"Post-GDM support would be really good for mothers": A qualitative interview study exploring how to support a healthy diet and physical activity after gestational diabetes.

BACKGROUND: Women with a history of gestational diabetes mellitus (GDM) are at high risk of developing type 2 diabetes mellitus (T2DM). They are therefore recommended to follow a healthy diet and be physically active in order to reduce that risk. However, achieving and maintaining these behaviours in the postpartum period is challenging. This study sought to explore women's views on suggested practical approaches to achieve and maintain a healthy diet and physical activity to reduce T2DM risk.
METHODS: Semi-structured interviews with 20 participants in Cambridgeshire, UK were conducted at three to 48 months after GDM. The participants' current diet and physical activity, intentions for any changes, and views on potential interventions to help manage T2DM risk through these behaviours were discussed. Framework analysis was used to analyse the transcripts. The interview schedule, suggested interventions, and thematic framework were based on a recent systematic review.
RESULTS: Most of the participants wanted to eat more healthily and be more active. A third of the participants considered that postpartum support for these behaviours would be transformative, a third thought it would be beneficial, and a third did not want additional support. The majority agreed that more information about the impact of diet and physical activity on diabetes risk, support to exercise with others, and advice about eating healthily, exercising with a busy schedule, monitoring progress and sustaining changes would facilitate a healthy diet and physical activity. Four other suggested interventions received mixed responses. It would be acceptable for this support to be delivered throughout pregnancy and postpartum through a range of formats. Clinicians were seen to have important roles in giving or signposting to support.
CONCLUSIONS: Many women would appreciate more support to reduce their T2DM risk after GDM and believe that a variety of interventions to integrate changes into their daily lives would help them to sustain healthier lifestyles.

Introduction

An estimated 17.8 million pregnancies resulting in live births were affected by gestational diabetes mellitus (GDM) worldwide in 2015 [1]. Estimates of prevalence vary greatly within and between regions and countries: the Middle East and North Africa have the highest prevalence at a median 12.9% of pregnancies affected (range 8.4 to 24.5%) and Europe has the lowest prevalence at 5.8% (range 1.8 to 22.3%) [2]; in Eastern and South-Eastern Asia, prevalence is 10.1% (95% confidence interval 6.5% to 15.7%) [3]. Approximately 5% of UK pregnancies were affected in 2015 [4]. Compared to women of an ethnicity associated with a high risk of GDM who are born in a Western country, many women who migrated from their native country to a Western country have higher rates of GDM [5].

GDM is associated with increased risk of pregnancy complications in both mother and baby, and maternal cardiometabolic disorders in later life [6]. Approximately a third of women with GDM are diagnosed with type 2 diabetes mellitus (T2DM) by 15 years postpartum, with recent data suggesting that the increased risk is sustained over time since GDM rather than being limited to the first few years after delivery [7]. T2DM risk factors including high body mass index (BMI) and ethnicity further increase T2DM risk in women who have had GDM: development of T2DM is 18% (95% confidence interval 5–34%) higher per unit BMI at follow-up, and 57% (95% confidence interval 39–70%) lower in White European populations compared to other populations (adjusting for ethnicity and follow-up) [7]. Women from Asia were found to have the highest incidence rate of T2DM after GDM at 46 cases per 1,000 person-years [8]. Factors such as poorer pregnancy glucose tolerance requiring treatment with insulin have been found to further increase risk of T2DM [9]. Overall, women who had GDM are 7–10 times more likely to develop T2DM over their lifetime than women with normoglycaemic pregnancies [7, 10, 11].

In addition to lifelong annual screening for diabetes after pregnancy, women with GDM should be offered postpartum lifestyle advice regarding weight control, diet and exercise [4]. Nevertheless, most women who have had GDM do not attempt or sustain changes to reduce modifiable risk factors but maintain lifestyles that increase their diabetes risk, and many show discrepancy between T2DM risk perception and behaviour [12]. Existing behaviour change interventions have focused on promoting physical activity and a healthy diet, while others have supported breastfeeding after GDM [13]. Intervention modes include group, individual and remote interventions, or a combination of approaches [13]. Positive effects on preventing T2DM progression are frequently observed but can be limited due to poor engagement, particularly in intensive interventions like the US Diabetes Prevention Programme, in this population [13-16].

In order to understand the facilitators and barriers towards lifestyle in women with a history of GDM, we conducted a qualitative synthesis of their views on reducing their risk of developing diabetes postpartum through lifestyle and behaviour changes [17]. We found that women who had had GDM identified themselves primarily as mothers who prioritised their family above themselves [17]. This motivated some to adopt healthy diets and to be active, but a need for resources, time, energy, information and support prevented others from making changes [17]. From these findings, we developed a set of recommendations for promoting a healthy lifestyle after GDM [17]. Only one of the 21 included studies was set in the UK (interviews with 35 women in total to explore influences on postpartum health behaviours and the feasibility of diabetes prevention intervention [18]) and we are aware of only one other UK study that has been completed more recently (interviews or focus groups with 50 women in total also to explore influences on postpartum health behaviours and preferences for lifestyle support [19]).

There is therefore a gap in recent literature in the UK population surrounding the acceptability of recommendations for intervention after GDM in a real-life context. In this study, we sought to address this gap by exploring the views of women with a history of GDM on possible interventions to support healthy diet and physical activity to reduce diabetes risk, in addition to participants’ own suggestions. We aimed to identify the most promising interventions for future development.

Participants and methods

The ‘Diet, Activity and Screening after gestational diabetes: an Interview Study’ (DAiSIeS) was approved by the West London and GTAC Research Ethics Committee (reference 19/LO/0441).

Recruitment

Participants were recruited from the Rosie Hospital in Cambridge and Peterborough Hospital. These sites were chosen to provide socioeconomic and ethnic diversity, and represent views from those attending both secondary and tertiary centres offering GDM and obstetric care. Posters were displayed at antenatal clinics to promote awareness of the study. Research midwives identified eligible participants from medical records, and sent them a postal or email invitation and participant information sheet describing the study. Those who were interested in taking part contacted the midwives, and the study researcher (the first author) called them to provide an opportunity to ask questions and arrange the interview.

We planned to interview approximately 20 women in order to reach data saturation, a comparatively large sample size based on the relatively low information power anticipated [20]. This was because this study had a broad aim (to explore the participants’ views on potential interventions) and the sample was not very specific (participants had a recent history of GDM but no criteria relating to lifestyle behaviours). One the other hand, the interview schedule and framework analysis were structured around the recommendations made in our systematic review [17], which increases the information power. As widely recommended for data saturation [21], we finished recruitment after several interviews did not lead to novel findings. We interviewed all 20 participants who wanted to take part. Although we did not record the final number invited, uptake was estimated to be around 50% for women spoken to directly and around 5% for women who were sent a letter or email only.

Inclusion criteria

Participants were recruited if they had any history of GDM, were over 18 years old, and between 12 weeks and four years postpartum. This timeframe was chosen to allow sufficient time for new mothers to recover from pregnancy and attend postpartum follow-up, and so that all pregnancies were managed according to the National Institute for Health and Care Excellence (NICE) guidelines that were updated in 2015 [4]. NICE recommends screening for GDM with a 75g 2 hour oral glucose tolerance test (OGTT) in women with one or more risk factors (BMI greater than 30 kg/m2, previous baby weighing 4.5 kg or more, previous pregnancy affected by GDM, family history of diabetes, and ethnicity with a high prevalence of diabetes) [4]. Diagnostic cut-offs were defined according to local protocols: at Peterborough Hospital, those with a fasting value ≥5.6 mmol/l or 2 hour value of ≥7.8 mmol/l were diagnosed with GDM (NICE guidelines [4]); at the Rosie Hospital, those with a fasting value ≥5.1 mmol/l, 1 hour value of ≥10.0 mmol/l or 2 hour value of ≥8.5 mmol/l were diagnosed with GDM (International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria [22]). Screening usually takes place at 24 to 28 weeks gestation, although can be repeated if the clinicians suspect GDM has developed. Following GDM diagnosis, women are closely managed with the aim of reducing glycaemia. This involves blood glucose monitoring, diet and exercise, and sometimes insulin and metformin medication.

Women who had experienced adverse pregnancy outcomes (such as stillbirth, neonatal death or major congenital anomaly), participated in a pregnancy or GDM-related intervention that was in addition to or in place of routine care (such as a clinical trial) or were considered unsuitable for any other reason at the discretion of the midwives who had access to their medical records were not invited.

Interview process

A single semi-structured interview was conducted at the time and private place of the participants’ choice. Children were welcomed in order to facilitate attendance. Firstly, the interviewer (the first author) introduced herself (as a public health PhD student with training in qualitative methods but little interviewing experience) and the purpose of the interview (to listen to their experiences of GDM pregnancy and, particularly, postpartum in order to improve support). Participants then gave written informed consent, confirming that they understood the purpose and procedure of the study and that they could stop the interview at any point, and were happy for it to be audio-recorded.

