Responding to Gestational Diabetes in Braybrook

Transcription

1 REPORT Responding to Gestational Diabetes in Braybrook HealthWest Partnership July 2015 HealthWest Partnership Level 1, 37 Albert St Footscray VIC

2 Written by Raini Nailer With support from HealthWest member organisations. July 2015 For more information contact: or visit 2

3 Contents Executive Summary Introduction 4 6 Section One: Gestational Diabetes in Melbourne s West and Braybrook Context of the West GDM Determinants and its Context in the West Overweight and Obesity GDM in Braybrook Social Knowledge and Pressures Regarding Pregnancy and Developing GDM Section Two: Ethnographic and Environmental Context of Gestational Diabetes Mellitus Vietnam and Diabetes Burma and Diabetes Conclusion Section 3: Possible Interventions, Past Interventions and Research Programs Areas for Intervention Previous Projects Addressing GDM Important Findings from Previous Studies Section Four: Recommendations Appendices Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 References

4 Executive Summary This report was produced as a follow up to the Responding to Diabetes in Braybrook report released in 2014, which found that gestational diabetes mellitus (GDM) was a significant issue for Melbourne s west, particularly Braybrook. GDM has severe and lifelong health implications for both mother and child, in pregnancy and beyond. The likelihood of the mother developing type 2 diabetes later in life increases by 1.7% one year after pregnancy, 17% after 10 years and 25% after 15 years (Lee et al 2007). It can therefore be suggested that GDM acts as a gateway to developing type 2 diabetes, and the high rates of diabetes in Braybrook women is partly attributable to GDM. High rates of GDM exist in Braybrook despite having the third smallest population of women in likely childbearing years, as well as displaying the lowest overweight and obesity levels in the west (compared to its neighbouring suburbs). The burden of GDM is not evenly distributed amongst all women. According to known statistics (when controlling for sex) it is estimated that 37.9% of Burmese females would have GDM. Comparatively the Vietnamese (largest Braybrook ethnic population) who have the greatest raw number of women registered as having GDM would have a rate of 1.70% (data controlled for sex) (Profile ID 2011). Knowledge of what GDM is, what causes it, and how to control it seems to be misunderstood in the community. New mothers and pregnant women often spoke about healthy eating, but seldom mentioned physical activity in regards to keeping healthy during pregnancy. Medical and socio-cultural behaviours and advice are followed during pregnancy to promote optimal health. The endorsed behaviours and advice of these systems are equally as important, but often do not match. Misinformation and misunderstanding within these systems may be a large contributor to GDM rates in Braybrook and the west. In addition to misunderstandings of this condition it was pinpointed that postnatal testing was found to be a particular problem, with around half of pregnant women not undertaking post-testing. An Australian study found there was no difference in postnatal diabetes testing regardless of whether a woman was born in or outside Australia (Nielsen et al 2014). Essentially there is a lack of testing amongst all women. GDM has severe and lifelong health implications for both mother and child, in pregnancy and beyond. Women with GDM are an effective diabetes prevention audience, as they are diagnosed and engaged in the appropriate services. Thus GDM should not be underdiagnosed like other types of diabetes (Lee et al 2007). The prevention and effective management of GDM is a strategy that can contribute to the reduction of type 2 diabetes across populations. Recommendations to prevent and more effectively manage GDM include: Better integration of the health system that women use in the gestational and post-natal period Increase knowledge and support among pregnant women and the community about GDM; working with specific at risk groups Promotion of breastfeeding in the postnatal period, as this has health benefits for both mother and child (improves insulin sensitivity, prevents overweight and obesity and type 2 diabetes in mother and child) Advocate for easier testing circumstances in the postnatal period using Hba1c Address obesogenic qualities in the environment that inhibit healthy behaviours (access to healthy food, walkability, perceptions of safety etc.) 4

