When it comes to providing health-care facilities, almost all centers in India and
other developing countries focus mainly on the medical or surgical condition in question.
Surprisingly, no or minimal attention is paid on the psychosocial factors that impact
the overall health of the individual. Diabetes is one such medical condition where
numerous studies focus on the physical and medical aspects, but fewer are concerned
with the psychosocial experiences and needs of the patients. Diabetes mellitus is
defined as carbohydrate disturbance characterized by hyperglycemia with peripheral
insulin resistance or insulin deficiency. Incidence varies from 1% to 14% in the world
depending on ethnicity, selection criteria, and the diagnostic tests performed.[1]
Transition to motherhood is a major life-changing event and also a common concept
in developmental, stress, and adaptation theories.[2]
[3] Transitions at any point of time are usually associated with significant change,
complex decisions, and increased stress, which can affect problem-solving and coping
abilities of an individual.[4]
[5] When this transition is associated with an added medical condition, the psychological
stress on the woman is huge.
In our country, most of the known diabetics belong to the affluent class. Most of
them are educated, and being a chronic illness, they know their medical condition
well. Many women are also aware of the fact that uncontrolled diabetes can lead to
pregnancy-related complications. Hence, planning pregnancy in itself becomes a reason
for a lot of stress to them. Consulting an obstetrician and an endocrinologist for
preconception counseling may help the woman to optimize her health and her blood sugars
to a level which is safe for the fetus. Many women miss this opportunity, and they
would report only after pregnancy is confirmed. We have many women coming to us in
the outpatient department in their late first trimester. Some have an HbA1c of over
12%. When the patients are counseled about the effect of increased HbA1c on the fetus,
they become more concerned adding to the stress of their underlying medical condition.
Some patients with very high HbA1c plan medical termination of pregnancy after consulting
the geneticists and the obstetricians and understanding the risk of having a fetus
with neural tube defects and other congenital malformations. Many of them wait for
all the prenatal diagnostic tests including serum markers and ultrasound, and they
proceed with pregnancy when the reports come normal although none of the tests are
100% sensitive. Whether the woman opts for termination of pregnancy or awaits all
the investigations to be completed, she spends every minute of her life in a big psychological
stress, the stress of losing her baby. Poor glycemic control of diabetes in itself
is associated with increased incidence of miscarriage in the first trimester.[6] Due to a failed pregnancy, spontaneous miscarriage, or induced abortion in view
of malformations, the woman is left in a profound grief. The spouse and relatives
may overlook the situation, and the woman may not get adequate psychological and emotional
supports.
According to Bridge et al.[2] and other authors[7]
[8] a big concern among diabetic women with pregnancy was the sense of losing control
of their body and their diabetes.[2]
[7]
[8] According to King et al., many women felt that they could no longer rely on their body's signs of recognizing
hypoglycemic symptoms.[9] This made it difficult to manage fluctuating blood sugar levels.[9]
[10] To compensate for unpredictable blood sugar fluctuations, women monitored their
sugar levels more frequently, which disrupted their daily routines and their sleep,[7]
[9]
[10] one more component contributing to the stress. Uncontrolled diabetes, whether gestational,
type 1, or type 2 diabetes in pregnancy, is also associated with increased incidence
of other obstetric complications such as full-term fetal demise. This complication
should not arise with proper monitoring, biophysical profile, and timely management;
despite all measures if such a mishap happens, additional psychological support and
counseling should be provided to the grief stuck woman.
Various studies stated that pregnant women with type 1 diabetes experienced greater
anxiety and depressive moods[11]
[12] and were more distressed[13] compared to pregnant women without preexisting diabetes. They also reported more
intense pregnancy-related negative feelings and fewer positive emotions than pregnant
women without diabetes.
During pregnancy, women with type 1 diabetes mellitus reported greater anxiety and
more depressive and hostile moods compared to women with gestational diabetes.[12]
[14]
Berg and Honkasalo stated that many women were afraid to sleep alone because of their
fear for hypoglycemia.[10] They would prefer to rely on their partners or relatives for support in unexpected
complications. Women with known diabetes before conception are more aware of their
condition and hypoglycemic symptoms compared to women who are diagnosed with overt
diabetes during pregnancy. Women with diabetes before pregnancy know their dietary
schedule well; they are already adjusted and used to a diet with low glycemic index.
Women experience cravings for different foods during pregnancy and those diagnosed
with diabetes in pregnancy find it hard to kill their craving for sweets and other
food items to be avoided in diabetes. Fighting with those cravings is not an easy
task for a pregnant woman; still, she thinks of the fetus first and feels that one
mistake committed by her may give rise to big mishaps. Ultimately, she is left with
only a few options in diet, and this definitely adds up to the stress.
Health professionals have an important role in helping women achieve optimal pregnancy
outcomes and also help them develop the confidence to manage their diabetes during
their pregnancy and after delivery.[15] A review by Rasmussen et al. states that for some women, meeting their health-care professionals was more of
a one-way communication, with the patient not having the opportunity to say much.
Further, the aim of the health-care professional seemed to control the blood sugars
only overlooking her emotional and psychological needs.[16] Women living in rural communities experienced additional difficulties accessing
knowledgeable health professionals and services and moving on to some other place
with advanced health-care facilities which added on to the cost and exacerbated their
stress.[9]
[16] However, they also reviewed that women who were supported and acknowledged for their
efforts by their medical team were highly satisfied.[9]
[16]
In an Indian set up, the role of the mother-in-law is immense; she is the one spending
most of the time with the pregnant woman. A positive support from the mother-in-law
helps neutralize many components of emotional upset. It is a good practice to involve
the mother-in-law in the patient management. She should be explained in detail about
the disease and its implications on the mother and the baby's health. Very few studies
have examined the effect of psychosocial support in pregnant women with diabetes despite
sufficient evidence that stress and psychological support affect health and pregnancy
outcomes.[16] Overall management including following the diet schedule and timely medicine intake
was more likely to be followed when social support was provided to the patient.[17]
Sparud-Lundin et al. studied the use of internet among diabetic patients with pregnancy, and they found
that women found internet as a source of reliable information related to diabetes
and pregnancy, interactive support, and social networking among similar patients.[18]
Many women residing in the urban areas in India too use Internet as a source of information
regarding their medical condition. The web-based approach may be helpful in providing
psychological support to the pregnant women who provided the information on the website
was true and reliable.[18]
The phase after delivery is another big transition in a woman's life. In general,
women experience combined feelings of joy and stress. Some women suffer from certain
psychological conditions during this phase. Many women do not receive attention as
the care is now diverted to the new member. Lack of support and care by the family
members may lead to more of emotional and psychological upset. After discharge from
the hospital, women feel a sense of disconnectedness from her health-care providers.
Here comes the role of specific support from the family members. Rasmussen et al. stated that support from the partners was essential to enable women to manage daily
life with a newborn baby and their diabetes.[16]
Social environment plays an integral role in women's perception of stress, their sense
of control over their diabetes, and their transition to motherhood in general.[16]
Optimal psychosocial support should meet the needs, recognize a woman's knowledge
and capabilities, and help her build a trustworthy relationship with the health-care
professional. We, as a developing nation, have miles to go to reach that level of
health system; however, higher centers are doing their bit to provide optimal psychosocial
support along with treatment of the underlying illness.
To conclude, apart from health-care providers, the supportive role of spouse and in-laws,
especially mother-in-law, in an Indian set up cannot be ignored, and this is of immense
importance during all phases of this major transition of a woman's life, called pregnancy
and childbirth.
Financial support and sponsorship
Nil.
