After gestational diabetes: Postpartum glucose tolerance testing and the dilemma of risk across the life course

Gestational diabetes mellitus(GDM) is a complication of pregnancy with high stakes for women across the life course. Within 10 years after delivery, 60% of women with GDM develop type 2 diabetes. Postpartum glucose testing is a critical first step for lifelong prevention; however, testing rates are low, and reasons are poorly understood. We conducted the first known study of postpartum glucose testing among low-income, primarily black women who delivered at an urban safety net hospital. We first analyzed clinical data (N=415, 2003-2009 births) using logistic regression to assess effects of patient-, provider-, and system-related factors on testing. We then conducted in depth interviews with 30 patients and 24 providers to explore how each makes sense of GDM and its risks,and barriers to postpartum testing. By 6 months, only 23.4% of GDM-affected women received any kind of glucose test, and less than one-third of these were the recommended Oral Glucose Tolerance Test (OGTT). Younger women (<=5) and women with a family practice provider were significantly less likely to be tested than their counterparts (OR 0.51; 0.32, 0.83 and OR 0.36; 0.19, 0.71). Our analysis of women's and providers' narratives revealed conflicting priorities: women either denied or exaggerated future risks in light of the disease as deadly in their communities. Providers focused mainly on infant-centered and transient risks bound to pregnancy. Both contribute to under-use of postpartum testing. Failure to follow-up GDM reflects patient-provider gaps and a broader systems failure to prioritize women's health during the transition from pregnancy to primary care.