5 5 Introduction

6 Background In 2014 the Responding to Diabetes in Braybrook project was undertaken by HealthWest Partnership. This project found the known diabetes rate in Braybrook to be double the rate of the state average. The highest rates of known diabetes in Braybrook was amongst women, which opposes the national trend. Gestational Diabetes Mellitus (GDM) in the Braybrook community was found to be higher than surrounding areas. This type of diabetes occurs in women (during pregnancy) and contributes to diabetes rates in women. GDM is a significant health risk as it can increase a woman s likelihood of developing type 2 diabetes later in life, and can also increase the child s likelihood of developing this disease. Purpose The purpose of this report is to build upon the information found in the Responding to Diabetes in Braybrook report. The aim of this needs analysis is to uncover the particular determinants that lead to barriers in Braybrook, to identify the women most vulnerable to this disease and to provide recommendations. This work is conducted for the use of health care professional and other community stakeholders to better understand the context of GDM in Braybrook and inform work in this area. Scope To conduct this needs analysis prominent aspects relating to women with diabetes or gestational diabetes arising from the initial needs analysis were further investigated. This report, like the first, also focused on place: limited to Braybrook and parts of its surrounding suburbs. Methodology Interviews with health professionals, academics, community workers and Braybrook community members were conducted to advise the information presented in this needs analysis. A literature review was also undertaken to support the information provided through interviews. Limitations The information provided in this report was limited by factors including: available data, available participants and a short time frame. The highest rates of known diabetes in Braybrook was amongst women; which opposes the national trend. 6

7 Section One: Gestational Diabetes in Melbourne s West and Braybrook 7

8 Context of the West Melbourne s west is known to have high diabetes rates, and many western suburbs have similar diabetes patterns. Women across Braybrook s neighbouring suburbs (for SEIFA see appendix 1) experience higher registered rates of diabetes than men, except in Avondale Heights (See appendix 2) (Diabetes Australia 2010). Studies have shown that developing GDM increases the likelihood of developing type 2 diabetes later in life Diabetes Rates per Western Suburb It can be seen from these statistics that Braybrook has the third highest known prevalence for type 2 diabetes among these western suburbs, all of which are higher than the national average (NDSS 2015). However known rates of GDM are experienced at the highest rate in Braybrook, compared to neighbouring suburbs. In fact Braybrook experiences GDM at a prevalence 13% greater than West Footscray, 26% higher than Sunshine and 89% higher than the national average Type I Type II GDM Sunshine Braybrook West Footscray Avondale Heights National Figure 1. Percentage rates of diabetes per suburb compared to national average. National Gestational Diabetes in the West GDM is a significant issue for the Braybrook community, which has health implications for both mother and child, in pregnancy and beyond. Studies have shown that developing GDM increases the likelihood of developing type 2 diabetes later in life (Lee et al 2007). An ongoing study of women with GDM found their risk of developing type 2 diabetes increased by 1.7% one year after pregnancy, 17% after 10 years and 25% after 15 years (Lee et al 2007). It is not a stretch to therefore suggest that the high rates of type 2 diabetes in women may be related to high rates of GDM in the Braybrook community. GDM Determinants and its Context in the West There is no doubt that GDM is one of the biggest preventable disease burdens for women in the west. Figure 3 shows diabetes by type in young women of the west Women in the West with Diabetes Braybrook Avondale Heights West Footscray Sunshine Gestational Diabetes in the West Figure 2. GDM rates in Braybrook and surrounding areas shown as percentage of known diabetes rates per region. Type I Type II GDM Figure 3. Number women giving birth at Sunshine Hospital by diagnosed diabetes type in 2014 (Western Health 2015). Risk factors for diabetes stem from both genetic and behavioural influences, and risk factors for GDM are similar to those of type 2 diabetes (overleaf): 8

