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eGestational\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonitoring of diabetes in most recent pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eFinger prick\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eContinuous glucose monitoring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eManagement of diabetes in most recent pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eDiet (or diet + exercise)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eDiet followed by metformin later in pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eDiet followed by insulin later in pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eMetformin from diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eInsulin throughout pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 319px;\"\u003e\n \u003cp\u003eMetformin followed by insulin later in pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour themes were developed, shown with subthemes in Figure 1.\u003c/p\u003e\n\u003ch3\u003eTheme 1: The antenatal information gap\u003c/h3\u003e\n\u003ch3\u003eDiagnosis and timing of information\u003c/h3\u003e\n\u003cp\u003eOnly one mother with T2D had received preconception diabetes advice, which she had found very helpful. Several mothers with T1D had received comprehensive preconception information, but others had not, particularly before first pregnancies. In some cases, they felt that lack of information before pregnancy and in the first trimester may have contributed to poor outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;This is my third pregnancy, but I didn\u0026apos;t have any preconception clinic ever\u0026hellip;\u003c/em\u003e \u003cem\u003eI felt really guilty [in the first pregnancy which ended in miscarriage] because my blood sugar was not very well controlled initially, because I did not know.\u0026rdquo;\u0026nbsp;\u003c/em\u003eM32-T1D\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Once I was [in my] early twenties it was mentioned every diabetes appointment \u0026hellip; With both of my children, I attended a preconception clinic and they went through optimal conditions and what pregnancy as a diabetic could look like.\u0026rdquo;\u0026nbsp;\u003c/em\u003eM09-T1D\u003c/p\u003e\n\u003cp\u003eReceiving a diagnosis of GDM was a shock for most mothers, and their priority was to find out what they needed to do. While some had received prompt information from the diabetes team about managing their condition, others said that they were extremely worried during a prolonged gap between diagnosis and access to reliable information.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The nurse said the nutritionist would have a conversation and that wasn\u0026rsquo;t until two or three weeks later. So, there was two and a half weeks where I was a bit like, \u0026lsquo;Oh my God, I don\u0026rsquo;t know what I\u0026rsquo;m doing.\u0026rsquo; Cos you\u0026rsquo;re scared that you\u0026rsquo;re gonna hurt the baby more\u0026hellip;\u003c/em\u003e \u003cem\u003eIt was really overwhelming and I felt like it was almost the end of the world.\u0026rdquo;\u003c/em\u003e M04-GDM\u003c/p\u003e\n\u003cp\u003eMothers had generally attempted to fill this information gap by looking for information online. A few mothers who had health anxiety or a history of disordered eating said they had reacted with extreme food restriction.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If they\u0026rsquo;d gone through that information with me, I wouldn\u0026rsquo;t have thought, \u0026rsquo;Oh my God, you need to eat \u003cu\u003enothing\u003c/u\u003e.\u0026rsquo;\u0026rdquo;\u0026nbsp;\u003c/em\u003eM22-GDM\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eVaried quality of information\u003c/h3\u003e\n\u003cp\u003eThere was no standardisation in the scope and format of diabetes information which mothers with GDM or T2D received about recommended lifestyle changes. Some mothers were offered a group or individual session with a dietitian, others were not; some received a brief telephone call while some had a half day in-person session covering both how to use the glucose testing kit and how to manage diabetes through diet. Some were simply given a dietary advice leaflet of variable quality, while others were signposted to the NHS diabetes webpage or to non-NHS sources of information on social media, in apps or books. Some mothers were advised to increase protein intake while others were simply advised to reduce carbohydrate intake and portion sizes. Some were given detailed information about the glycaemic index of different foods, while others were given a short list of \u0026lsquo;good\u0026rsquo; or \u0026lsquo;bad\u0026rsquo; foods. Some were given advice on exercise (particularly walking shortly after meals to stabilise blood sugar), but many were not. A few were given information about \u0026lsquo;food pairing\u0026rsquo; (eating a high fat food with a high carbohydrate food).\u003c/p\u003e\n\u003cp\u003eA couple of mothers said they had received excellent information that was relevant to them as individuals, including real-time access to a member of the diabetes team if they had questions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It was really clear information, so I made changes straight away to my diet\u0026hellip; I could just go straight and phone [the team], \u0026lsquo;I\u0026rsquo;m going out for tea tonight and I was going to have this, is that ok?\u0026rsquo; \u0026hellip; and she was really helpful.\u0026rdquo;\u003c/em\u003e M23-GDM\u003c/p\u003e\n\u003cp\u003eHowever, most mothers had received limited and generic information which they did not find useful and which became increasingly irrelevant as pregnancy progressed and their glucose tolerance changed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;And I never really got any kind of diet help. They obviously tell you to reduce your carbs, your processed stuff, blah, blah, blah, but I was never given any kind of formal training or information to help with it\u0026hellip;[The diabetes team says] \u0026lsquo;\u003c/em\u003e\u003cem\u003eWhat are you eating? Oh, maybe you could just eat a bit less of that and eat more of this,\u0026rsquo; and you\u0026rsquo;re on your way.\u003c/em\u003e\u003cem\u003e\u0026rdquo;\u0026nbsp;\u003c/em\u003eM05-T2D\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral mothers said that the NHS information they were given in leaflets or on the website was inaccurate, outdated or contradicted their own experience, and this had led them to lose trust in \u0026lsquo;official\u0026rsquo; information.\u0026nbsp;For other mothers, the main problem with the information received was that it gave suggestions that were not culturally relevant.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;It was an ancient, photocopied sheet that looked like it had been made in the eighties and all the information was really wrong\u0026hellip;\u003c/em\u003e \u003cem\u003eBefore I had gestational diabetes I was just looking on the NHS website because there is so much other bogus information out there. But this threw that all into\u0026nbsp;\u003c/em\u003e\u003cem\u003edisarray because suddenly the NHS advice was not good anymore.\u0026rdquo;\u0026nbsp;\u003c/em\u003eM30-GDM\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I didn\u0026apos;t follow that recipe book at all because it just wasn\u0026apos;t for me or my palette. I guess maybe in different cultures people eat different things.\u0026rdquo;\u0026nbsp;\u003c/em\u003eM17-GDM\u003c/p\u003e\n\u003cp\u003eThe dearth of comprehensive practical information could lead a mother to infer that GDM could not be a serious problem, thus undermining the health behaviours that were being promoted.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I thought that I\u0026rsquo;d have a bit of a conversation with [the specialist] about things like your diet, testing. But it was quite rushed. I didn\u0026rsquo;t receive a leaflet or any written information... It made me think that maybe it\u0026rsquo;s not as serious as I\u0026rsquo;m led to believe.\u0026rdquo;\u003c/em\u003e M22-GDM\u003c/p\u003e\n\u003cp\u003eSome mothers commented that the diabetes teams should make it clear that the advice given would not apply to every pregnant woman in the same way. A couple of mothers said that the team had talked about blood glucose targets without checking the mothers\u0026rsquo; understanding of the information they were given.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;d misunderstood what I was supposed to be doing with my readings. I\u0026rsquo;d been eating to make sure that they were kept at around a specific level. \u0026lsquo;Oh no, you\u0026rsquo;re supposed to be \u003cu\u003eunder\u003c/u\u003e that!\u0026rsquo;\u0026hellip;You\u0026rsquo;re overloaded with information and you\u0026rsquo;re worried so you don\u0026rsquo;t take it all in, you need very clear information of \u0026lsquo;This is what you need to be doing and how you need to be doing it.\u0026rsquo;\u0026rdquo;\u0026nbsp;\u003c/em\u003eM11-GDM\u003c/p\u003e\n\u003cp\u003eSome mothers felt frustrated when diabetes teams were not able to give them useful suggestions when they reported particular foods spiking their glucose levels, and instead told them that they would need to find out what they could tolerate through trial and error. When asked what information they would ideally have wanted from the NHS, mothers highlighted two key things: comprehensive, practical information that included food swaps and recommended recipes, and access to personalised information, which few had received.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The dietitian said to me, \u0026lsquo;Just experiment and see what works for you\u0026rsquo;\u0026hellip; She didn\u0026rsquo;t give me any suggestions. Felt like a complete waste of time because I thought, I\u0026rsquo;ve just relayed all of my story, but for what?