Our previous systematic review informed the interview guide and suggestion cards, which were adapted from 20 recommendations (Fig 1 and S1 Table) [17]. The first part of the interview focused on diet and physical activity while the second part focused on screening for T2DM (reported separately [23]); ten suggestion cards were used as prompts in each part. We conducted three pilot interviews and collected written feedback from our patient and public involvement group, composed of mothers with GDM. This feedback was incorporated into the final version, which was refined after reflection on the first interviews. This involved changing the first question of the interview schedule from asking about their current diet (which we expected would be an easy discussion topic) to asking them to describe “what your GDM pregnancy was like for you”. Although this was not the focus of the interview and sometimes brought up upsetting accounts, the participants appreciated being able to tell their ‘story’ and it proved to be useful context for the remainder of the interview. Additionally, more signposting was incorporated into the interview such as “to help us understand any lasting impact GDM might have had…” or “before we talk about exercise, I’d like to ask you about your diet…”.

Fig 1

Adaptation of recommendations developed in the qualitative synthesis [17] to the DAiSIeS interview schedule.

H: high confidence; M: medium confidence; L: low confidence in the recommendation in accordance with the GRADE-CERQual evaluation [24].

Participants were first asked to share their experience of GDM in order to understand the background for their behaviours and attitudes. They then described their current dietary and physical activity habits and perceptions of the influence of GDM. We discussed whether any support for these behaviours would be helpful, and what format might be most effective (such as online, face-to-face with clinicians, peer support groups, etc.). Participants were asked about their own ideas first, then to comment on the ten suggestion cards provided by the interviewer (e.g. whether they agreed, disagreed or would add anything). It was emphasised that disagreement (they probably would not find that intervention helpful) as equally useful to hear as agreement (they might find that intervention helpful). If the participants did not want to make any further changes themselves, they were asked what they thought might help others with GDM based on their own experience. Prompts were used as required. Occasionally the interviewer decided not to show a particular participant a suggestion card if she considered that it was not appropriate given the earlier content of the interview and sometimes the participant did not provide clear feedback (e.g. due to natural distractions or initiating a different train of thought). We then discussed how to facilitate attendance at diabetes screening after GDM in the second part of the interview [23]. Finally, demographic information (including age band, ethnic group, employment status and pregnancy history) and interview feedback were collected through a short questionnaire. The interviewer recorded reflexive field notes on each interview including the context (e.g. setting, if anyone else was nearby) and subjective reflections.

Analysis

A professional transcription service transcribed the interview recordings. The first author checked the transcripts for accuracy and removed names, places and other potentially identifiable information.

We used a framework approach to analyse the interviews [25], with the aid of NVivo 12 (QSR International Pty Ltd; version 12; released 2018):

Familiarisation: We familiarised ourselves with the data by listening to the recordings and reading the transcripts and field notes, and making notes about important concepts.

Identifying a thematic framework: We developed a thematic framework that was based on the suggestion cards then refined it as required upon analysing the interviews by incorporating additional repeating concepts (such as communication requires a positive, non-judgemental tone). We distinguished between suggestions initiated by participants and responses to the suggestion cards in the analysis. The final codebook for the framework is reported in S2 Table.

Indexing: Next, we coded each transcript according to the thematic framework.

Charting: We drew charts to summarise what each participant said in relation to each part of the thematic framework. One row was used for each participant interviewed, and one column was used for each code within the framework.

Mapping and interpretation: We carefully studied the charts for repeating or characteristic ideas to describe and explain the phenomena observed. Where differences and deviant cases were observed, we attempted to understand the ways in which they different and why, according to the information the participants provided.

The first author coded all of the transcripts and developed the charts, and another author coded and charted four transcripts to ensure general agreement with the coding strategy and discuss alternative explanations. The other authors read some or all of the transcripts and charts in order to support interpretation. During these discussions, we considered the authors’ clinical (obstetrics, diabetes and general practice) and non-clinical backgrounds and made notes to record the analytical and interpretational decisions.

To supplement the qualitative analysis, we classified the participants’ collective response to each suggestion card as overall agreement, disagreement or mixed in order to create a general indication or impression of their views. The classification was based on the authors’ interpretations of the participants’ responses: whilst we counted the number of agreements or disagreements, we also considered the vigour with which each participant responded. Where the classification was not obvious, consensus among the authors was sought.

We also invited the participants to provide feedback on a summary of the findings (not the transcripts) and incorporated any responses into the final version.

Results

Twenty participants were interviewed between June 2019 and February 2020; 11 were recruited from Peterborough Hospital and nine from the Rosie Hospital in Cambridge. Most interviews took place in homes and two were at a hospital. The median (interquartile range) number of pregnancies per participant was 2 (1–2.25), with 1 (1–2) pregnancy affected by GDM. None of the 16 participants who had had a diabetes screening test since pregnancy had been diagnosed with T2DM. Table 1 shows the participants’ characteristics at the time of the interview. Interviews had a mean duration of 38 minutes (range 21–62 minutes).

Table 1

Participant characteristics at the time of the interview.

	N (percent)
Age band
26–30 years	3 (15)
31–35 years	9 (45)
36–40 years	6 (30)
≥41 years	2 (10)
Ethnicity
White British or European	14 (70)
Asian or Asian British	6 (30)
Chinese	2 (10)
Indian	3 (15)
Any other Asian background	1 (5)
Education level
Secondary or further (GCSEs, A levels, BTEC, apprenticeships or equivalent)	5 (25)
Higher (Bachelor’s degree or equivalent)	6 (30)
Postgraduate (Master’s degree, PhD or equivalent)	9 (45)
Employment (when not on maternity leave)
Full time	10 (50)
Part time	9 (45)
Home parent	1 (5)
On maternity leave
Yes	11 (55)
No	8 (40)
NA	1 (5)
Household status
Lives with partner	18 (90)
Does not live with partner	2 (10)
Number of children
1	6 (30)
2	9 (45)
≥3	5 (25)
Number of pregnancies affected by GDM
All pregnancies affected by GDM	13 (65)
Have also had normoglycaemic pregnancies	7 (35)
Management of GDM
Required medication (metformin and/or insulin)	10 (50)
Managed by dietary and lifestyle changes alone	10 (50)
Experience of GDM pregnancy and postpartum a
GDM management required significant/challenging lifestyle changes	17 (85)
They were attempting to maintain a healthy postpartum lifestyle	14 (70)
They felt adequately supported to maintain a healthy postpartum lifestyle	10 (50)

aElicited from transcripts. NA: not applicable.

Many participants had made significant lifestyle changes during pregnancy to manage GDM, and felt as if GDM had ruined their pregnancy or their lives had revolved around their blood glucose levels. The perception of care they received during pregnancy was mostly very good, yet several mentioned not wanting to have another child in fear of GDM.

Overall, the participants were eager to make changes to and take responsibility for their health. Many highlighted the importance of their individual mindset and desire to be helped. Seven participants had sufficient knowledge about healthy diet and exercise going forward, or knew where to find more support if they needed it. Seven participants acknowledged that more postpartum follow-up would be helpful, but they had been able to manage. The remaining participants reported sentiments such as “I don’t feel like I’ve been given the help that I think there should be really out there” [Participant 1, attempting healthier postpartum lifestyle but felt unsupported overall], “post-GDM support would be really good for mothers” [P2, healthier, unsupported] and two participants explained that they had been unaware of an association between GDM and T2DM. Those who had struggled through pregnancy found the postpartum period particularly challenging.

The participants’ views on suggestions to support a healthy postpartum diet and physical activity are summarised in Table 2, plus S3 Table indicates their agreement with each suggestion card. Many of the participants were positive towards the suggestions despite already making healthy changes. Others had mixed responses because they had specific questions, and one participant felt that “they’re [the suggestion cards] all quite similar, aren’t they? You know, I think I know those things already…” [P3, not attempting healthier lifestyle].

Table 2

Summary of the themes and participants’ agreement with whether the suggestion cards will support healthy diet and physical activity.