9 Type 2 Diabetes Have a family history of diabetes Over 55 years of age (the risk increases with age) Over 45 years of age and are overweight or obese Over 45 years of age and have high blood pressure Over 35 years of age and are from an Aboriginal or Torres Strait Island, Pacific Island, Indian subcontinent or Chinese cultural background Have given birth to a child over 4.5 kg (9 lbs), or had gestational diabetes when pregnant Have Polycystic Ovarian Syndrome. GDM Have a family history of type 2 diabetes Are over 30 years of age Are overweight or obese Are from an Indigenous Australian or Torres Strait Islander, Pacific Islander, Vietnamese, Chinese, Middle Eastern, background Have previously had gestational diabetes Have a family history of gestational diabetes Have previously given birth to a large baby Have Polycystic Ovarian Syndrome Figure 4. Risk factors for type 2 and GDM (NDSS 2013) Essentially, age, ethnicity, overweight/obesity and other health issues act as significant risk factors for diabetes. Age Structure The prevalence of GDM could be related to the proportion of women of specific age groups in particular suburbs. As discovered through the Responding to Diabetes in Braybrook needs analysis, the Braybrook community is young1, and is largely made up of families (Profile ID 2011). Thus the proportion of women in childbearing years may influence the rates and apparent significance of GDM in Braybrook. Comparison between suburbs shows that the proportion of Braybrook women in childbearing years are less than in Sunshine and almost equal to West Footscray (figure 5). This suggests that the GDM rate in Braybrook is more significant than surrounding suburbs as the GDM rate is higher but the proportion of childbearing age women is lower. Considering the likely childbearing years which is (see appendix 3), Sunshine has the highest proportion of women of childbearing age, and has a GDM rate that is 26% smaller than Braybrook (see figure 5). This would indicate that the presence of GDM is not related to the proportion of childbearing aged women in each suburb. Women Aged Women Aged Avondale Heights Avondale Heights Braybrook Braybrook West Footscray West Footscray Sunshine Sunshine Percentage Percentage Figure 5. Women in childbearing years from western area (Profile ID 2011). Figure 6. Western women of most common childbearing age (Profile ID 2011). 1 The Braybrook population has a median age of 34 (Profile ID 2011). 9

10 Ethnicity It is well known that ethnicity can be a risk factor for diabetes (Lee et al 2007, Oldroyd et al 2005, Ramachandran et al 2012, Tillin et al 2012, Diabetes Australia 2010). This is a complicated factor that is underpinned by varying biological, cultural and social determinants (Section 2 details a cultural case study and will provide more information in this area). Diabetes Australia (2010) and the International Diabetes Federation (IDF) (2014a) indicate that certain ethnicities are more susceptible to diabetes than others. Victoria is the most culturally diverse state in Australia (State Government Victoria 2014), and Melbourne s west is a highlight of this: Avondale Heights Braybrook West Footscray Sunshine As can be seen in figure 7, Braybrook is more ethnically and culturally diverse than its neighbouring suburbs. Sunshine West Footscray Ethnicity per Suburb Ethnicities at High Risk of Diabetes in the West Avondale Heights Braybrook Aboriginal and Torres Strait Islander Vietnamese Chinese Indian Pacific Islander Middle Eastern Australian* *Australian described as an ethnicity most likely indicates those of Anglo Saxon decent. Figure 7. Ethnicities identified as at risk of diabetes, as well as Australian* and others for comparison. Avondale Heights Braybrook West Footscray Sunshine Figure 8. Ethnic groups per suburb who are considered higher risk for diabetes (Diabetes Australia 2010, Profile ID 2011). 2 Overweight and obesity is clinically measured as a BMI of 25> and BMI 30> respectively which is the standard measure for people of European descent. BMI does not consider a person s body composition or adipose distribution- which is a paramount factor of diabetes (Tillin et al 2012). 3 Obesity is not distributed evenly geographically or among social classes Other As can easily be seen from the table (bottom left), the Braybrook community is home to a significant population who are considered at higher risk of diabetes compared to other ethnic groups, such as Anglo Saxons. Unfortunately this data cannot be filtered by sex and therefore includes both males and females (see appendix 5 for ethnicity of mothers giving birth). However, this data can indicate that ethnicity as a risk factor a significant contributor to the high rates of GDM in Braybrook. Other Health Conditions Diabetes is often experienced as a comorbidity which adds to the complication of managing the disease. In fact women who develop GDM are over twice as likely to develop antenatal and postnatal depression, with the risk being marginally higher if a woman had been using insulin during pregnancy (Diabetes WA, no date). Among the selected western suburbs there are a number of health issues that are quite prevalent including stroke, ischemic heart disease, obesity and cardio vascular disease (Brimbank et al 2011). Overweight and obesity2 are one of the most significant factors for diabetes (NDSS 2013, Nagle et al 2013, Ramachandran and Snehalatha 2011). In fact being overweight or obese during pregnancy results in an increased likelihood of developing GDM (Nagle et al 2013). Overweight and Obesity There is much clinical health advice given to women, particularly around food, which recommends eating high quality nutrient dense foods (State Government of Victoria 2015). However, for many women the correct dietary information may be difficult to practically execute. Kragelund-Nielsen et al (2014) reported that women found it difficult to stick to recommended foods for a variety of reasons including cravings, bulimia, binge-eating and use of comfort foods. If eating habits were different prior to pregnancy, this sudden healthier change in diet might also be difficult to adhere to. In the same study it was found that women with GDM who were non-english speakers ate less vegetables and bread, but ate more fried foods than English speaking women3. Another critical aspect of executing recommended dietary behaviours is access and affordability; this was seen as a major barrier in the Responding to Diabetes in Braybrook needs analysis. in Australia. It is often the most disenfranchised people that suffer the highest rates of overweight and obesity. This is due not to food choice, but often to affordability, availability, accessibility and environmental layout (Lake and Townshend 2006). Kragelund-Nielsen et al (2014) also found that self-efficacy was associated with high vegetable consumption and the ability to cook healthy foods. 10