\u0026rdquo;\u003c/em\u003e M06-T2\u003c/p\u003e\n\u003ch3\u003eTrusting experiential knowledge\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eMany mothers had turned to online sources to fill the NHS information gaps, citing the websites of UK-based diabetes organisations and nutritionists on social media for their practical and holistic advice (\u0026ldquo;\u003cem\u003eyour bible to getting through it\u0026rdquo;\u0026nbsp;\u003c/em\u003eM30-GDM). These online sources were, for many, the only way they learned about the benefits of exercise after meals. Some online sources included recommendations that were not part of official NHS advice, such as \u0026lsquo;food combining\u0026rsquo; or eating protein and vegetables before carbohydrates in individual meals. Mothers said that these unofficial sources were both more empathetic in tone and more useful than official ones, because they addressed real-life situations and recognised that pregnant women with diabetes still wanted to enjoy food. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They had some tips of what to do, like when your nurse tells you not to snack, they have a laughing emoji and then they tell you what kind of snacks you should have before bed which could actually help with your dawn phenomenon [the increase in blood sugar levels in the early morning]\u0026hellip; They made you not feel so bad about yourself \u0026lsquo;cos they\u0026rsquo;d always remind you it\u0026rsquo;s not your fault, and you can still have nice treats.\u0026rdquo;\u003c/em\u003e M07-GDM\u003c/p\u003e\n\u003cp\u003eMany mothers particularly valued online peer support forums where they could find out how other mothers managed their diabetes during pregnancy. Some said that they found experiential evidence was more credible and more effective than theoretical information provided by the diabetes team. Across all types of diabetes, mothers were enthusiastic about how these forums had given them moral support as well as useful ideas.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I\u003cem\u003et was nice to feel like you\u0026rsquo;re not alone\u0026hellip; other people are experiencing it too and it\u0026rsquo;s OK to have a wobble and be stressed out by it, but to feel supported too.\u003c/em\u003e M13-T2D\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;The midwife and the dietitian had both told me that maybe have two Weetabix [blocks of processed wheat] for breakfast, and \u0026hellip; it spiked me straight away, really high. So I posted in that group\u0026hellip;and about 15 other people commented on it, saying, \u0026lsquo;You\u0026rsquo;ll probably find people who have gestational diabetes can\u0026rsquo;t tolerate cereals and Weetabix, try more protein-based things.\u0026rsquo; I felt like that was a bit disheartening, \u0026lsquo;cos if all of these people who have gestational diabetes know all this from trial and error, why don\u0026rsquo;t the midwives and the dietitians know that?\u0026rdquo;\u0026nbsp;\u003c/em\u003eM20-GDM\u003c/p\u003e\n\u003cp\u003eMany of the mothers who had \u003cu\u003enot\u003c/u\u003e been signposted to external resources said that a recommendation by the diabetes team would have been influential and reassuring. However, a couple of mothers described how online peer support could have risks as well as benefits, because they felt frightened or undermined by reading other mothers\u0026rsquo; descriptions of their maternity care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I thought, I\u0026apos;ll join a group. It was actually probably one of the worst things I could have done for my mental health. Because it becomes an echo chamber, doesn\u0026rsquo;t it? \u0026hellip;People share their horror stories. I know people need a place to share, but it was really triggering and people in the group were very anti-induction. So I felt crap for my choice [to have a planned induction].\u0026rdquo;\u0026nbsp;\u003c/em\u003eM28-GDM\u003c/p\u003e\n\u003ch3\u003eTheme 2: Monitoring and management\u003c/h3\u003e\n\u003ch3\u003eTechnology: convenience, clarity and accountability\u003c/h3\u003e\n\u003cp\u003eThere was no consistency in what was offered to mothers to test their blood glucose and to communicate the results to the diabetes team. All of the mothers with GDM, three mothers with T2D, and one mother with T1D used finger prick testing, with the results given to the diabetes team by telephone, text message, showing them the results in a notebook, or through an app. Eight mothers with T1D or T2D had used continuous glucose monitoring.\u003c/p\u003e\n\u003cp\u003eMany of the mothers who had monitored their blood glucose through finger prick testing commented that this was unpleasant, burdensome and difficult to fit into working life. All mothers who had used continuous glucose monitoring said that this had improved their diabetes control, in part because the diabetes team could give real time feedback without waiting for the next appointment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I've got phobia of needles, so… it was traumatic for me to do that testing. And then they were saying to me, the more stressed that you're getting, you're probably spiking your sugars before you are testing because you're working yourself up.”\u003c/em\u003e M19-GDM\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“My diabetic midwife could look at my [CGM] sensor, look at my blood sugars without having to contact me. She could review them and say, ‘We’ll tweak your insulin down’, things like that. She would check them at least once a week.”\u003c/em\u003e M18-T2D\u003c/p\u003e\n\u003cp\u003eMothers who were given an app to record and communicate their glucose readings said that this was more convenient, helped them to notice patterns of highs or lows, and enabled the team to be proactive in following up high readings. Where the app synchronised automatically with the glucose monitor, several mothers said that this helped by making them more accountable. Without this, there was a temptation to manipulate the results to avoid being \u003cem\u003e“told off”\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“[The app synchronising] meant that obviously I couldn't lie… They actually were really monitoring me. And while that feels a bit big brothery, it makes you take accountability.”\u003c/em\u003e M24-GDM\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;“If I knew I was going to have a cheat day, I would put a different reading, because I knew I was going to get told off…I did tell my nurse afterwards, ‘I had a naughty reading and I might have lied on it. But only because I didn't want you having a go at me.’\u003c/em\u003e\" M19-GDM\u003c/p\u003e\n\u003ch3\u003eContrasting attitudes to medication\u003c/h3\u003e\n\u003cp\u003eWhereas the mothers with T1D and T2D were used to taking metformin and/or insulin, many of the mothers with GDM said they wanted to avoid taking medication, citing concerns about side effects, the potential impact on the baby, and unwillingness to inject insulin: \u003cem\u003e“That's going to feel like one failure too many”\u003c/em\u003e (M28-GDM). This had inspired some to strictly observe a restricted diet, but they then found it upsetting when even this was not enough as their pregnancy progressed:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I was on a militant diet… but\u003c/em\u003e \u003cem\u003eI had to go on metformin towards the end, it just made me feel horrible.”\u0026nbsp;\u003c/em\u003eM10-GDM\u003c/p\u003e\n\u003cp\u003eA few mothers were critical of what they felt was an over-hasty decision by the diabetes team to move them to medication instead of giving them support to manage their blood glucose through diet. By contrast, a couple of mothers accepted the offer of medication with relief when they felt unable to cope with the dietary restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I wasn’t given any help in finding out what to eat instead. It felt very dismissive, ’We’ll just put you on medication rather than anything else.’”\u003c/em\u003e M11-GDM\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I had a one-year-old toddler, I was shattered. I developed [a health condition] and I decided, ‘Diabetes and what the hell I'm eating is another thing I just don't want to deal with…Yeah, put me on medication then.’”\u003c/em\u003e M19-GDM\u003c/p\u003e\n\u003ch3\u003eFeeling safe: personalised care and positive feedback\u003c/h3\u003e\n\u003cp\u003eSome mothers said that they had experienced excellent care from individuals or the team. The key positive aspects of care were that it was non-judgemental, empathetic, responsive, and individualised to their needs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I did speak to a number of exceedingly patient, kind individuals who talked me off ledges … and were very empathetic in their ‘I can understand it must be very difficult’ and gave me a lot of grace. …I never felt like they were pushing me off the phone. Even with them being under-resourced and under-staffed, I didn’t feel like I was being an idiot for asking questions.”\u003c/em\u003e M02-GDM\u003c/p\u003e\n\u003cp\u003eThis sense of safety was particularly reported by some mothers with T1D or T2D who experienced continuity of care from a diabetes specialist who made them feel known as an individual, and by mothers who appreciated the increased medical surveillance:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The [specialist] midwifery care was what set my pregnancy up for success… because I had that longitudinal support from one person who knew me. She was the constant.”\u003c/em\u003e M14-T1D\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“That was very, very lucky that we have so much regular contact made with us, it’s classed as specialist care... So the midwife checks up on you. You have extra scans and you have the consultant checking in with you.”\u003c/em\u003e M06-T1D\u003c/p\u003e\n\u003cp\u003eMothers with T1D also described good care as being listened to and recognised as the expert on their own body within a robust diabetes maternity care pathway:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“They had a clear system in place that they followed for their diabetic mums … And the thing that I really valued with [the diabetic nurse] was she would acknowledge that she was not necessarily the expert in my diabetes. And she would listen to me and take on board what I was saying was working well and not working well.”