Theme	Overall response	Illustrative quotations
Information and understanding	Suggestion card 1: agree	• “I think the more information a person can have, the more able they are to make an informed decision, and I think that’s, especially as a mum, what you want.” [P4, not healthier]• “I think people know about healthy diet and exercising and they know that’s good for you and good for your weight but whether people can do it might be another thing.” [P2, healthier, unsupported]• “I don’t think that’s [card 2] as necessary, because I feel like that’s widely available, and I know that. But in terms of the link to diabetes [card 1], I didn’t know that.” [P5, not healthier]
	Card 2: mixed
Improving diet	Card 6: agree	• “The diet I was given to follow during pregnancy, bits of it felt very counter to what I understood to be healthy… I understood for the purposes of really stabilising my blood sugar that was important to do but… My vision of what a healthy long-term diet are don’t include most of those features… I suppose that would be quite useful if there was some sort of follow-up information, ‘Okay, you’ve done this, now you’re going to rebound a bit and we’re not asking you to keep it like this but it would be a good idea to…’, you know, ‘These ones are worth following, these ones aren’t.’ Maybe that exists but I don’t think I’ve seen it.” [P6, healthier, supported]• “If you have a clean track of what you want to eat and what are the things that add up your calories and what other things are good for you to control your diabetes, like the sugar levels. I think that can help a lot.” [P7, healthier, supported]
Improving physical activity	Card 5: agree	• “Like how to exercise around the home, because it’s really difficult trying to work out when you’re going to fit everything in, especially when you’ve got a small person that generates more washing than you could ever imagine…” [P8, not healthier]• “Having a baby carrier… you can keep an eye on them and they are happy because they’re [across your chest]. But also it gives you both your hands free to do stuff. Also it is exercise because you’re carrying them around and they’re getting heavier and heavier. Just make sure you get a good one that supports your back.” [P9, healthier, supported]• “Just a bit of a pointer in where to go and who to go to and what also would fit into a family life in terms of finance and childcare, and potentially meeting up with other mums or other people who’ve had diabetes as well.” [P10, healthier, supported]
	Card 7: agree
Family	Card 3: mixed	• “…Sometimes [my children] won’t agree to what you give… there’s green food–‘I don’t want’, they want some kind of pizza or burger all those things but still I somehow try to convince her with this kind of food.” [P7, healthier, supported]• “We both [her and her husband] did a lot of research… we are much more health-conscious and we try to exercise more, so I think we’ve both changed our lifestyle, and it carries on as well.” [P11, healthier, unsupported]• The children “don’t struggle with blood sugars, they don’t struggle with not being able to get out and get fresh air.” [P10, healthier, supported]
	Card 4: mixed
Money	Card 9: mixed	• “I mean it’s always good to know about how to save money but I just don’t think people don’t go on a healthy diet because of money problems.” [P2, healthier, unsupported]• “I don’t think there’s much useful guidance about maintaining that kind of healthy diabetes-friendly diet on a budget actually. A lot of healthy meals tend to be focused on things like lasagnes and stuff like that, like big batch cook things that aren’t necessarily the right thing for someone who is trying to like minimise diabetes risk to be eating.” [P12, healthier, unsupported]
Monitoring	Card 10: agree	• “It’s always nice to see your results to see some sort of benefits that you’ve been achieving, I think spurs you on.” [P13, healthier, supported]• “Apart from contacting my doctor to get a HbA1c test every year, no one’s contacted me to say, ’Have you made any lifestyle changes, how you getting on?’ So, it’s almost like you’re just left to get on then afterwards.” [P14, healthier, supported]
Sustainability	Card 8: agree	• “I think that would be really useful because I know a lot of people would perhaps make the change and then slip back into bad habits.” [P15, healthier, unsupported]• “Because people lose motivation quite quickly, they have the best intentions, and then… I think that’s probably where support groups that motivate one another would help.” [P14, healthier, supported]
Delivery of support or interventions	NA	• “I think it needs to be someone that’s personable, because I think from my experience, sometimes when you go to the hospital you get really nice consultants and sometimes you don’t… just needs to be someone that can be relatable and friendly and isn’t going to come across hostile or judgey, it is just here if you need a chat sort of thing.” [P16, healthier, unsupported]• “That is all while you are pregnant but then maybe afterwards you don’t get that side to carry on… Like a little leaving parcel of like here’s a little pack of how to keep going with the good work you’ve done, and help you prevent it in the future and just make it clear that actually although it is gestational and it goes, it doesn’t mean you are rid forever.” [P16, healthier, unsupported]• “If somebody had said to me at that point, ‘You need to be eating this, this and this,’ I think I’d have probably cried”, and “I just think that rather than checking, so that people don’t feel like they’re being checked up on, because if you’ve been ill and you haven’t got out of the house, you don’t want to feel like you’re failing your child.” [P8, not healthier]• “Especially when you’re doing feedings… late night feeds or whatever, you can sit and have a look at your phone and get that support 24/7.” [P14, healthier, supported]

Overall agreement is based on the authors’ interpretation of the responses. Not all participants were shown each card, and some did not comment or agreement was unclear. For each quote, we report the participant number, whether they were attempting healthier postpartum lifestyle or not (healthier/not healthier), and whether overall they felt supported to do this (supported/unsupported).

NA: not appropriate.

Information and understanding (suggestion cards 1 and 2)

Most of the participants felt that they would benefit from more information about the impact of healthy behaviours on their diabetes risk. Some would add this to existing knowledge, whereas others had poor awareness of the long-term implications of GDM because they hadn’t been told or remembered. It was important that information was adapted to mothers who had had GDM and perceived themselves to be knowledgeable (“not sort of trivial, such as ‘eat a healthy balanced diet, exercise more’” [P6, healthier, supported], and focused on how to be healthy in relation to T2DM.

Opinions varied about information on the impact of healthy diet and exercise on their wider health since most already had general awareness or found that this was covered by existing postpartum support, such as that provided by children’s centres.

Improving diet (suggestion card 6)

The majority of the participants were attempting to eat healthily by continuing elements of their GDM diet. Further guidance or tips would help them to do this because they received little or no information about what to eat after delivery (in contrast to pregnancy).

A couple of participants were uncertain because the GDM diet wasn’t a ‘normal’ healthy diet, such as eating peanut butter instead of fruit. Others wanted advice that was relevant to other aspects of their new situation, including managing cravings, balancing healthy diet with calorie intake for breastfeeding, with children of different ages, and different family mealtimes. It was important for advice to be individualised (“how to keep your diet… right for you” [P1, healthier, unsupported]) and in accordance with their palate or culture.

Two participants thought that they had the necessary knowledge but that other people did not. Three participants already had enough information by drawing on previous experiences and GDM diets.

Improving physical activity (suggestion cards 5 and 7)

Although many participants reported doing less physical activity than before pregnancy, several prioritised running (while their partner looked after the children), dance classes or home workouts. Others did lower-intensity activity, like pushing the buggy. Many wanted to do more exercise, and felt this would be achievable when the children were older, they finished breastfeeding, or had better recovered from pregnancy.

Help to exercise with others was frequently considered to facilitate physical activity because it had helped them in the past or they walked with others now, or it might make exercise less boring. Some preferred mother-and-baby classes or GDM groups, which would be accessible, and could provide an opportunity for socialising and sharing experiences alongside exercise. Local groups might need signposting because they didn’t know where to find them or hadn’t thought to look. Conversely, a few felt distracted when exercising with others or liked to exercise at their own pace.

Almost all the participants were eager for advice about how to be active alongside a busy schedule (including around the home and exercise for the whole family together), explaining that was the thing they had issues with and hadn’t received any advice about. Appropriateness for postpartum period was important: one participant suggested cards with postpartum-friendly exercises “like little diagrams and exercise routine that build the further on you get in your health… especially to what kind of birth you’ve had” [P16, healthier, unsupported]. Several participants shared what had helped them, including splitting exercise throughout the day and using a baby carrier.

Family (suggestion cards 3 and 4)

A young family made having a healthy lifestyle harder than it used to be due to increased demands on their time, and the need to meet others’ dietary preferences/requirements. On the other hand, parenthood could provide new opportunities: one participant’s older child encouraged her to exercise, and others walked with their antenatal groups. Some also found that their children motivated them to be healthier because they wanted to stay well for their family, prevent unhealthy habits in their children, and/or their partners wanted to be healthier too after they both learnt more about diabetes.

They therefore had mixed views regarding whether more information about the impact of healthy diet and exercise on their family would help them. Some participants reasoned that being healthy was something they would do as a family whereas others felt that it was only relevant to themselves. Others already knew the information, or it had been provided by their health visitor (although not everyone received this kind of guidance). Similarly, the suggestion of ways for the family to be healthier received mixed agreement; those that agreed wanted practical tips for fitting a healthy lifestyle in with family life, ideas for activities involving wider family and friends, and how to easily adapt child-friendly recipes for parents.

Money (suggestion card 9)

Twelve participants were in favour of advice about saving money and maintaining a healthy lifestyle because they found generic advice could not be applied to diabetes prevention. They also needed healthy options for the family to do, particularly because costs increased with a larger/growing family. Conversely, other participants considered that cost didn’t prevent a healthy lifestyle because cheap or free options were available. Some noted that cooking from scratch was already cheaper than buying prepared food; they therefore had fewer options for saving more money.

Monitoring (suggestion card 10)

Almost all of the participants had positive views towards monitoring their progress after pregnancy, anticipating it to make a big difference. They discussed either monitoring themselves (by recording their weight, diet, exercise, calories in and out, or ‘nice’ things like visiting the park) or through meeting with a health professional. Importantly, it was seen as a way to maintain motivation for changes through seeing their achievements and the benefits, or recreate targets like they had during pregnancy. A health professional could give more information and feedback on individual diabetes risk and blood glucose control. At the same time, several were cautious that monitoring could have the opposite effect: seeing weight increase could be demoralising and involving others might be stressful.