11 This needs analysis found that Braybrook is in fact a food desert. This essentially would have an impact on pregnant women developing GDM. An Australian study found that women with GDM in the past 6-24 months had an unhealthy diet and insufficient physical activity levels (Kragelund- Nielsen et al 2014). According to Nagle et al (2013) over one-third of pregnant women in Australia are overweight (see appendix 6). Although overweight and obesity are major health concerns across Melbourne s west, women appear to have lower overweight and obesity levels than men. Additionally, Braybrook s council Maribyrnong City Council, is recorded to have the lowest rates of obesity in the western suburbs. However, this is not to say that overweight and obesity is not of concern in Maribyrnong. Often BMI is recorded using standard measurements for European peoples, which is not suitable for all ethnic groups, ignoring the fact that fat distribution is a more important factor. It is known that other ethnic groups can experience comorbidities of overweight and obesity at both lower and higher BMI range than Brimbank (Sunshine) Overweight or Obesity Rates Maribyrnong (Braybrook and West Footscray) Overweight or Obese Males Victoria Overweight or Obese Females Australia Figure 9. Percentage of overweight or obese men and women per LGA by standardised age (Medicare Local 2014). Information for Moonee Valley (Avondale Heights) was not available. Diabetes educators and dietitians report that many women who were considered healthy prior to pregnancy with no health complications still find themselves diagnosed with GDM. Evidence clearly shows that women in Braybrook are developing GDM, despite being thought to lead relatively healthy lifestyles. Further studies would be required to determine whether weight gain during the gestational period is a contributing factor in the development of GDM among the women from Braybrook, or if other factors are more significant % of women in Maribyrnong (includes Braybrook and West Footscray) are recognised as being obese. Avondale Heights, part of the Moonee Valley Municipality has the second lowest obesity rate among women; 12.3% prevalence. While women in other areas such as Sunshine are recorded as having 18.4% obesity rate (Brimbank et al 2011). Another area for exploration could be the influence of socio-cultural attitudes regarding pregnancy and childrearing and the impact of these on behaviours, beliefs and diabetes risk during pregnancy. GDM in Braybrook As shown age, ethnicity and other health conditions (particularly overweight and obesity) are significant factors of GDM. The most significant known diabetes factor for Braybrook is ethnicity. However, according to the National Diabetes Service Scheme (NDSS) Braybrook has the smallest ethnic diversity among women who register for GDM (see figure 3). The largest population of Braybrook women to register are from Asian backgrounds, which includes: Vietnam, India, China, Malaysia and Bangladesh. Vietnamese women make up 42.8% of Braybrook GDM registrants and are by far the largest group of registered women (Diabetes Australia 2015). Australian born women (possibly of Anglo-Saxon decent) accounted for only 14% of GDM registrants from Braybrook (Diabetes Australia 2015). An Australian study found there was no greater likelihood of having GDM if you were born outside of Australia (Kragelund et al 2014). This may indicate that GDM can be attributed to the environment, economic conditions and behaviours related to both these factors by particular groups in Australia. 100% 80% 60% 40% 20% 0% NDSS Registrants Braybrook West Footscray Sunshine Avondale Heights Asia Middle East Africa Europe Oceania Australia/NZ Unknown Figure 10. GDM registrants by country of birth per suburb. Age, ethnicity and other health conditions (particularly overweight and obesity) are significant factors of GDM. 11