\u0026nbsp;\u003c/em\u003eM25-T1D\u003c/p\u003e\n\u003cp\u003eSome mothers with T2 or GDM said they judged themselves for having developed diabetes, particularly if they described themselves as overweight. They appreciated healthcare professionals who encouraged self-kindness and were tolerant of occasional deviations from dietary advice.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“It was always ‘This is your hormones, it’s nothing to do with the size or the weight of you, it’s simply because your body can’t manage the insulin’ … When they said, ‘It’s not your fault’, that’s the best thing to hear, because you do think it’s your fault.”\u003c/em\u003e\u0026nbsp; M23-GDM\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The guilt comes into it…They were always really supportive about having a lifestyle, saying that it’s OK to go out and have a bit of birthday cake if it’s your birthday, and normalising that you are human.”\u003c/em\u003e M13-T2D\u003c/p\u003e\n\u003cp\u003eSome mothers said they found it motivating to have regular positive feedback about how they were controlling their glucose.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I liked the fact that they’d always say that I was doing really well; they always used to be encouraging, even though I thought I wasn’t doing really well.”\u003c/em\u003e\u0026nbsp; M05-T2D\u003c/p\u003e\n\u003cp\u003eHowever, where praise was given without personalised care, this could lead to harm for a mother with a history of disordered eating who managed her glucose through extreme restriction, and contrasted her experiences of professional support in her two pregnancies:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;“I had no carbs in my first pregnancy from about week 29 when I was diagnosed … I got so much praise for being diet controlled, but nobody was looking at what I was eating. They just kept saying, ‘Oh, your numbers are great. Keep doing what you're doing.’…The second time they picked up that I had problems with food. [The dietitian] went, ‘What's your relationship with food like?’ So she opened the door for me to make the confession… It was very individual-centred.”\u0026nbsp;\u003c/em\u003eM28-GDM\u003c/p\u003e\n\u003ch3\u003eFeeling unsafe: rushed, inconsistent, judgemental care\u003c/h3\u003e\n\u003cp\u003eMost mothers reported interactions which they experienced as poor care with some (or most) of the health professionals they encountered. Although many mentioned that they knew the quality of care was affected by short staffing, they described impersonal encounters where they felt they were processed hastily and without having a genuine chance to ask questions or to check they had understood.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“T\u003c/em\u003e\u003cem\u003ehey were rushing and so you felt kind of dismissed: ‘Do you have any questions - no - OK, bye!’”.\u003c/em\u003e M10-GDM\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“When the people that you see haven't read what the last person said, there's nothing linked together…They need to talk to you like you're a person. Because we came home with words written down that we then googled because we didn't know what they meant … [The staff] were putting a coat on. They would get you out the door before you had a chance to think.”\u0026nbsp;\u003c/em\u003eM26-T2D\u003c/p\u003e\n\u003cp\u003eMany mothers also described being treated in ways which alienated them: they were disbelieved, reprimanded, accused of eating against medical advice, and treated patronisingly by staff. This made them feel judged, humiliated, and infantalised.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“They were shaming. I was trying my very best with what I had. My basals had gone from 18 units a day to 280 units a day… [They told me] this was all my fault because I should be doing things differently… They were saying, ‘We don't believe you're following our advice.’ And I was.”\u003c/em\u003e M14-T1D\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I'd only been testing for two days [and] I was being interrogated [by the nurse], ‘You're not taking this seriously. You've got all these red [high glucose] readings. Do you not understand the need to be green [low glucose]?’ And I was like, ‘I do understand. But when I was given the kit by the midwife, she explained it will take me a few days to understand what is a trigger for me.’ And the nurse was like, ‘Nope, you do not understand! This is going to harm your baby. If your sugar levels don't get controlled, it could be fatal.’… I was literally being told off like a child as though I'm doing something on purpose.\u003c/em\u003e \u003cem\u003eAnd they made me feel, excuse my language, like shit. I literally came out of that crying.”\u003c/em\u003e\u0026nbsp; \u0026nbsp;M19-GDM\u003c/p\u003e\n\u003cp\u003eIn particular a few mothers felt explicitly stigmatised by health professionals because of the association between diabetes, overweight and poor diet, and the moral overtone to professionals’ language when they talked about eating, which reinforced mothers’ wider sense of shame and guilt.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“People assume if you’ve got diabetes, you tend to be more on the obese side. And then all of a sudden, you’re labelled as part of it.\u003c/em\u003e \u003cem\u003eI\u003c/em\u003e\u003cem\u003et’s got connotations…The nurse said, ‘You’ve \u003cu\u003ebeen good\u003c/u\u003e, you haven’t had any reds [high glucose readings].’”\u003c/em\u003e M12-GDM\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“My high readings were always because I knew I had eaten something bad… It's one of those situations like if your teacher or your parents tell you off and you know what you've done anyway, it's more annoying than when you don't know what you've done…\u003c/em\u003e \u003cem\u003eSo there could be a way that they speak where they talk \u003cu\u003ewith\u003c/u\u003e you rather than \u003cu\u003eto\u003c/u\u003e you.”\u003c/em\u003e M24-GDM\u003c/p\u003e\n\u003cp\u003eStigmatising encounters were also reported by some mothers who described themselves as slim or who had T1D, particularly when health professionals showed a limited understanding of the different types of diabetes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“It was a very brusque person on the phone, who just wanted to bark the diagnosis at you … And I was saying, ‘Hang on, what should I do?’ and she said to me, ‘You should try and be healthier’. It makes you feel extraordinarily guilty and your fault for this happening…[\u003c/em\u003eOn meeting the diabetes team later]\u003cem\u003e\u0026nbsp;It feels like they’ve taken you into the ‘fatty room’ because there’s an absolutely enormous chair for the patient but then everyone else is in normal chairs…\u0026nbsp;\u003c/em\u003e\u003cem\u003eI just wanted to get out as quickly as possible. I didn’t ask half the stuff I wanted to.”\u0026nbsp;\u003c/em\u003eM30-GDM\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Some people don’t know the difference between type 1 and type 2 diabetes, which happened a few times in hospital with midwives. If I'd ordered my food and there was a pudding with it, they'd be like, ‘Are you allowed that, you shouldn't be eating that.’ … I kept trying to say ‘No, I'm type 1 diabetic,” and it gets draining having to explain to them. And it's that sense of judgment, they're trying to say that I'm doing stuff wrong, and you think about what they're thinking.”\u0026nbsp;\u003c/em\u003eM15-T1D\u003c/p\u003e\n\u003cp\u003eSome of the Asian mothers felt that they had been unfairly targeted for GDM testing (as national guidance is to offer testing for GDM to mothers with risk factors, including an ethnicity with a high prevalence of diabetes). Some also said that staff had then applied stereotyped generalisations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“What's hard is that you only go for the test if you're in a certain group …\u003c/em\u003e \u003cem\u003eWhen you're in the waiting room, it's just a room full of ethnic minorities.\u003c/em\u003e” M16-GDM\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;“T\u003c/em\u003e\u003cem\u003ehe midwife I spoke to [by telephone] made some assumptions about me and it really upset me: ‘I can see your sugars are still very high... clearly, you must be eating this [type of food],’ and it was very judgemental. And in my opinion they saw my name, I’m Asian … I don’t actually have a typical Asian diet because I actually eat more Englishy food than I do traditional Indian food.’”\u0026nbsp;\u003c/em\u003eM07-GDM\u003c/p\u003e\n\u003cp\u003eFor some mothers, feelings of safety were undermined when they received contradictory information about how to manage their diabetes safely. This made them uncertain who to trust.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“One person that I’d speak to would be like, ‘You can have ice cream here and there, and you don’t need to contact us every time you have a high [glucose reading] that’s explained.’ And then another one would be textbook, ‘The minute you have another high, contact us!’ …When some things conflict, it makes it really difficult to understand what’s the right way.”\u0026nbsp;\u003c/em\u003eM02-GDM\u003c/p\u003e\n\u003cp\u003eFor other mothers, a key problem was being treated as the condition rather than as a pregnant women who had the condition:\u0026nbsp;\u003cem\u003e“My time in hospital, I was constantly referred to as ‘the diabetic’”\u0026nbsp;\u003c/em\u003e(M09-T1D).This could lead to an apparent reduction in normal maternity care when all the attention was placed on diabetes. Likewise women who had other medical issues in their pregnancies as well as diabetes said that a lack of joined-up working between the different teams left them unclear if anyone had an overview of their care and who to turn to when there were complications.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“From the minute I was diagnosed with diabetes, it was all about the diabetes and not about the pregnancy. It’s a whistlestop tour of ‘Let’s quickly listen to baby …[now] let’s talk about the diabetes!’\u003c/em\u003e” M07-GDM\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“It was starting to get confusing with all the teams... I wanted to know who was the team that was really on top of everything … If someone had to take a decision, who was going to?”