Sustainability (suggestion card 8)

With the exception of those who were not attempting to eat a healthier diet and exercise more, the participants wanted advice about sustaining changes and knew that maintaining a healthy lifestyle would be challenging. In practice, they felt that sustainability could be facilitated through the earlier themes; for example, that advice about healthy food that is suitable for the whole family, exercises that can be done around the house, and more follow-up will all help them to maintain behaviours to reduce their risk of T2DM.

Delivery of support or interventions

The participants also suggested how the above support could be delivered. This included the preferred format (including in-person peer support groups, appointments with healthcare professionals and written information), source and timing.

In-person peer groups

Seven participants wanted to share experiences in a peer support group throughout GDM pregnancy and postpartum. “Mum-centric” postpartum groups [P13, healthier, supported] could include tips for reducing diabetes risk, be linked to exercise classes and hosted through children’s centres, where other educational classes, such as for breastfeeding and postpartum mental health, already took place.

Appointments with healthcare professionals

This was the most frequently suggested intervention. Midwives, hospital diabetes teams, health visitors and GPs had provided GDM care and were a trustworthy and respected source of information.

Most participants were keen to receive advice about postpartum diet and exercise, and long-term diabetes risk during pregnancy. It would be good to be briefed while they were most aware of GDM, knowing that more information would follow. Only one participant felt that this would overwhelm her because there was already too much to think about during pregnancy.

Similarly, four participants felt that follow-up should be mentioned, in a casual way, while they were on the maternity ward or alongside other discharge information. Women who had more complicated births spent more time in hospital and generally felt abandoned with regards to GDM at that time, therefore would like the opportunity to make sure that they “knew the plan of action” with a professional [P4, not healthier]. One participant disagreed because she lost all of the many discharge papers she was given.

Thirteen participants discussed attending postpartum appointments with a clinician. Many suggested that GDM follow-up become part of the six-week mother-and-baby healthcheck with the GP, which would be after the initial overwhelming stage. In practice, this appointment focused on the baby, which was very important, but they too needed time with an expert to debrief: to be asked how they were, have some reassurance, discuss what to do next and, notably, receive feedback on each blood test result.

Written information

The participants thought that written information about postpartum lifestyle would be beneficial, such as a booklet, website or interactive smartphone app, like they had sought during pregnancy. Support would then be available at all times, including during night feeds. One proposed a “website that can make suggestions or to have a community of people with GDM who share recipes, what their concerns are” [P11, healthier, unsupported], because social media groups had the potential to be informative and supportive. Regardless of format, this would be most beneficial if it was provided alongside face-to-face care or if a clinician directed them to trusted resources.

Delivery of messages

Six participants, particularly those with specific struggles during pregnancy and/or postpartum, felt strongly that information should be shared in an individualised and sensitive fashion. Positive framing was important in the context of postpartum stress, diabetes-related fear, and outstanding feelings of guilt or judgment from having GDM.

Discussion

In this study, we explored the views of 20 mothers with recent GDM towards suggested support for having a healthy diet and being active in light of their T2DM risk. These women thought that additional advice about how to eat healthily and exercise when they were busy, and practical suggestions for making these changes sustainable in their context, would most help them to reduce their risk of T2DM. Many wanted more individualised information about their long-term risk of T2DM after GDM, and how they might mitigate that risk, but they often knew enough about the overall benefits of a healthy lifestyle. Although written information in any format would be acceptable, access to other mothers with GDM and a clinician talking to them about follow-up in a supportive manner was anticipated to be beneficial.

The DAiSIeS study was designed to build on our recent qualitative synthesis [17], bridging the gap between barriers and facilitators to diabetes prevention behaviours and intervention programme design. Comparing the findings of that review [17] and this interview study, we found that influences on healthy diet and exercise were similar, such as spending time with children instead of exercising and how the family could facilitate healthy behaviours. We had reported a lack of time and energy as barriers to healthy lifestyles; this was also true in this interview study, particularly in the early postpartum period that was considered to be a time for learning to adapt to life with their new baby. Women were more supportive of integrating activity into their daily routine than of participating in family-based exercise activities, which had appeared to be important in the review. Even though most of the DAiSIeS participants had a positive experience of GDM pregnancy and knew about having a healthy lifestyle, many felt that more specific information about lifestyle behaviours in T2DM risk prevention was important (such as what foods would be best for them to eat). This echoes a participant in Lindmark et al. 2010 who said ‘…even if it is old knowledge it is good to hear it once more’ [26]. The participants tended only to maintain selected elements of their GDM diet, which aimed to minimise spikes of high blood glucose during pregnancy, because they considered it was too extreme to sustain (such as a slight/moderate reduction in carbohydrate intake and strict avoidance of all high glycaemic index foods and high sugar fruit). Educational interventions may therefore support them to learn what things to continue and what not to in order to lose weight and maintain a balanced diet. Of particular note, these changes were anticipated help women maintain healthy lifestyle in the long term.

Previous studies have reported varying views regarding the best timing for intervention: some suggest during pregnancy [17, 27, 28] while others suggest postpartum [17-19]. We concluded that women with GDM should be prepared for more specific follow-up interventions such as those described above during their pregnancy, provided that this is done in a sensitive manner, echoing the findings of Ingstrup et al. regarding the importance of rapport with peer councillors [29]. In general, any healthcare professional involved in the care of women with GDM can promote a longer-term perspective.

Strengths and limitations

We used qualitative semi-structured interviews to understand the views of women with GDM towards improving postpartum support for heathy behaviours to reduce T2DM risk. While focusing on their own views towards effective interventions, we based the study design, interview schedule and analysis on recent systematic review evidence meaning that a clear evaluation of suggestions could be elicited.

The participants were from a mixture of ethnic and socioeconomic backgrounds, although many were more highly educated than the rest of the UK [30]. Nonetheless, the need for postpartum support–therefore the anticipated benefits of interventions–was high in this population, and may be higher in other settings. This may have been influenced by recruitment bias, with more health-conscious women or those in need of particular support more likely to engage in the study. We were also unable to capture the number or any characteristics about the women who were aware of the study (through seeing the posters displayed at GDM clinics or being invited specifically) and chose not to take part. However, the participants’ characteristics were comparable to those of the women attending these clinics [31, 32]. We did not collect data on BMI or whether participants were overweight because we did not access their medical record, and to ask them to self-report this could be insensitive during the postpartum period. It is important to facilitate all women to maintain a healthy diet and be physically active after GDM, regardless of their BMI, yet we were unable to comment on whether BMI affected requirements for support. Furthermore, social desirability bias may have led some participants to agree with the prompted suggestions, although it was clarified in the question that negative responses would be as informative as positive ones. Finally, as is true for all qualitative research, other interpretations of the data collected in this study might be possible, although no participants disagreed with the summary of the findings that we sent to them.

Implications for practice

In this study, the participants were keen to have a healthier diet and increase their physical activity after pregnancy. Importantly, many recognised the dedication and support they would need to sustain changes they had managed during pregnancy. Because intention and self-efficacy, influenced by past experience, have been associated with healthy diet and exercise at one and two years postpartum [33, 34] nurturing these beliefs is imperative. We identified a wide range of more specific requirements that could be addressed through various multi-faceted approaches (Fig 2).

Fig 2

Summary of key proposed amendments to current GDM pregnancy and postpartum care.

Proposed amendments are shaded in grey. Abbreviations: FPG–fasting plasma glucose test; HbA1c –glycated haemoglobin test.

Our findings support the important role that clinicians play in promoting healthy behaviours and signposting resources during pregnancy and postpartum [35]. Additionally, we suggest that it would be acceptable for the longer-term implications of GDM to be discussed in an informal manner throughout pregnancy and mentioned while mothers are on the postnatal ward. Many studies have reported pregnancy to be a ‘teachable moment’ for a range of behaviours due to increased motivation and regular contact with health professionals [36, 37]. As a result, informing women about postpartum recommendations in pregnancy is likely to be beneficial although not an end in itself [14].

The participants also expressed interest in a postpartum follow-up appointment. If the blood test was undertaken in advance, the six-week mother-and-baby healthcheck [38] could be extended to include specific GDM follow-up, such as discussion of future plans for diet and exercise going forward in light of the test result. This would also provide an opportunity to ask specific outstanding questions. Since half of mothers receive inadequate time to discuss their own mental and physical health [39], both the mother and GP should have aligned expectations about this appointment.

Postpartum contact also provides opportunity for a healthcare professional to signpost mothers to existing resources. Although some DAiSIeS participants preferred to meet other mothers with GDM, many expressed similar experiences and needs as women without GDM, therefore general postpartum dietary information or exercise classes could be beneficial. A recent study of mothers in a similar area identified the need to increase capability for exercise through signposting to suitable mother-and-baby exercise classes (which would be an environment where they felt comfortable about themselves and bringing their baby), and guidance about how to exercise safely after the birth [40].