12 Braybrook Females per age group Percentage of total Female Population in Braybrook % 0.68% % 2.18% % 0.35% Percentage registered as diagnosed with GDM Figure 11. Braybrook women per age group proportion of population and GDM rate (Profile ID 2011, NDSS 2015). Of the registered women in Braybrook, 57% spoke another language at home other than English. These languages included Amharic, Bengali, Cantonese, Hindi and Vietnamese. Vietnamese was the largest foreign language spoken at home, and accounted for 33% of registrants. 33% of the GDM registered population of Braybrook also spoke English at home. GDM registration rates are the highest in Braybrook among women aged in their thirties, followed by women in their twenties; this is also the pattern across West Footscray and Sunshine. The largest proportion of women bearing children in Australia are in their 30s followed by women in their 20s. This indicates that childbearing patterns in the west are no different from the national (Li et al 2013, Diabetes Australia 2015). Of the Braybrook women registered as having GDM, 47% are insulin dependent, which is the same prevalence as Sunshine (Diabetes Australia 2015). West Footscray has the lowest rate of pregnant women using insulin to assist in controlling GDM. Women who require insulin during pregnancy find it difficult to control blood sugar through means of lifestyle modification (which is the same for insulin use for type 2 diabetes). New evidence suggests that women who require insulin during pregnancy have an even higher risk of developing type 2 diabetes later in life, than those women with GDM who do not need insulin5 (Kim 2014). Births and BMIs of Women in Braybrook Braybrook women accounted for 15% of all women in the west diagnosed with GDM giving birth at Sunshine Hospital in 2014 (Western Health 2015). Only 9.24% of these women were diagnosed as being clinically obese at first antenatal appointment (Western Health 2015). This statistic corresponds with obesity rates among women in Maribyrnong LGA (Brimbank et al 2011). The ethnic background of the women giving birth at Sunshine Hospital who were diagnosed with GDM was quite different from the population reflected in the NDSS data: GDM in Braybrook Not Stated Australia Burma Vietnam India *Other NDSS GDM Registrants WH GDM Births *Other included Bangladesh, China, Ethiopia and Malaysia Figure 12. Number of women (by country of birth) from Braybrook who are registered with NDSS for GDM, and women who are recorded to have GDM birthing at Sunshine Hospital (Diabetes Australia 2015, Western Health 2015). According to Western Health (2015) birthing statistics, women from Burma6 have the greatest prevalence of GDM in the Braybrook community. This is significant because the Burmese communities are among the smallest in Braybrook. According to these statistics 18.9% of the Burmese population in Braybrook would have GDM; controlling this data for sex it is estimated that 37.9% of Burmese females would have GDM. Comparatively the Vietnamese (largest Braybrook ethnic population) would have a GDM rate of 1.70% (data controlled for sex) (Profile ID 2011). 5 A German study found that 90% of women who used insulin during pregnancy developed diabetes within 15 years post-partum, regardless of maternal weight (Kim 2014 p8). 6 The country Myanmar formally known as Burma is still referred to by many who live/lived there as Burma. This, in this report the country Myanmar will be referred to as Burma. 12