\u003c/em\u003e M27-GDM\u003c/p\u003e\n\u003cp\u003eA final issue that undermined feelings of safety was when the food that mothers were offered in hospital contradicted all the dietary advice they had been told was essential. Although some mothers had been offered choices that included diabetic-friendly options, others had not; they had resorted to asking family to bring in food for them, or ate the unsuitable food. This could be a particular problem for Asian mothers when the only vegetarian or halal options were carbohydrate-heavy, so mothers faced a choice between going hungry or undoing their own dietary glucose control.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The night I was in before the c-section they gave me a triple carb meal. I inherited the person’s meal selection that was there before. So, obviously I had to eat it because I had nothing else. I think that is why my levels went high… The midwife told me she was type 1 herself, but still, plonking a triple carb meal in front of me! She was really blasé. She said, ‘You’ll be fine. Just take some insulin.’”\u003c/em\u003e M05-T2D\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;“[Pakistani women] are given a label of either you’re a vegetarian or halal. [For vegetarians] all you’re given is a cheese sandwich… [And] they just assume that anything that’s halal basically must mean that you want a curry, naan and rice!”\u003c/em\u003e\u0026nbsp; M06-T2D\u003c/p\u003e\n\u003ch3\u003eInconsistent management during birth\u003c/h3\u003e\n\u003cp\u003eMothers’ experiences of diabetes management during induction and labour or in preparation for elective caesarean birth were very varied. Some mothers were asked to monitor their own blood glucose during this time, some had this done for them by the midwives, and some were not tested.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I asked my midwife, ‘Do I need to bring my monitor?’ And they were like, ‘No, no. The midwives will check.’ But they didn't check my sugar during labour at all.\u0026nbsp;\u003c/em\u003eM24-GDM\u003c/p\u003e\n\u003cp\u003eSeveral mothers experienced difficulties in managing their blood sugar when they were told to fast before an elective caesarean birth, but the operation was then delayed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“[The midwife] told me that I would be the first in. Because of the fasting, it can send your blood sugar levels haywire. In the end I was the last in; I didn’t get seen until the afternoon. I was having a hypo, quite a big one.”\u0026nbsp;\u003c/em\u003eM30-GDM\u003c/p\u003e\n\u003cp\u003eSome mothers who were using an insulin pump were told they could to keep it on, while others were told that the policy was to use a sliding scale during birth. One mother found herself in an unsafe situation when maternity staff did not appear to understand how to care for a mother who needed insulin. In response to frequent hypoglycaemic episodes in late pregnancy, the diabetes team had documented a plan for her to go on a sliding scale the evening before her caesarean birth to protect the baby by achieving 24 hours of stable blood sugar. When the mother had taken off her insulin pump and taken long-acting insulin, maternity professionals on a new shift \u0026nbsp;refused to put her on the sliding scale, but she was unable to go back to the insulin pump because of the long-acting insulin.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“[They said] that I would have to just monitor myself and shout to them if I had any problems. I challenged them a lot on that and they absolutely refused… I had to stay up all night and keep monitoring my blood sugars. But the stress of that was absolutely horrific. Because my consultant had been really honest about the risks if my blood sugars was deranged before having baby. So to know that they had increased my risk of it going wrong, I was frustrated, really angry, really scared… They didn't have that knowledge to understand what I was saying.\u003c/em\u003e\u003cem\u003eIt was one of them times where I thought, ‘I don't trust these people to actually look after me.’\u003c/em\u003e” M15-T1\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eTheme 3: Communicating risk and choice\u003c/h3\u003e\n\u003ch3\u003eSupporting informed choice or gaining compliance through fear\u003c/h3\u003e\n\u003cp\u003eMothers accepted that healthcare professionals had a duty to give them information about the potential risks of diabetes for pregnancy outcome, and felt that these facts could potentially motivate behaviour change and enable them to make informed choices. They were, however, very critical when the risks were communicated in ways which they experienced as hysterical and frightening.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I was trying so bloody hard and my sugars were not getting better and I was just having to up and up that insulin. And I then felt like I wasn’t doing good enough and the person on the phone was like, ‘Oh my God, this is so bad for your baby, this is so dangerous!’ The way she was saying it made me worry even more.”\u0026nbsp;\u003c/em\u003eM07-GDM\u003c/p\u003e\n\u003cp\u003eMothers were adamant that information about mitigating risk should always be communicated at the same time as information about the risk itself (see subtheme \u003cem\u003eDiagnosis and timing of information\u003c/em\u003e). Without this they felt intensely vulnerable:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I felt like I was being left to my own devices…If the repercussions is that bad then I felt like there wasn’t enough emphasis on how to manage it properly\u003c/em\u003e.” \u0026nbsp;M10-GDM\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor some mothers, the way that health professionals talked about risk had felt as if it was actively intended to coerce them to accept an intervention, rather than to offer informed choice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“We'd had a scan and they'd said, ‘You're carrying a big baby, so we're going to induce you.’ And if there'd have stopped there, that would've been fine. But the diabetic lady, she put the fear of God in me by saying, ‘You've got a HUGE baby. And if it's a vaginal delivery, we might have to break arms and limbs to get her out. And it might get stuck.’ It was horrific. Tuesday, Wednesday, I think I cried every minute of every day. And then on the Thursday we had a normal midwife appointment, and she said the exact opposite. She said, ‘They say that to frighten you into having an elective caesarean’… And [the baby] wasn't big. She was seven and a half pounds.”\u0026nbsp;\u003c/em\u003eM26-T2D\u003c/p\u003e\n\u003cp\u003eMothers said that it was frustrating when guidelines about birth were applied without any personalisation relating to their actual glucose control or predicted size of the baby, and some had pushed for specific information about the scientific basis for particular recommendations and policies.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;“Just because I am diabetic, doesn’t mean that I fall into that broad spectrum of other diabetics. We’re all individuals. So, yes, I understand their recommendations and procedures that have worked, but don’t forget that we are more than diabetes\u003c/em\u003e.” M09-T1D\u003c/p\u003e\n\u003cp\u003eIn particular, it was impossible for mothers to evaluate the magnitude of their personal risk and make a genuinely informed choice if they were told only relative and not absolute risks of adverse outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“It was almost like a threatened choice because I wasn't sure that I was actually at high risk. How bad was my levels compared with other people?…There's another fear in you [when] the doctor says you’re ‘choosing stillbirth’, basically…I didn't know how small the risk really was. Still today, I don't know.”\u003c/em\u003e M17-GDM\u003c/p\u003e\n\u003ch3\u003eBirth options: choice offered or doctor decides\u003c/h3\u003e\n\u003cp\u003eThe issues of explaining risk and offering choice were most graphically reflected in the discussions mothers described about where, when and how they would give birth. \u0026nbsp;All of the mothers had been told their only option for place of birth was a consultant-led obstetric unit. A quarter of the mothers, across all types of diabetes, said that they felt they were offered genuine choice in their options for mode and timing of birth, with enough information to make this choice confidently. Some had opted to wait for labour to start spontaneously, some had chosen early induction and some had chosen elective caesarean section.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“They weren’t favouring one [type of birth] over the other in trying to encourage me to pick one. It was all what \u003cu\u003eI\u003c/u\u003e wanted to do; I had plenty of time to decide and they gave me all the information that I needed... I was really happy with my decisions.”\u0026nbsp;\u003c/em\u003eM08-T1D\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, the majority of mothers had not experienced discussions about the timing or mode of birth that respected their autonomy as decision makers. Across all types of diabetes, many described being told at the outset that they were \u003cem\u003e“not allowed”\u003c/em\u003e to continue the pregnancy past a particular gestation. If they tried to negotiate, the health professionals implied that slightly delaying intervention was a favour they could grant. Mothers said these encounters were unnecessarily stressful.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“As soon as I got diagnosed with diabetes, my community midwife said, “They’re not going to let you carry to 40 weeks. We will get you induced from 38-39 weeks” … It’s like ‘Go and prepare for an induction!’\u003c/em\u003e\u003cem\u003e”\u003c/em\u003e M31-GDM\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I said that I would think about it, when they were forcing me to have an induction … The doctor said, ‘But I have given you an extra few days compared to women who would be taking tablets!’ I got an extra few days.”