Like many others, the women in our study reported accessing and interacting with websites, forums, social media and other sources of written information during pregnancy and postpartum. For example, mothers reported accessing Facebook more frequently in the postpartum period [41], such as to connect with other breastfeeding mothers for advice [42, 43]. Information was accessible at all times and could be informative and supportive, but many users raise doubts about trustworthiness [42, 44, 45]. A recent analysis of posts on Mumsnet and Netmums forums concluded that the support provided does not encourage T2DM prevention because diabetes risk was rarely discussed and users downplayed the seriousness of GDM and its association with lifestyle behaviours [46]. Instead of searching for such groups themselves, mothers could be directed to reliable resources by a trusted professional or body.

Conclusions

Many women wanted more support to sustain healthy lifestyles to reduce their T2DM risk after a GDM-affected pregnancy. We identified a broad range of interventions that could offer this support. These mothers thought that additional advice about how to eat healthily and be active when they were busy, and tips for maintaining these changes, would help them most. Many wanted more specific information about their long-term T2DM risk, but they often knew enough about the universal benefits of a healthy lifestyle. This support could be provided throughout pregnancy and postpartum, in a range of formats including face-to-face with healthcare providers or peers and online or physical written information. Directing women to existing trusted resources or groups, or adapting existing interventions to the needs of this population is likely to improve care for mothers after GDM.

DAiSIeS interview schedule.

(PDF)

Click here for additional data file.

Thematic framework used to analyse the DAiSIeS interviews.

(PDF)

Click here for additional data file.

DAiSIeS participants’ agreement with whether the suggestion cards will support healthy diet and physical activity.

Agreement was based on the authors’ interpretation of their responses. Not all participants were shown each card, and some did not comment or agreement was unclear. Dark green: strongly agree; green: agree; red: disagree; dark red: strongly disagree; grey: not shown or agreement is unclear. A: overall agreement; M: overall mixed response; D: overall disagreement.

(PDF)

Click here for additional data file.

5 Mar 2021

PONE-D-21-01829

“Post-GDM support would be really good for mothers”: a qualitative interview study exploring how to support a healthy diet and physical activity after gestational diabetes

PLOS ONE

Dear Dr. Dennison,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we have decided that your manuscript does not meet our criteria for publication and must therefore be rejected.

I am sorry that we cannot be more positive on this occasion, but hope that you appreciate the reasons for this decision.

Yours sincerely,

Wing Hung Tam

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Thank you for the submission to Plos One. Given the reviewers comment and the small number of highly selected participants on a qualitative review, the manuscript is not considered to be suitable for publication in Plos One.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this manuscript. This study aims to conduct a qualitative interview study on the views of women with history of GDM on the need for post-partum support. Given the high prevalence of GDM (affecting 10-20% of all pregnancies in many parts of the world), and the high risk of progressing to T2D after GDM (approximately 7-8x risk compared to non-GDM women), locally-relevant strategies to support women with GDM to reduce progression to T2D are very important. This study provides a systematic assessment of the attitudes and needs of women with GDM, and provide some useful information, in particular towards developing interventions and support networks within the UK healthcare setting and beyond.

Major comments

Introduction

More reference to the risk of T2DM after GDM might be helpful in the introduction. This may include data from systematic review highlighting the increased risk of T2D afer GDM compared to non-GDM pregnancies.

Page. 4 Line 82

It was stated that all women had history of GDM. Please clarify the prevailing diagnostic criteria which would have been used to diagnose GDM in these subjects

Page 6 Line 135

It was stated that none of the participants had been diagnosed with T2D. Please clarify if all the women with GDM had undergone postpartum OGTT screening

Table 1

Is any information available on the proportion of women who were overweight/obese, or their mean BMI?

Page 8 Line 151

Although I understand this is a qualitative interview study, are the authors able to state the number of women who were aware of the link between GDM and T2D, which would significantly affect the interpretation of the results?

Page 14 Line 246-248

Please provide further details on the responses from the participants on the preferred format, source and timing of providing support . Are the responses summarized by the later comments on In person peer groups, appointments with healthcare professionals and written messages?

Reviewer #2: The authors conducted semi-structured interviews with 20 participants with a history of GDM to explored the views of women on possible interventions to support healthy diet and physical activity to reduce diabetes risk and aimed to identify the most promising interventions for future development. The sample size was small and less representative. I also have some other concerns about the interpretations and discussions.

Major comments:

1. The participants were women who were interested in the study topic and the sample size was only 20 women. The representativeness and potential selection bias is one of the major problems of the study.

2. In table1, “education level” was not defined in methods.

3. The results of each theme were not concise, and some other interpretations might also possible, which should be discussed in full.

4. There are some published articles that investigated views of women with prior GDM on about diet and physical activity interventions. A detailed discussion about the similarity and differences and the underlying reasons is warranted.

**********

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Reviewer #1: No

Reviewer #2: No

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- - - - -

For journal use only: PONEDEC3

14 Apr 2021

Please see the cover letter for our response to the reviewers' feedback (with clearer formatting). I have copied this below for convenience.

_____

The Primary Care Unit

Department of Public Health and Primary Care

University of Cambridge

Cambridge, UK

CB2 0SR

Prof Wing Hung Tam

Academic Editor

PLOS ONE

14 April 2021

PONE-D-21-01829

“Post-GDM support would be really good for mothers”: a qualitative interview study exploring how to support a healthy diet and physical activity after gestational diabetes

Dear Prof Tam

Thank you for considering our manuscript and for the opportunity to resubmit it. We would also like to thank the reviewers for their time and feedback on our study.

We have concerns about one of the criticisms of this study. As requested, please see a point-by-point response to each of the comments in the decision letter below. We have also marked the resulting changes in the manuscript.

We look forward to hearing from you and hope that this manuscript can be considered for publication in PLoS ONE.

Yours sincerely,

Rebecca Dennison, Simon Griffin, Juliet Usher-Smith, Rachel Fox, Catherine Aiken and Claire Meek

***

Decision letter (email)

Dear Dr. Dennison,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we have decided that your manuscript does not meet our criteria for publication and must therefore be rejected.

I am sorry that we cannot be more positive on this occasion, but hope that you appreciate the reasons for this decision.

Yours sincerely,

Wing Hung Tam

Academic Editor

PLOS ONE

***

Additional Editor Comments (if provided)

Thank you for the submission to Plos One. Given the reviewers comment and the small number of highly selected participants on a qualitative review, the manuscript is not considered to be suitable for publication in Plos One.

RESPONSE:

Thank you for considering our manuscript. We would also like to thank the reviewers for their time and feedback on our study.

Reviewer 1 reported that the manuscript is technically sound and had six suggestions for improving it. These points are simple for us to address.

The decision to reject the manuscript appears to be based on Reviewer 2’s feedback – primarily ‘the small number of highly selected participants on a qualitative’ study, therefore concerns over representativeness and potential selection bias. We would like to briefly raise the following points:

1. In qualitative research, we are not interested in generalisability but understanding a phenomenon of interest in depth [1] – in this case, this group of women with a history of GDM’s views on support for postpartum behaviour change.

2. We planned the sample size using the concept of information power [2], which we have added to the Methods of the manuscript (lines 87-90 of the highlighted manuscript): “We planned to interview approximately 20 women in order to reach data saturation, based on the relatively low information power anticipated [2]. This was because this study had a broad aim, sparse sample specificity but used purposive sampling and was a cross-case analysis. The interviews were structured around pre-defined recommendations.” As explained in the manuscript, we stopped interviewing when the data collection process no longer offers any new or relevant data (data saturation) [3].

3. Our sample size of 20 participants is larger than many semi-structured interview studies. For example, the qualitative systematic review that informed this interview study included 12 studies using face-to-face interviews [4]. Only three of those had a sample size >20 participants (23, 23 and 35 participants) and median sample size was 16 participants. PLoS ONE has also published several qualitative interview studies with a comparable number of participants in recent months (e.g. [5,6]).

***

Reviewers' comments

***

Reviewer's Responses to Questions

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

RESPONSE: Note, there is no quantitative/statistical analysis in this qualitative study.

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

RESPONSE: Note, the data underlying the findings of this study are interview transcripts. We have ethical approval and consent from participants to share the pseudo-anonymised transcripts with researchers upon their request to us directly, but not to make them publicly available.

As suggested in the PLoS ONE Editorial policies for availability of qualitative data, we have made excerpts of the transcripts available within the paper and upon request.

We will include a data availability statement such as that of Backhausen et al. or Fleming et al. [5,6] (qualitative studies published in PLoS ONE in 2021).

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters).

***

Reviewer #1: Thank you for the opportunity to review this manuscript. This study aims to conduct a qualitative interview study on the views of women with history of GDM on the need for post-partum support. Given the high prevalence of GDM (affecting 10-20% of all pregnancies in many parts of the world), and the high risk of progressing to T2D after GDM (approximately 7-8x risk compared to non-GDM women), locally-relevant strategies to support women with GDM to reduce progression to T2D are very important. This study provides a systematic assessment of the attitudes and needs of women with GDM, and provide some useful information, in particular towards developing interventions and support networks within the UK healthcare setting and beyond.

