After just six months of working with her midwife team at Royal Surrey County Hospital, Paula Bandera knew something had to change.
“They were calling patients one by one and spending more than an hour on the phone, taking glucose readings and writing them down,” she says. “I said, ‘This is not working’.”
Managing the care of hundreds of expectant mothers at a busy major hospital can be extremely time-consuming for midwife teams, and Bandera says they were finding increasing incidents of gestational diabetes mellitus (GDM) in expectant mothers.
The hospital made the decision to set up a new team of midwives and specialists to see how the GDM patients could be managed more efficiently without decreasing the quality of care.
“I had to create a team from scratch,” Bandera explains. “I spent six months listening to all my colleagues – how do you work, what things work, what things don’t?”
Bandera says this approach of listening extended to her patients too: “Only then did we start to gradually change things.”
What causes GDM?
GDM is a high blood sugar condition that can develop during pregnancy as hormones and other factors interfere with insulin activity, which controls glucose levels.
The condition affects 4–5% of women in the UK[1]. High-risk groups include: women with a body mass index (BMI) of 30 or higher; those who have previously given birth to a baby weighing more than 4.5kg; those who have previously had gestational diabetes; and women whose direct family members have diabetes, or they are of South Asian, Chinese, African-Caribbean or Middle Eastern ancestry.
Most mothers have normal pregnancies and healthy babies, but GDM can lead to labour and delivery issues and, in extremely rare circumstances, the infant’s death. GDM typically subsides post-birth, but it does increase the likelihood of developing it in future pregnancies and potentially Type 2 diabetes in later life.
Unfortunately, the prevalence of GDM is increasing in the UK[2]. Several reasons have been put forward, including the lowering of diagnostic thresholds and increases in the proportion of women at risk, either due to ethnicity, high BMI or age.
Managing diabetes – the midwife’s view
Bandera’s experience as a midwife spans 17 years. Her interest in health and nutrition was sparked as a child, when being small for her age, she was given hormone treatments.
“That led to me studying and learning for myself about nutrition, hormones and how they affect women especially,” she says. “We know that hormones change as we get older, and women are having their first child later because they don’t find the time. Also, people are bigger and heavier.”
Bandera has now been at Royal Surrey County Hospital for six years. As the lead on the new maternity team, the first action she took was to change over to email for collecting glucose readings, with expectant mothers being issued a logbook. This proved much quicker than phone calls. The next step was to expand the team of specialist midwives.
“Before I started, there were only two midwives with an interest in diabetes,” says Bandera. “They hadn’t done any specialist training. But now, with this hospital, the multidisciplinary team is fabulous.”
Bandera’s maternity team meets every Thursday, bringing together the obstetric team, which has two allocated consultants, and the endocrine team with one consultant. Bandera has also added another specialised diabetes nurse, focused on maternity.
Although she no longer runs her own clinic, Bandera still works closely with patients and often accompanies them to appointments as support.
The initial monthly meetings gave the team a chance to discuss what was working and what wasn’t. This is when Bandera suggested using an app to manage more women with GDM safely.
The GDm-Health app
Although emails and phone calls are still an option, Bandera was concerned about the accuracy of the data the team was receiving. A garbled or incomprehensible message could easily lead to errors.
“Now we use the app,” she says.
Although it is not suitable for everyone, with some patients preferring the logbook, Bandera says readings via the app can be collected in just two minutes. This allows the team to intervene more quickly when they see a high reading and offer more personalised care.
The app used by Bandera and her team is GDm-Health (Gestational Diabetes Support), powered by Huma Therapeutics, which was introduced to the NHS-run hospital in 2019.
The app allows women with GDM to input their blood sugar readings themselves, which are then displayed using a ‘traffic light’ system. Personal data is encrypted and sent securely to the hospital, where the health team uses a web-app dashboard to review readings from their patients, prioritise call backs and send feedback via text messages.
Many women find the app gives them more control over their condition and more involvement in decision-making. It also helps them plan their day by providing instant blood sugar readings, enabling them to adjust levels as needed. A green traffic light gives them the confidence to go about their daily routine.
Additionally, the app offers reminders and logs of previous readings, as well as allowing users to annotate blood glucose data with meal tags and medication doses.
Research into the use of mobile health technology for help in monitoring GDM has found the adoption of web-based and smartphone digital tools can significantly reduce hospital visits in women with GDM[3].
Studies report satisfaction with and acceptability of smartphone-based, digital health tools for diet and weight management in more than 80% of women with GDM[4], along with observed higher glucose monitoring compliance, the modification of dietary habits by consuming food with a low glycaemic index and changes in gestational weight gain[5].
Post-delivery care
Bandera is keen for care to continue post-delivery. “That is my next step,” she says.
Even after a successful pregnancy, some women will go on to develop Type 2 diabetes or present with GDM again during their next pregnancy. Bandera believes better follow-up care could reduce the incidence of both conditions.
Currently, the women complete a routine fasting blood glucose test for diabetes eight weeks after delivery and then every year – but Bandera found only 60% of mothers received accurate follow-up.
“So, we created letters that included everything from the moment they start with us until after birth. Then I started sending these letters by email to the GPs, and I personally follow them up… and place those letters automatically into maternity notes.
“The whole intention of this new programme is to reduce as much as possible the cases of Type 2 diabetes.”
The future of mobile health
For Bandera and her team, the advantages of using the app have been huge, and she says that she couldn’t manage without it now. About 98% of the maternity patients with diabetes are opting in to use the app for their pre-natal care[6], reducing call volumes by 70% and freeing up clinical time.
“Professionally, it makes your work easier, because it’s safer and it’s quicker,” Bandera says. “You can action really quickly, saving the women having to go on medication, and they feel safe as well because they’re independent – they don’t need to be in the hospital all the time.
“Last year alone, we diagnosed 700 women through the app.”
Annabelle Miles, marketing director at Huma Healthcare, says:
“Feedback from midwives and midwifery teams is invaluable for refining the app, and making meaningful adjustments and improvements. This allows the healthcare teams to continue to provide excellent care for their mothers-to-be.”
For more information on Huma’s GDm-Health app, please download the whitepaper below.
[1] https://www.rcog.org.uk/for-the-public/browse-our-patient-information/gestational-diabetes/
[2] https://www.ncbi.nlm.nih.gov/books/NBK401113/
[3] https://pubmed.ncbi.nlm.nih.gov/29425836/
[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4495541/
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851209/
[6] https://www.royalsurrey.nhs.uk/news/maternity-diabetes-care-goes-digital-4744