\u0026nbsp;\u003c/em\u003eM03-GDM\u003c/p\u003e\n\u003ch3\u003e Theme 4: The postnatal cliff edge\u003c/h3\u003e\n\u003ch3\u003eLack of preparation for the postnatal period\u003c/h3\u003e\n\u003cp\u003eMost mothers reported receiving minimal information during pregnancy about how their diabetes and its consequences would be handled postnatally. For example, mothers mentioned that they were not told about the risk of jaundice, or about expressing colostrum antenatally in case their newborn baby experienced hypoglycaemia. Some with GDM were also not told that they could stop testing their blood glucose after birth, and some with T1D had not been prepared for the complexity of managing insulin while breastfeeding.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;“Nobody had that conversation [about insulin while breastfeeding]’ with me. So I had no idea about that… That would have been useful… A nice little leaflet saying, ‘Diabetes after birth; if you’re breastfeeding, try this. If you’re not breastfeeding, try this.’”\u003c/em\u003e M09-T1D\u003c/p\u003e\n\u003cp\u003eBy contrast, a couple of mothers with T1D had received clear information about postnatal blood glucose and insulin in advance, which helped them to cope better.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Quite a bit of time before my c-section was due, I sat down with the consultant and we wrote out a proper plan … It really reassured me that’s going to give me the best control, and that helped me prepare.\u003c/em\u003e” \u0026nbsp; M08-T1D\u003c/p\u003e\n\u003ch3\u003eDiabetes care is cut off\u003c/h3\u003e\n\u003cp\u003eJust one mother with GDM described a specific local policy for the diabetes team to follow up mothers after birth with comprehensive information about self-care and an opportunity to ask questions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“When I was leaving the hospital, the diabetes midwives came and saw me. They made it a policy that every woman that had been under their care, they would check in on your baby, answer any questions about post-pregnancy …I was given information on leaving the hospital that was really useful…She was, hand on heart, the best healthcare professional I've ever dealt with.”\u0026nbsp;\u003c/em\u003eM28-GDM\u003c/p\u003e\n\u003cp\u003eMost mothers said they were shocked by the total withdrawal of care from the pregnancy diabetes team from the moment of birth: \u003cem\u003e“The only thing they focused on was getting you to 37 weeks. And then it seems like you drop off the edge of a cliff after that in terms of the support\u003c/em\u003e” (M15-T1D). In hospital, this loss of care manifested immediately in postnatal staff who were unaware or did not remember that the baby’s and mother’s blood glucose should be tested after birth: \u003cem\u003e“We had to ask them should the baby be tested, because they forgot\u003c/em\u003e.” (M10-GDM)\u003c/p\u003e\n\u003cp\u003eThe abrupt loss of care after intensive antenatal support also left many mothers with all types of diabetes feeling vulnerable and neglected in the community. This loss of care was unsettling for many mothers but was particularly problematic for mothers with T1D who experienced significant difficulties in managing their blood glucose after birth.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I felt confident when I was pregnant that the gestational diabetes team would keep me safe…I do not have any confidence that my GP practice knows that I had gestational diabetes or what to do in terms of long-term monitoring.”\u0026nbsp;\u003c/em\u003eM11-GDM\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;“There was absolutely no diabetic care after delivery whatsoever…I had to manage myself with my blood sugars after and they were everywhere…I was fluctuating between hypo and high constantly [while breastfeeding]. … I was worried because I was just guessing [how many units of insulin to use] every single time\u003c/em\u003e.” M32-T1D\u003c/p\u003e\n\u003cp\u003eMothers said that it did not make sense for all the resources to be allocated to pregnancy and nothing at all to the postnatal period, and suggested that the diabetes team’s care should extend into the immediate weeks after birth. They said it was not realistic to put the onus on mothers with a newborn baby to proactively try to get help when they were exhausted and worried about being seen as a nuisance or being criticised, especially if they were also experiencing mental health challenges.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“When I was pregnant, it felt like everyone really cared. As soon as she came out, it was like I didn't matter anymore. They just said that if I had any questions, to give them a ring... I think it's really difficult when you're struggling [with postnatal depression and anxiety] to reach out to people…\u003c/em\u003e\u003cem\u003e\u0026nbsp;And if you've been struggling for say three weeks and you think, ‘I’ll get into trouble because my blood sugars have been running really high all this time and I’ve not done anything about it,’ then you're even less likely to reach out.”\u003c/em\u003e M15-T1D\u003c/p\u003e\n\u003ch3\u003eUnsystematic follow up by GPs\u003c/h3\u003e\n\u003cp\u003eMothers with GDM described inconsistent experiences of having their blood sugar checked by the general practitioner (GP) in the community, using the recommended\u0026nbsp;fasting plasma glucose test at 6–13 weeks after birth. A few mothers said they were proactively told by the GP that this test was needed, and one mother described a local process where her hospital team had alerted the GP to make this appointment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“When I got the original prescription from the hospital to get the pipettes to do the [finger prick] test, I had to take it to my doctors so they could write the prescription and in it was also a note for them to arrange an appointment after I’d had the baby. And so that was actually arranged before I’d even had the baby.\u003c/em\u003e\u003cem\u003e\u0026nbsp;My doctors were really, really good\u003c/em\u003e.” M12-GDM\u003c/p\u003e\n\u003cp\u003eMost mothers said that there appeared to be no communication between the hospital and the GP to flag that the mother had had GDM, even if the GP had issued prescriptions for metformin. It was left to the individual mother to remember to book the appointment, but in some cases the mother was unaware that she was supposed to do it this: \u003cem\u003e“No one ever told me about a follow-up or to book in a follow-up”\u0026nbsp;\u003c/em\u003e(M19-GDM). Mothers pointed out that this was a flawed system because it was easily forgotten in the chaos of postnatal life, and a mother might not take the initiative if she was worried about the result.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Truthfully, I forgot… I’ve got a new baby, my priority went down the list. It was like, I’ve been cleared, I don’t need to worry anymore.”\u0026nbsp;\u003c/em\u003eM01-GDM\u003c/p\u003e\n\u003cp\u003eWhere mothers had booked to have the test, they frequently encountered perplexity at the GP surgery about what was needed, differing policies over whether or not this could be combined with their own postnatal check at 6-8 weeks, and confusion over whether or not it should be a fasting test. Many women said they took the test but were not given the result. They commented that this process was particularly unsafe for women who did not speak English.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“They didn’t know what to do for the blood test either. It was supposed to be fasted blood test, they hadn’t told me to fast in the morning for it…And when I turned up for it they had to ring the other GPs and ask questions about, ‘Well she’s saying she needs it ‘cos she had gestational diabetes, is this right?’ And I feel like there’s going to be a lot of people here [who don’t speak English] that slip through the gaps of connective care afterwards.”\u0026nbsp;\u003c/em\u003eM11-GDM\u003c/p\u003e\n\u003cp\u003eLikewise the onus was on the mothers to arrange annual blood sugar testing follow-ups, but not all mothers were confident they would remember to do this.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“They did mention that we will probably have to have yearly checks, to check sugar levels … We have to remember, amongst everything else in life!”\u0026nbsp;\u003c/em\u003eM03-GDM\u003c/p\u003e\n\u003ch3\u003eInconsistent advice about reducing future risk\u003c/h3\u003e\n\u003cp\u003eFor mothers with GDM, there were inconsistent messages about whether or not they should maintain the diet and exercise regime that had been recommended for pregnancy. Some mothers remembered being given clear and specific information, either in hospital or following a 6-13 week blood glucose test, about their future risk of developing \u0026nbsp;T2D and how to avoid this, and said they were motivated to maintain lifestyle changes to minimise their risk.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“They did say, ‘You're 50% more likely now to develop type 2 diabetes in the next five years after you've had your baby.’ That wasn't nice to hear because I've got diabetes in my family anyway. I did go back to my better diets again... I really don't want to develop diabetes.”\u003c/em\u003e\u0026nbsp; M21-GDM\u003c/p\u003e\n\u003cp\u003eHowever, most mothers said that they were not advised to maintain a risk-reducing lifestyle, but were told they could resume their pre-pregnancy diet without the health professional having established the suitability of that diet. The message that there was no need to pay attention to diet was reinforced in hospital when women were offered sweet biscuits or white bread and jam straight after giving birth.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“They said maybe in your second pregnancy, you could get [gestational diabetes] again and you are obviously more at risk of type two in the future. They didn't say anything about taking care of it. They were like, ‘After giving birth, just eat as you want.’ That's it.”\u0026nbsp;\u003c/em\u003eM24-GDM\u003c/p\u003e\n\u003cp\u003eMothers pointed out that even when they were given advice to continue a diabetes prevention lifestyle, this was intrinsically difficult while looking after a newborn baby, when it was hard to prioritise their own needs. After the stress of following dietary restrictions during pregnancy, they were relieved to return to pre-pregnancy eating and exercise patterns if health professionals appeared to encourage this, or did not give them clear advice on what they should do to reduce their risk. This had direct negative consequences for a mother who had lost weight during pregnancy and a mother who was diagnosed as pre-diabetic after her first baby and developed T2D before the second.