RESPONSE: We thank the reviewer for reviewing our paper and for reinforcing the importance of these findings for intervention development.

Major comments

Introduction

More reference to the risk of T2DM after GDM might be helpful in the introduction. This may include data from systematic review highlighting the increased risk of T2D after GDM compared to non-GDM pregnancies.

RESPONSE: We thank the reviewer for this suggestion. We have expanded the description of T2D risk after GDM with data from recent systematic reviews including absolute risk data, relative risk data and factors associated with higher rates of progression: “GDM is associated with increased risk of pregnancy complications in both mother and baby, and maternal cardiometabolic disorders in later life [7]. Approximately a third of women with GDM are diagnosed with type 2 diabetes (T2D) by 15 years postpartum, with recent data suggesting that the increased risk is sustained over time since GDM rather than being limited to the first few years after delivery [8]. T2D risk factors including high body mass index (BMI) and ethnicity further increase T2D risk in women who have had GDM: development of T2D is 18% (5–34%) higher per unit BMI at follow-up, and 57% (39–70%) lower in White European populations compared to other populations (adjusting for ethnicity and follow-up) [8]. Factors such as poorer pregnancy glucose tolerance requiring treatment with insulin have been found to further increase risk [9]. Overall, women who had GDM are 7–10 times more likely to develop T2D over their lifetime than women with normoglycaemic pregnancies [8,10,11].” (lines 48-59).

Page. 4 Line 82

It was stated that all women had history of GDM. Please clarify the prevailing diagnostic criteria which would have been used to diagnose GDM in these subjects.

RESPONSE: We have expanded this section to describe the NICE guidelines for diagnosing GDM at this time, plus some details on GDM management (lines 98-109): “NICE recommends screening for GDM with a 75g 2 hour oral glucose tolerance test (OGTT) in women with one or more risk factors (BMI greater than 30 kg/m2, previous baby weighing 4.5 kg or more, previous pregnancy affected by GDM, family history of diabetes, and ethnicity with a high prevalence of diabetes) [12]. Diagnostic cut-offs were defined according to local protocols: at Peterborough Hospital, those with a fasting value ≥5.6 mmol/l or 2 hour value of ≥7.8 mmol/l were diagnosed with GDM (NICE guidelines); at the Rosie Hospital, those with a fasting value ≥5.1 mmol/l, 1 hour value of ≥10.0 mmol/l or 2 hour value of ≥8.5 mmol/l were diagnosed with GDM (International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria [13]). Screening usually takes place at 24 to 28 weeks gestation, although can be repeated if the clinicians suspect GDM has developed. Following GDM diagnosis, women are closely managed with the aim of reducing glycaemia. This involves blood glucose monitoring, diet and exercise, and sometimes insulin and metformin medication.”)

Page 6 Line 135

It was stated that none of the participants had been diagnosed with T2D. Please clarify if all the women with GDM had undergone postpartum OGTT screening.

RESPONSE: We thank the reviewer for raising this point – none of the participants had been diagnosed but not all have been screened for diabetes. We have revised this to read “None of the 16 participants who had had a diabetes screening test since pregnancy had been diagnosed with T2D.” (lines 158-159).

Table 1

Is any information available on the proportion of women who were overweight/obese, or their mean BMI?

RESPONSE: This is a valid point to raise, given the association between postpartum BMI and diabetes risk explained in the introduction. However, we did not collect this data since we did not access patients’ medical records and did not ask them to self-report BMI in the demographics questionnaire at the end of the interview. We considered that this would be an insensitive question to ask in the context of this interview and during the postpartum period, following a pregnancy where many women are particularly sensitive about weight (some participants noted the stigma associated with GDM, particularly for overweight women, and how this could lead them to disengage with healthcare/behaviour change).

Furthermore, it is important for all women to maintain a healthy diet and be physically active after GDM, regardless of their weight/BMI.

We have commented on this in the Strengths and Limitations section in order to bring it to the readers’ attention: “We did not collect data on BMI or whether participants were overweight because we did not access their medical record, and to ask them to self-report this could be insensitive during the postpartum period. It is important for all women to maintain a healthy diet and be physically active after GDM, regardless of their BMI, yet we were unable to comment on whether BMI affected requirements for support.” (lines 353-357).

Page 8 Line 151

Although I understand this is a qualitative interview study, are the authors able to state the number of women who were aware of the link between GDM and T2D, which would significantly affect the interpretation of the results?

RESPONSE: Sixteen of the 20 participants were clearly aware of the association between GDM and T2D. Two participants were not aware of the association and two participants seemed to be inconsistent across their interviews.

We have added this information to this paragraph (lines 173-177), stating, “The remaining participants reported sentiments such as “I don’t feel like I've been given the help that I think there should be really out there” [Participant 1, attempting healthier postpartum lifestyle but felt unsupported overall], “post-GDM support would be really good for mothers” [P2, healthier, unsupported] and two participants explained that they had been unaware of an association between GDM and T2D.”

It is also worth noting that the interview was consistently framed in the context of preventing T2D in women who had had GDM (e.g. this was the first sentence of the participant information sheet and explained in the introduction to the interview). We suggested that the participants seek advice from their GP if they had questions or concerns.

Page 14 Line 246-248

Please provide further details on the responses from the participants on the preferred format, source and timing of providing support. Are the responses summarized by the later comments on In person peer groups, appointments with healthcare professionals and written messages?

RESPONSE: Yes, the participants’ responses on the preferred format, source and timing of support are reported in the section “Delivery of support or interventions” (lines 271-311). We have clarified this by saying “This included the preferred format (including in-person peer support groups, appointments with healthcare professionals and written information), source and timing.” (lines 272-274).

***

Reviewer #2: The authors conducted semi-structured interviews with 20 participants with a history of GDM to explored the views of women on possible interventions to support healthy diet and physical activity to reduce diabetes risk and aimed to identify the most promising interventions for future development. The sample size was small and less representative. I also have some other concerns about the interpretations and discussions.

Major comments:

1. The participants were women who were interested in the study topic and the sample size was only 20 women. The representativeness and potential selection bias is one of the major problems of the study.

RESPONSE: As we describe in our response to the editorial comments above, we would like to respond with the following brief points:

1. In qualitative research, we are not interested in generalisability but understanding a phenomenon of interest in depth [1] – in this case, this group of women with a history of GDM’s views on support for postpartum behaviour change.

2. We planned the sample size using the concept of information power [2], which we have added to the Methods of the manuscript (lines 87-90): “We planned to interview approximately 20 women in order to reach data saturation, based on the relatively low information power anticipated [2]. This was because this study had a broad aim, sparse sample specificity but used purposive sampling and was a cross-case analysis. The interviews were structured around pre-defined recommendations.” As explained in the manuscript, we stopped interviewing when ‘the data collection process no longer offers any new or relevant data’ (data saturation) [3].

3. Our sample size of 20 participants is larger than many semi-structured interview studies. For example, the qualitative systematic review that informed this interview study included 12 studies using face-to-face interviews [4]. Only three of those had a sample size >20 participants (23, 23 and 35 participants) and median sample size was 16 participants. PLoS ONE has also published several qualitative interview studies with a comparable number of participants in recent months (e.g. [5,6]).

In addition, recruiting participants who are interested in the study is a universal source of bias in every research study. We have already commented on this in the Strengths and Limitations section: “This [the need for postpartum support] may have been influenced by recruitment bias, with more health-conscious women or those in need of particular support more likely to engage in the study.” (lines 352-353).

2. In table1, “education level” was not defined in methods.

RESPONSE: The different education levels reported in Table 1 are universal terms to describe education in the UK. Nevertheless, we will include examples of qualifications gained at these levels in Table 1 (under line 162):

• Secondary or further (GCSEs, A levels, BTEC, apprenticeships or equivalent)

• Higher (Bachelor’s degree or equivalent)

• Postgraduate (Master’s degree, PhD or equivalent)

3. The results of each theme were not concise, and some other interpretations might also possible, which should be discussed in full.

RESPONSE: We are not clear from this comment which of the Results are not concise. Each of the themes is summarised in one to three short paragraphs, with a total word count that is shorter than many quantitative papers.

As is true for all qualitative research, we acknowledge that other interpretations of these data might also be possible, and have acknowledged this in the Strengths and Limitations section by concluding with “Finally, as is true for all qualitative research, other interpretations of the data collected in this study might be possible, although no participants disagreed with the summary of the findings that we sent to them.” (lines 360-362). We came to these conclusions as a multidisciplinary team with expertise in qualitative research, GDM healthcare and primary care after being immersed in the interview data. We have tried to be as transparent as possible in presenting the findings, exploring deviant cases and presenting evidence (e.g. quotations) so that the reader is able to draw their own conclusions. We have also added the coding frame to the supporting information to increase transparency (line 146: “The final codebook for the framework is reported in S2 Table.”).

There must always be a balance between being concise and reporting in enough detail to explain how we came to these interpretations.

4. There are some published articles that investigated views of women with prior GDM on about diet and physical activity interventions. A detailed discussion about the similarity and differences and the underlying reasons is warranted.

RESPONSE: In lines 321-332, we compared the findings of this study to our recent systematic review on women’s views towards having a healthy diet and physical activity after GDM (similarities, differences and underlying reasons) [4]. This review includes intervention studies as well as those investigating barriers and facilitators to the behaviours (e.g. Nicklas et al. 2011, O’Dea et al. 2015). We have expanded and clarified this section to read: “… We found that influences on healthy diet and exercise were similar between the review and this interview study, such as spending time with children instead of exercising and how the family could facilitate healthy behaviours. Lack of time and energy were particularly evident in the early postpartum period in this interview study, which was considered to be a time for learning to adapt to life with their new baby. Women were more supportive of integrating activity into their daily routine than of participating in family-based exercise activities, which appeared to be important in the review. …”

Additionally, in lines 333-343, we compared our findings on timing of the intervention to those of previous studies related to this topic. We have added reference to Ingstrup et al. 2019 (nine women’s experience with peer counselling and social support during a lifestyle intervention among women with previous GDM), which highlighted that rapport was important for social support to be effective: “We concluded that women with GDM should be prepared for more specific follow-up interventions during their pregnancy, provided that this is done in a sensitive manner, echoing the findings of Ingstrup et al. regarding the importance of rapport with peer councillors [14].” (lines 339-342).

We would be happy to add any other recent papers the reviewer is aware of.

***

References

1. Myers M. Qualitative Research and the Generalizability Question: Standing Firm with Proteus. Qual Rep. 2000; Available from: https://nsuworks.nova.edu/tqr/vol4/iss3/9/. Date last accessed: 01 March 2021.

2. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies. Qual Health Res. 2016;26(13):1753–60.

3. Dworkin SL. Sample Size Policy for Qualitative Studies Using In-Depth Interviews. Arch Sex Behav. 2012;41(6):1319–20.

4. Dennison RA, Ward RJ, Griffin SJ, Usher-Smith JA. Women’s views on lifestyle changes to reduce the risk of developing Type 2 diabetes after gestational diabetes: a systematic review, qualitative synthesis and recommendations for practice. Diabet Med. 2019;36(6):702–17.

5. Fleming T, Collins AB, Bardwell G, Fowler A, Boyd J, Milloy MJ, et al. A qualitative investigation of HIV treatment dispensing models and impacts on adherence among people living with HIV who use drugs. Ahmed SI, editor. PLoS One. 2021;16(2):e0246999.

6. Backhausen MG, Iversen ML, Sköld MB, Thomsen TG, Begtrup LM. Experiences managing pregnant hospital staff members using an active management policy—A qualitative study. Doraiswamy S, editor. PLoS One. 2021;16(2):e0247547.

7. Okoth K, Chandan JS, Marshall T, Thangaratinam S, Thomas GN, Nirantharakumar K, et al. Association between the reproductive health of young women and cardiovascular disease in later life: umbrella review. BMJ. 2020;371:m3502.

8. Dennison RA, Chen ES, Green ME, Legard C, Kotecha D, Farmer G, et al. The absolute and relative risk of type 2 diabetes after gestational diabetes: A systematic review and meta-analysis of 129 studies. Diabetes Res Clin Pract. 2021;171:108625.

9. Rayanagoudar G, Hashi AA, Zamora J, Khan KS, Hitman GA, Thangaratinam S, et al. Quantification of the type 2 diabetes risk in women with gestational diabetes: A systematic review and meta-analysis of 95,750 women. Diabetologia. 2016;59(7):1403–11.

10. Song C, Lyu Y, Li C, Liu P, Li J, Ma RC, et al. Long-term risk of diabetes in women at varying durations after gestational diabetes: a systematic review and meta-analysis with more than 2 million women. Obes Rev. 2018;19(3):421–9.

11. Vounzoulaki E, Khunti K, Abner SC, Tan BK, Davies MJ, Gillies CL. Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis. BMJ. 2020;369:m1361.

12. National Institute for Health Care and Excellence. Diabetes in pregnancy: management from preconception to the postnatal period. NICE Clinical Guideline. 2015. Available from: www.nice.org.uk/guidance/ng3/chapter/introduction. Date last accessed: 01 March 2021.

13. Metzger BE, International Association of Diabetes and Pregnancy Study Groups Consensus Panel, Metzger BE, Gabbe SG, Persson B, Buchanan TA, et al. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care. 2010;33(3):676–82.

14. Ingstrup MS, Wozniak LA, Mathe N, Butalia S, Davenport MH, Johnson JA, et al. Women’s experience with peer counselling and social support during a lifestyle intervention among women with a previous gestational diabetes pregnancy. Heal Psychol Behav Med. 2019;7(1):147–59.

10 Aug 2021

PONE-D-21-01829R1

“Post-GDM support would be really good for mothers”: a qualitative interview study exploring how to support a healthy diet and physical activity after gestational diabetes

PLOS ONE

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Reviewers' comments:

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Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

Reviewer #4: (No Response)

Reviewer #5: (No Response)

Reviewer #6: All comments have been addressed

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Reviewer #4: Partly

Reviewer #5: Partly

Reviewer #6: Yes

**********

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Reviewer #3: Yes

Reviewer #4: N/A

Reviewer #5: N/A

Reviewer #6: Yes

**********

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Reviewer #3: Yes

Reviewer #4: No

Reviewer #5: Yes

Reviewer #6: Yes

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Reviewer #5: Yes

Reviewer #6: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: FPG test ?? in Figure 2. Please provide the full form of FPG test before providing the abbreviated form.

Reviewer #4: Thank you very much for having me to review the work entitled “Post-GDM support would be really 1 good for mothers”: a qualitative interview study exploring how to support a healthy diet and physical activity after gestational diabetes.

The study aims to explore women’s views on suggested practical approaches to achieve and maintain a healthy diet and physical activity to reduce T2D risk. Please consider the following comments to improve the manuscript.

1. Abstract

Line 33 – Line 35: Suggest to include the percentages of “a third” participants for “transformative”, “beneficial” and “did not want additional support”.

Line 35: Suggest to put the percentage after “the majority”.

Line 38: Suggest to put the percentage after “four”.

2. Introduction

Line 55 - Line 56: Since you mentioned “These sites were chosen to provide socioeconomic and ethnic diversity, and represent views from those attending both secondary and tertiary centres offering GDM/ and obstetric care” in line 80 to line 81 (page 4), hence, it is better to specify the prevalence of GDM of different ethnicities (Chinese, Indian, Japanese) instead of putting “as compare to other populations”.

Line 57: Please specify the type of risk for “glucose tolerance requiring treatment with insulin have been found to further increase risk”. It this refer to GDM risk or T2D risk?

Line 64: Please specify the activities of behaviour change intervention. For example, the type of intervention done by previous researchers to give a better picture for the readers. Support your sentence with reference.

Line 65: Please specify the type of population. Is this referring to women with GDM history or without GDM history? Because GDM history may influence the effectiveness of the behavioural change intervention.

Line 66 - Line 67: Please provide a reference for “we found that women who had had GDM identified themselves primarily as mothers who prioritised their family above themselves”.

Line 71: Considering a small sample size in the present study, please provide the sample size for Reference 13 and Reference 14. This is to give an overall picture for the readers to understand the common sample size being used in qualitative research.

Line 71: Please provide brief details for Reference 13 and Reference 14. What are the previous activities conducted by the researchers?

Line 72: Please mention the research gap before your study adjective.

Line 74: Is this objective “We aimed to identify the most promising interventions for future development” reflect in your findings? If not, please remove this sentence.

3. Recruitment

Line 86: Please provide the response rate of this study. Out of the total contacted participants, how many of them agreed or rejected to participate in the present study.

Line 87 – Line 89: These sentences are not strong enough to support your final sample size (n=20). Since you mentioned “to reach data saturation”, have you conducted data saturation assessment in your study? Please explain how you assess the data saturation.

Line 88 – Line 89: What do you mean by “this study had a broad aim sparse sample specificity but used purposive sampling and was a cross-case analysis”? This sentence is unclear and needs further improvement.

Line 90: What do you mean by “the interviews were structured around pre-defined recommendation”? Please provide more details and also a reference for this statement.

Line 90 - Line 91: Is Reference 16 correctly cited?

Line 91 – Line 92: How many participants you have interviewed in your study? Do you include data of all participants that have completed the interview or only part of them? Please provide the response rate.

4. Inclusion criteria

Line 98: Do you conduct GDM screening in your study? Or do you obtain GDM data from the participants’ medical history?

Line 110 – Line 113: Please mentioned how many women you have excluded from the study.

5. Interview process

Do you conduct any pre-test prior to the interview? Modification of interview guide and suggestion cards are required before you conduct the actual interview. If yes, how many attended the pre-test and what modifications you have done?

Line 122 - Line 123: Based on Table S2, it seems like No 11 to 20 in Table S1 are not including in your study. Please clarify the number of suggestion cards in your study. Please mention how many suggestion cards you have included in the final version.