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I got really good feedback from the practice nurse: ‘Your risk is really low now [after losing weight], so we don’t need to do anything. Just go home and eat and catch up on everything you’ve missed.’ …Then I kind of went the other way, because I was emotionally deprived of food as well…So, obviously what’s ended up happening over the course of this year is I put all the weight back on.”\u003c/em\u003e M06-T2D\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I didn’t realise the severity of having pre-diabetes. I received a text message from my GP after having [baby 1] to say I was pre-diabetic and I didn’t think anything of it. I didn’t realise how important it would have been to change my diet back then, and I probably could have prevented having type 2 diabetes.”\u0026nbsp;\u003c/em\u003eM13-T2D\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study found that antenatal, birth and postnatal care experiences for mothers with all types of diabetes were mixed, with wide variation in practice, despite standardised national guidelines on diabetes in pregnancy being available for the National Health Service in England (National Collaborating Centre for Women's and Children's Health, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The themes identified were similar across all types of diabetes. Some mothers with T1D diabetes had received comprehensive pre-conception counselling; antenatal care from an expert team who followed a clear care pathway, respected their own expertise on their bodies, and offered meaningful informed choice about mode and timing of birth; well-planned intrapartum care that included management of their blood glucose before and during birth; and detailed planning for postnatal care that enabled them to prepare for the challenges of managing blood glucose after birth, especially when breastfeeding. Other mothers with T1D in different parts of England had received none of these things, and consequently felt unsafe at every stage.\u003c/p\u003e\u003cp\u003eSome mothers with GDM and T2D had received care that made them feel safe, understood and respected. They received clear, high quality and timely information about diet and exercise to manage the condition, and signposting to recommended resources; access to personalised advice from the diabetes team or a dietitian; real time communication of blood sugar test results to the diabetes team through the use of technology; clarity about the management of blood glucose during birth; choice about mode and timing of birth; and information to prepare for the postnatal period. Again, many had not received this support. Only a few mothers had received a proactive invitation from their GP for blood glucose testing at 6\u0026ndash;13 weeks after birth. Only one out of the five mothers with T2D had received any preconception advice. The patchy provision of preconception care for women with pre-existing diabetes has been attributed to the lack of a standardised care pathway (Dyer et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAcross all types of diabetes, mothers said that having a pregnancy complicated by diabetes had created additional stress, anxiety, feeling out of control, guilt and shame. This in line with previous findings about the psychological impact of a diagnosis of GDM or of becoming pregnant with pre-existing diabetes (Craig et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Pham et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Roddy \u0026amp; McGowan, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Sushko et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), which may be categorised as \u0026lsquo;diabetes distress\u0026rsquo; (Tschirhart et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This study found that good maternity and postnatal care could decrease mothers\u0026rsquo; diabetes distress, while poor care increased it, with the potential to create a vicious circle since increasing stress may in itself increase blood glucose instability and reduce self-care (Lloyd et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2005\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOne of the key ways in which distress could be decreased was through the provision of high quality information about self-management of diabetes, given at the time of diagnosis (for GDM) or before or early in pregnancy (for pre-existing diabetes). There were highly inconsistent approaches (between different hospitals and within the same hospital) to the content and format of information about diet and exercise that was made available to mothers, an endemic problem highlighted in previous reviews (Craig et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Van Ryswyk et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Mothers were very critical of services that had not given them enough specific and up-to-date information to make the recommended lifestyle changes, had delayed giving them this information, or had not offered a referral to a dietitian or advice about regularly exercising after meals, contrary to national guidance (National Collaborating Centre for Women's and Children's Health, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMany mothers had turned to online sources of information to fill the gap, and in some cases diabetes teams had signposted mothers directly to these external sources. Mothers particularly valued receiving practical and empathetic advice, recipes and food swaps from other mothers with diabetes, although some were cautious of other aspects of peer support. Pham et al. (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) have drawn attention to the important role that peer-led online communities can have in meeting information and support needs in the context of resource-constrained formal healthcare. However, some of the advice that mothers described receiving from online sources differed significantly from the NHS advice \u0026ndash; for example, standard NHS advice for mothers with GDM is to eat a diet based on starchy and low glycaemic index foods with plenty of fruit and vegetables (National Health Service, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), whereas a popular user-led website recommends a diet high in protein, natural fats and green vegetables and low in carbohydrates, with carbohydrates only eaten \u0026lsquo;paired\u0026rsquo; with natural fat or protein to slow down the release of glucose (Gestational Diabetes UK, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). There is currently insufficient evidence about the optimal dietary and exercise strategies that will improve outcomes for women with GDM (Dingena et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Han et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Yamamoto et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), and a review by Dingena et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) found that there were also no randomised controlled studies or crossover trials on diet or exercise interventions for pregnant women with pre-existing diabetes. Given the variation even between national guidelines in different countries on diet and exercise for mothers with diabetes in pregnancy (Rasmussen et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), this is an important topic for future research.\u003c/p\u003e\u003cp\u003ePrevious studies in the UK have reported paternalistic and judgemental encounters with health professionals (Parsons et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Stenhouse et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). NHS guidance specifically cautions health professionals against using value-laden language such as \u0026lsquo;good\u0026rsquo;, \u0026lsquo;bad\u0026rsquo; or \u0026lsquo;failing\u0026rsquo; when talking to people with diabetes, as this can increase shame and \u003cem\u003e\u0026ldquo;imply that following instructions will result in perfect glucose levels, even though it is known that the tools to manage diabetes are far from perfect\u003c/em\u003e\u0026rdquo;(NHS England, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2018\u003c/span\u003e, p. 8). This may be particularly relevant for those mothers with GDM and T2D who have previously felt stigma in the context of their weight (Duarte et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), which may be inadvertently reinforced by health professionals\u0026rsquo; choice of words. Contemporary dieting culture both creates feelings of moral transgression for food choices and engenders resistance (Madden \u0026amp; Chamberlain, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2010\u003c/span\u003e), and this culture was reflected in this study with some mothers describing themselves as \u003cem\u003e\u0026ldquo;naughty\u0026rdquo;\u003c/em\u003e and expecting to be \u003cem\u003e\u0026ldquo;told off\u0026rdquo;\u003c/em\u003e by an authority figure, while others asserted a right to \u003cem\u003e\u0026ldquo;treats\u0026rdquo;\u003c/em\u003e or a \u003cem\u003e\u0026ldquo;lifestyle\u0026rdquo;\u003c/em\u003e which went against strict dietary advice. This framing led to mistrust on both sides, with some mothers occasionally falsifying blood glucose results (as also found by Draffin et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)), and in other cases health professionals refusing to believe that a mother was could be following their advice if she was unable to control her blood glucose. Simplistic praise for \u0026lsquo;good\u0026rsquo; glucose control could also have a malign impact on women with a history of eating disorder who used extreme food restriction, a coping strategy also identified by Draffin et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Although mothers with T1D have been reported to have mixed feelings about using technology for diabetes management (Roddy \u0026amp; McGowan, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), in this study mothers with all types of diabetes welcomed the use of technology as convenient, supporting honest communication and increasing their control over their diabetes.