Line 132: Please elaborate type of format for “what format might be most effective”.

Line 133: Please mention how many suggestion cards you have shown to your participants.

Line 137: “These questions were then repeated for attending diabetes screening (reported separately)”: When did you conduct the diabetes screening? On the same day of the semi-structured interview? Do you conduct the diabetes screening on your own? Do you include the feedbacks of participants in your manuscript? Please provide the feedbacks of participants provided in the diabetes screening in the results or appendix.

Line 137 - Line 138: Do you collect social-demographic data or demographic data? Please specify the type of information you have collected for demographics (ethnicity, age, occupation and etc).

Line 138: Please write the full term of “RD” instead of its acronym.

6. Analysis

Line 142: Please provide brief details of the framework approach.

Line 143: Please provide the version number and manufacturer details of NVivo 12.

Line 143 – Line 144: “…and developed a thematic framework”. Please attach the thematic framework to the manuscript.

Line 144 – Line 145: Do you refine your thematic framework based on the first few interviews? Does the thematic framework represent the views of all participated participants?

Line 147 – Line 148: Please write the full term of “RD” and “RF” instead of their acronym.

Line 148: “… and charted four transcripts to ensure agreement”. Please explain how to assess agreement in your study. Do you have any references for the classification?

7. Results

Table 1: Please provide mean years of postpartum.

Table 1: Since this is a descriptive analysis, it will be good to present the number of participants for each ethnicity (Chinese, Japanese, Indian).

Table 1: Please check the distribution of participants of employment and maternity leave as their final number is more than 20.

Table 1: Please add the number of respondents who did not live with their partner.

Table 1: “……. All pregnancies affected by GDM”: Only 13 participants? Based on your inclusion criteria, you only include those with GDM history in your study. It is a confusing statement and please provide your justification.

Table 1: You mentioned in the methodology (Line 111 – Line 113) that “ …. Participated in a pregnancy or GDM-related intervention or were considered unsuitable… were not invited”. Please explain why you include those on medication of GDM as depicted in Table 1. Do you accept those with medication of GDM in your study?

Line 180: Please include the number of suggestion cards you have shown to the participants.

Line 187: How do you define the agreement? What are the cut-offs for overall agreement, overall mixed response and overall disagreement? Do you have any references for the classification?

Line 187: “… not all participants were shown each card, and some did not comment or agreement was unclear.”. Please justify why you exclude certain suggestion cards and how to define that “agreement was unclear”. This is important as it shows the quality of each suggestion card that you have proposed in your study.

Information and understanding

Line 193 – Line 194 and Line 200: “… most of the participants”; “some would add…” and “… others had poor awareness” and “since most already had general…”. Please provide the actual number of participants.

Improving diet

Line 203 and Line 206 – Line 207: “The majority of the …”; “A couple of participants…” and “Others wanted advice that was relevant…”. Please provide the actual number of participants.

Improving physical activity

Line 215, Line 217, Line 221, Line 224, Line 226 and Line 231: “… Although many participants…”; “Some preferred…”; “… a few...”; “Almost all the participants..” and “Several participants….”: Please provide the actual number of participants.

Family

Line 237, Line 241, Line 243 and line 245: “…. Others walked with …..”; Some also found ….”; “Some participant reasoned that….”; “Others already knew …..”; “those that agreed wanted ….”: Please provide the actual number of participants.

Money

Line 252 and Line 253: “other participants considered …..”; “Some noted that cooking…”: Please provide the actual number of participants.

Monitoring

Line 256 and Line 262: “Almost all of the participants ….”; “at the same time, several were cautions ….”: Please provide the actual number of participants.

Sustainability

Line 266: “The majority of the participants ….”: Please provide the actual number of participants.

What about others who did not want advice about sustaining changes? Please give more details on this.

Delivery of support or intervention

Line 272: “The participants also suggested ….”: How many of them give additional suggestions?

Appointment with healthcare professionals

Line 283 and Line 293: “Most participants were keen ……”; “Many suggested that …..”: Please provide the actual number of participants.

Written information

Line 300: “The participants thought that ……”: How many participants?

8. Discussion

Line 316: “… would help them to reduce their risk”: Please add “T2D” after the “risk”.

Line 317: “Many wanted more specific information about their long-term ……..”: Please add brief details of the specific information requested by the participants.

Line 323 – Line 324: “…. exercise between the review and this interview study”: Please give specific findings related to the previous review. Please add the reference of the review.

Line 326 – Line 327: “Lack of time and energy………, which was considered to be a time ……. new baby.”: Sentence unclear and do you have any reference to support this sentence? Please provide a reference to support this sentence.

Line 331: “…… many felt that more specific information about lifestyle……”: I believe that participants did provide specific information that they want to know more in the qualitative interview. Please add in the what are the specific information requested by the participants.

Line 334: “….. tended only to maintain selected elements of the GDM diet because…”: Please elaborate on the elements or example of the GDM diet so that readers know how does GDM diet looks like. If GDM diet is difficult to sustain, then what mothers can do? Any other diet that is suitable for the mothers to tackle T2D?

Line 335: “Interventions may therefore support…”: Please suggest the type of intervention that will be beneficial to the participants.

Line 336: “ …. these changes were anticipated help women ….”: The “changes” here refer to what kind of change? Please specify the type of change in your text.

Line 338 – Line 339: Please briefly explain the previous findings of previous research.

Line 340: “for more specific follow-up interventions during their pregnancy…:” Please suggest a suitable specific follow-up intervention in your conclusion.

9. Strength and limitations

Line 357: “yet we were unable …… for support”: Do you think future study needs to add in BMI data in the interview to elucidate the influence of BMI towards the requirement for support? If yes, please add a sentence on this.

10. Implications for practice

Line 372: “support the important role clinicians play…”: Please add “of” before “clinicians”.

11. Supporting information

Table S3: How do you define the agreement? What are the cut-offs for overall agreement, overall mixed response and overall disagreement? Do you have any references for the classification?

Reviewer #5: In the methods section, the trustworthiness of the data was not indicated.

Data collection technique analysis and report were not meticulously stated. The author should have used COREQ.

The authors have not clearly stated how the themes emerged. They have used a card which is pre-specified and may not explore the phenomenon very well

The quotations used in your manuscript contain potentially identifying information. Please amend your manuscript by either limiting the amount of potentially-identifying information presented, or by obtaining explicit consent to publish such information. To limit the identifying information, please remove the ages and occupation information from your quotes to help maintain participant confidentiality. Please use age ranges in place of the ages. Please check that the identifiers do not link to participants.

As far as qualitative research is concerned, descripting in number is not recommended. How ever, the authors stated state

the number of women who were aware of the link between GDM and T2D, which would significantly affect the interpretation of the results.

Generally, the title is of interest and current issue.

The paper can be accepted for publication after modification.

Reviewer #6: (No Response)

**********

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Reviewer #3: No

Reviewer #4: No

Reviewer #5: No

Reviewer #6: No

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Submitted filename: Manuscript Number PONE-D-21-01829.docx

Click here for additional data file.

28 Sep 2021

Please see the cover letter for our response to the reviewers' feedback.

Many thanks.

Submitted filename: Response to reviewers_PONE-D-21-01829R1.docx

Click here for additional data file.

20 Dec 2021

4 Jan 2022

Dear Dr Farrar

Thank you for considering our manuscript and for the opportunity to resubmit it. We would also like to thank the reviewers for their time and feedback on our study.

We have addressed the outstanding points (Review Comments to the Author) as follows:

> Reviewer #4: Previous comments were addressed by the authors. Please confirm the distribution of respondents under the maternity leave in Table 1 is correctly presented as the current sample size is less than 20. The paper is ready to be accepted after minor modification.

> RESPONSE: The distribution of respondents on maternity leave in Table 1 is correct. One participant was a ‘home parent’ therefore they cannot be on maternity leave from formal employment. We have added ‘NA’ in order to clarify this, with the changes highlighted.

> Reviewer #5: I appreciate the authors’ efforts. This revised draft addresses all of my concerns. So I don't have any more comments or questions.

There were no other comments, and all of the references are complete and correct.

We look forward to hearing from you and hope that this manuscript can be accepted for publication in PLoS ONE.

Yours sincerely,

Rebecca Dennison, Simon Griffin, Juliet Usher-Smith, Rachel Fox, Catherine Aiken and Claire Meek

7 Jan 2022

“Post-GDM support would be really good for mothers”: a qualitative interview study exploring how to support a healthy diet and physical activity after gestational diabetes

PONE-D-21-01829R3

Dear Dr. Dennison,

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Kind regards,

Diane Farrar

Academic Editor

PLOS ONE

11 Jan 2022

PONE-D-21-01829R3

“Post-GDM support would be really good for mothers”: a qualitative interview study exploring how to support a healthy diet and physical activity after gestational diabetes

Dear Dr. Dennison:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Diane Farrar

Academic Editor

PLOS ONE