\u003c/p\u003e\u003cp\u003ePrevious research has found that some mothers with diabetes simply do not want to hear about the risks of negative outcomes for their babies (Parsons et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), but it is a more common finding that mothers feel health professionals use the risks to pressurise them into compliance with interventions (Parsons et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Roddy \u0026amp; McGowan, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). All the mothers in this research accepted the importance of knowing about the potential risks, which could motivate them to make the sometimes difficult behaviour changes, but they were critical of health professionals who communicated these risks in ways that were alarmist, not personalised and lacked detail about absolute rather than relative risk. The challenges of communicating pregnancy risks in a way that is effective but not alarmist has been highlighted in other contexts such as maternal obesity (Duarte et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Parsons et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) suggest that health professionals\u0026rsquo; behaviour may be influenced by their own anxiety if mothers\u0026rsquo; blood glucose is not controlled and the baby\u0026rsquo;s health is at risk, but by contrast this study also found examples of health professionals who talked in a balanced and empathetic way about the causes of diabetes, food choices, and risk, and fully supported mothers\u0026rsquo; autonomy as experts on their own bodies and decision makers.\u003c/p\u003e\u003cp\u003eA couple of mothers in this study were uncomfortable that they had been offered GDM testing on the grounds of ethnicity, interpreting this as unfair targeting rather than being prioritised for an enhanced service. This suggests the need for more careful messaging about why the test may be offered, and echoes a finding, in a report about stillbirth, that Black and Asian parents may decline diabetes testing if ethnicity is cited as a risk factor without the reasons being well explained (Sands, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Some mothers also experienced stereotyping about the foods they were assumed to eat based on their ethnicity, and a lack of culturally relevant dietary information, as previously reported for women from minority ethnic and migrant groups (Bandyopadhyay, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Draffin et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Kirkham et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Where culturally inclusive resources have been developed locally (Bridle, undated), there is no mechanism for sharing them to other parts of the NHS.\u003c/p\u003e\u003cp\u003ePrevious research has found that mothers with diabetes may be unhappy about the medicalisation of their pregnancies, or reassured by it (Edwards et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Parsons et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Parsons et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The mothers in this study generally appreciated the additional monitoring they received provided it was meaningful, while being in some cases critical if they were told to take medication before they had a chance to try glucose control through dietary changes and exercise. Some were also frustrated at being seen only through the lens of diabetes so that normal maternity care was reduced or rushed (Edwards et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Parsons et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Being classed as a \u0026lsquo;high risk\u0026rsquo; pregnancy was directly linked to a reduction in the birth choices offered to the mothers, so that none were offered the option of a birth outside an obstetric unit, although it has recently been found that women with well controlled GDM may safely plan birth in a midwifery unit on the same site as obstetric and neonatal services (Morelli et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMany mothers reported that they were told, as soon as they were pregnant (for T1D and T2D) or as soon as they were diagnosed (for GDM), that they were \u003cem\u003e\u0026ldquo;not allowed\u0026rdquo;\u003c/em\u003e to continue their pregnancy past gestations of 37\u0026ndash;39 weeks. While national guidance supports advising to mothers with pre-existing diabetes and no other complications to give birth between 37 weeks and 38 weeks plus 6 days, it specifies that women with GDM should be advised to give birth before 40 weeks plus 6 days (National Collaborating Centre for Women's and Children's Health, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The evidence of this study is that in some hospitals, early induction was being applied to women with uncomplicated GDM as a matter of policy, and was not communicated as a recommendation but as the doctor\u0026rsquo;s decision.\u003c/p\u003e\u003cp\u003eWhereas mothers received an intensive level of specialist care during pregnancy, this did not continue during and after birth when they were handed over to non-specialist teams who did not necessarily have any understanding of diabetes management, putting mothers and babies at avoidable risk of harm. Mothers with T1D who were used to autonomy in managing their blood glucose found it disempowering when they were \u003cem\u003e\u0026ldquo;not allowed\u0026rdquo;\u003c/em\u003e to control their own insulin during labour and birth, and frightening when maternity teams did not demonstrate understanding of how to keep their blood glucose stable. Some mothers reported that during in-patient stays in hospital they were given food that undermined the dietary guidance they had been given for diabetes, and that this was a particular problem for Asian mothers. In line with earlier findings (Craig et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Parsons et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Roddy \u0026amp; McGowan, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), mothers with all types of diabetes felt vulnerable and unsafe when their specialist diabetes care was suddenly cut off from birth, and they suggested that it should ideally be continued into the immediate postnatal period. This postnatal \u0026lsquo;cliff edge\u0026rsquo; had immediate consequences for mothers with T1D who had great difficulty in managing their fluctuating blood glucose while breastfeeding (Sparud-Lundin \u0026amp; Berg, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Most mothers had not been prepared for this loss of care, and nor had their diabetes team tried to fill this gap by giving them information in advance about how diabetes might affect mother and baby postnatally.\u003c/p\u003e\u003cp\u003eThe absence of continuity of care between the antenatal diabetes team and the staff on labour suites and postnatal wards was mirrored in many cases by the lack of joined-up working between the hospital and community health services, with some women and some GPs unaware of follow up testing for mothers with GDM. There is a substantial literature on prevention of T2D after GDM, including the reasons why mothers may not take up testing (Dennison et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Dennison et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2019\u003c/span\u003e); this study highlights a key barrier from within the healthcare system itself, with lack of communication and awareness meaning that considerable persistence was needed to get tested at some GP practices. The absence of joined-up care carried a real risk of future harm when GPs and postnatal staff in hospital and the community had a limited understanding of diabetes and reassured mothers with GDM that they could go back their pre-pregnancy lifestyle, instead of recommending that they continue a diabetes prevention lifestyle in line with national guidance (National Collaborating Centre for Women's and Children's Health, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). However, on most of these postnatal issues there were also some examples of good practice \u0026ndash; where mothers were given full information about likely postnatal challenges and how to manage them, were followed up by the antenatal diabetes team before leaving hospital, were given comprehensive information about future risk and how to avoid it, or were automatically invited for follow up testing with liaison between hospital and GP. The fact that following guidance and providing person-centred care was achievable in some NHS services in England suggests that it should be achievable for all.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThis study included mothers with all three types of diabetes, and from diverse backgrounds and diverse parts of England, and explored their experiences across the whole maternity and postnatal care continuum. While this has enabled their experiences to be thematically analysed and compared, it also meant that more limited numbers of mothers with the less common T1D and T2D were included.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThere were examples of both good and poor practice. Mothers\u0026rsquo; experiences of care during a diabetic pregnancy could be improved if all NHS services followed existing national guidelines and offered person-centred, non-judgmental care that respects the autonomy of the mother as a decision-maker based on sufficient information about personal risk. Mothers need high quality, consistent, evidenced-based, culturally relevant and timely information about managing diabetes, with specific practical tips and recipes and access to support from other mothers, and this might be achieved by services working in partnership with third sector organisations. Primary and secondary healthcare needs to be joined up so that women with diabetes receive pre-conception counselling, support in pregnancy and for a transitional period after birth, and intrapartum and postnatal care that addresses their needs as mothers who have or have had diabetes and may be at future risk. The continuing increase in pregnancies affected by diabetes means that all health professionals who are involved in maternity and postnatal care need the knowledge, skills and confidence to support mothers with all types of diabetes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe University of Oxford Medical Sciences Interdivisional Research Ethics Committee approved the study (R85996/RE001).\u0026nbsp;Informed consent was obtained from all participants and all methods were carried out in accordance with the Declaration of Helsinki and relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during the current study are not publicly available due to the consent process but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-1217-21202. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contrib\u003c/strong\u003eu\u003cstrong\u003etions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJM and FA designed the study. \u0026nbsp;JM conducted the interviews and analysed the data, and FA analysed a subset of the data. JM wrote the first draft, and FA reviewed and agreed the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThank you to the mothers who took part in this study, and to our PPI contributors who reviewed the study documents, advised on the interview topic guide, publicised the study to recruit participants, and commented on the findings: \u0026nbsp;Niki Beslin, Sarah Dunkley, Amber Marshall (Big Birthas), Anna Morris (Diabetes UK), Vanathy Nathan, Joanne Paterson (Gestational Diabetes UK).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJM \u0026amp; FA: NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Public Health, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAyman, G., Strachan, J. 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Characteristics and outcomes of pregnant women with type 1 or type 2 diabetes: a 5-year national population-based cohort study. \u003cem\u003eLancet Diabetes Endocrinol, 9\u003c/em\u003e(3), 153-164. doi: 10.1016/s2213-8587(20)30406-x\u003c/li\u003e\n\u003cli\u003eNational Collaborating Centre for Women\u0026apos;s and Children\u0026apos;s Health. (2015). Clinical Guidelines Diabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the Postnatal Period \u003cem\u003eDiabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the Postnatal Period\u003c/em\u003e. London: National Institute for Health and Care Excellence (UK).\u003c/li\u003e\n\u003cli\u003eNational Health Service. (2022). Gestational Diabetes - Treatment. Retrieved 25 March 2025, from https://www.nhs.uk/conditions/gestational-diabetes/treatment/\u003c/li\u003e\n\u003cli\u003eNHS Digital. (2023). National Pregnancy in Diabetes Audit 2021 and 2022 (01 January 2021 to 31 December 2022).\u003c/li\u003e\n\u003cli\u003eNHS England. (2018). \u003cem\u003eLanguage Matters: Language and diabetes\u003c/em\u003e. NHS England.\u003c/li\u003e\n\u003cli\u003eParsons, J., Ismail, K., Amiel, S., \u0026amp; Forbes, A. (2014). Perceptions Among Women With Gestational Diabetes. \u003cem\u003eQualitative Health Research, 24\u003c/em\u003e(4), 575-585. doi: 10.1177/1049732314524636\u003c/li\u003e\n\u003cli\u003eParsons, J., Sparrow, K., Ismail, K., Hunt, K., Rogers, H., \u0026amp; Forbes, A. (2018). Experiences of gestational diabetes and gestational diabetes care: A focus group and interview study. \u003cem\u003eBMC Pregnancy and Childbirth, 18\u003c/em\u003e(1), 25-25. doi: 10.1186/s12884-018-1657-9\u003c/li\u003e\n\u003cli\u003ePham, S., Churruca, K., Ellis, L. A., \u0026amp; Braithwaite, J. (2022). 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Diet and Healthy Lifestyle in the Management of Gestational Diabetes Mellitus. \u003cem\u003eNutrients, 12\u003c/em\u003e(10). doi: 10.3390/nu12103050\u003c/li\u003e\n\u003cli\u003eRoddy, J., \u0026amp; McGowan, L. (2024). What are the childbearing experiences of women with type 1 diabetes? A scoping review of qualitative literature. \u003cem\u003eMidwifery, 128\u003c/em\u003e, 103884. doi: 10.1016/j.midw.2023.103884\u003c/li\u003e\n\u003cli\u003eSandelowski, M. (2000). Whatever Happened to Qualitative Description? \u003cem\u003eResearch in Nursing and Health, 23\u003c/em\u003e, 334-340. doi: 10.1002/1098-240X(200008)23:4\u0026lt;334::AID-NUR9\u0026gt;3.0.CO;2-G\u003c/li\u003e\n\u003cli\u003eSands. (2023). The Sands Listening Project: Leraning from the experiences of Black and Asian bereaved parents. London: Sands (Stillbirth and Neonatal Death Society).\u003c/li\u003e\n\u003cli\u003eSparud-Lundin, C., \u0026amp; Berg, M. (2011). 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Women\u0026apos;s views and knowledge regarding healthcare seeking for gestational diabetes in the postpartum period: A systematic review of qualitative/survey studies. \u003cem\u003eDiabetes Research and Clinical Practice, 110\u003c/em\u003e(2), 109-122. doi: 10.1016/j.diabres.2015.09.010\u003c/li\u003e\n\u003cli\u003eWoolley, M., Jones, C., Davies, J., Rao, U., Ewins, D., Nair, S., \u0026amp; Joseph, F. (2015). Type 1 diabetes and pregnancy: a phenomenological study of women\u0026apos;s first experiences. \u003cem\u003ePractical Diabetes, 32\u003c/em\u003e(1), 13-18. doi: https://doi.org/10.1002/pdi.1914\u003c/li\u003e\n\u003cli\u003eYamamoto, J. M., Kellett, J. E., Balsells, M., Garc\u0026iacute;a-Patterson, A., Hadar, E., Sol\u0026agrave;, I., Gich, I., van der Beek, E. M., Casta\u0026ntilde;eda-Guti\u0026eacute;rrez, E., Heinonen, S., et al. (2018). Gestational Diabetes Mellitus and Diet: A Systematic Review and Meta-analysis of Randomized Controlled Trials Examining the Impact of Modified Dietary Interventions on Maternal Glucose Control and Neonatal Birth Weight. \u003cem\u003eDiabetes Care, 41\u003c/em\u003e(7), 1346-1361. doi: 10.2337/dc18-0102\u003c/li\u003e\n\u003cli\u003eYe, W., Luo, C., Huang, J., Li, C., Liu, Z., \u0026amp; Liu, F. (2022). Gestational diabetes mellitus and adverse pregnancy outcomes: systematic review and meta-analysis. \u003cem\u003eBMJ, 377\u003c/em\u003e, e067946. doi: 10.1136/bmj-2021-067946\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Type 1 diabetes, type2 diabetes, gestational diabetes mellitus, pregnancy, postnatal, qualitative","lastPublishedDoi":"10.21203/rs.3.rs-6855141/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6855141/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eDiabetes is a significant health issue during and after pregnancy, with increased risks of adverse outcomes for mothers and babies if maternal blood glucose is not controlled. National guidelines in England cover maternity care for women with pre-existing (type 1 or type 2) and newly-diagnosed (gestational) diabetes, but as the incidence of pregnancies affected by diabetes increases, it is unclear to what extent this guidance is being followed.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003e32 mothers in England with type 1, type 2 or gestational diabetes were interviewed about their experiences of antenatal, intrapartum and postnatal care. Interviews were analysed using thematic analysis.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eFour themes were developed: ‘The antenatal information gap’, ‘Monitoring and management’, ‘Communicating risk and choice’, and ‘The postnatal cliff edge’. There were examples of good and poor practice across all themes, and themes were similar across all types of diabetes. Mothers felt safe when care met their needs for pre-conception counselling; high quality and timely information about diet and exercise; access to personalised advice; real time communication of blood glucose results through the use of technology; non-judgemental support that recognised their expertise on their own bodies; meaningful informed choice about mode and timing of birth with risks explained clearly and without drama; well-planned intrapartum care that included management of their blood glucose; and information to prepare for the postnatal period. Inconsistent, poorly-informed and judgemental interactions made mothers feel coerced and unsafe. Most reported intensive antenatal support but a lack of postnatal support.\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eMaternity services should offer mothers with diabetes person-centred, non-judgmental care that respects the autonomy of the mother as a decision-maker based on sufficient information about personal risk. Mothers need high quality, consistent, evidenced-based, culturally relevant and timely information about managing diabetes, with practical tips and recipes and access to support from other mothers, and this might be achieved by services working in partnership with third sector organisations. Primary and secondary healthcare needs to be joined up, particularly to increase postnatal support. All health professionals who are involved in maternity and postnatal care need the knowledge, skills and confidence to support mothers with all types of diabetes.\u003c/p\u003e","manuscriptTitle":"“We are more than diabetes”: a qualitative study of maternity and postnatal care experiences of mothers in England with type 1, type 2 and gestational diabetes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 10:01:36","doi":"10.21203/rs.3.rs-6855141/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"249789817386496903891330725833087028565","date":"2026-05-14T12:30:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-13T07:44:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30909857966780589486985147458797582942","date":"2025-07-20T14:16:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"251495697445144703657437338765732960789","date":"2025-07-13T22:14:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-11T06:08:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-13T06:36:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-11T03:26:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-11T03:26:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-06-09T13:48:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a67693cf-7350-4ea8-8d66-d8f3288a565c","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"249789817386496903891330725833087028565","date":"2026-05-14T12:30:02+00:00","index":101,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-15T10:01:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 10:01:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6855141","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6855141","identity":"rs-6855141","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}