13 Braybrook Women with GDM Birthing at Sunshine Hospital 33% 11% Services for GDM In and Around Braybrook The health services commonly used by women in the period of gestation are general practitioner (GP), obstetrics and midwifery. Other health professionals such as dietitians and diabetes educators may be used throughout this period also. Postnatal care is also monitored by these health professionals, especially midwives. Once at home with the baby, maternal and child health nurses are able to provide home visits (State Government Victoria 2015) (See appendix 4 for medical services in and around Braybrook). Braybrook Women s Knowledge and Experiences In a group interview women in Braybrook reported that their only concern regarding their health during pregnancy was weight gain and diabetes7. Many women mentioned that they were tested for diabetes during their pregnancy but fortunately did not have the condition. As a result there was little to no knowledge regarding gestational diabetes, aside from a few women who either had it themselves, or knew someone who had it. The knowledge of GDM that did exist related to complications, such as the possibility of a caesarean section and the need for insulin and diet control. Food was the main topic of conversation amongst the women as a form of weight and diabetes control. Interestingly physical activity was seldom mentioned. In regards to why GDM occurred, little was known other than it occurs during pregnancy. It was surprising that so many women knew so little or nothing at all about GDM. 12% 25% 19% India Vietnam Australia Burma Not recorded Figure 13. Braybrook women by place of birth with diagnosed GDM birthing at Sunshine Hospital over a 15 month period (beginning 2014) (Western Health 2015). More concerning, was the lack of knowledge of the severity and lifelong implications of GDM which appeared in most of the women, including those who had more knowledge of the disease. It is fair to say that education about GDM and its severity is lacking in the Braybrook community. Social Knowledge and Pressures Regarding Pregnancy and Developing GDM Socio-cultural expectations and knowledge surrounding pregnancy may give some insights into the incidence of GDM in Braybrook. Pregnancy is a particular time during which medical behaviours such as attending regular medical appointments and using supplements for example are expected to be adhered to for optimal health. These behaviours indicate to the medical community how well a pregnant woman is caring for herself and the baby. Equally there are also informal socio-cultural practices that measure and indicate optimal care to the community. The endorsed behaviours of these two systems often do not match, but are equally important. From a socio-cultural perspective, the mother s health and wellbeing is highly scrutinised during pregnancy, and her body acts as a symbolic indicator of the baby s health. Thus women are expected to carry out socially perceived health promoting behaviours (which can be instead of or in addition to medically recommended behaviours). Many diabetes and maternal health professionals have indicated that specific cultural practices and beliefs around pregnancy influence women s behaviours. Consuming particular foods, perceptions of physical activity, as well as a woman s role in the family can all contribute to the development and poor management of GDM. From a socio-cultural perspective, the mother s health and wellbeing is highly scrutinised during pregnancy. 7 The concern of diabetes during pregnancy may have been triggered by the interviewers presence and about the topic being discussed- this maybe a limitation to this finding. The concern of weight gain however was far more concerning to the women and was their first and immediate answer. 13

14 Firstly, eating and weight gain are popular topics regarding pregnant women in both a medical context and socio-cultural context. From a cultural perspective (particularly among Western cultures) pregnancy is often viewed as a time to have less eating restrictions, as there are expectations that pregnant women must gain weight. There is a particular expectation that women need to eat high volumes of food in order to produce a healthy baby (concept of eating for two). The gestational period may also be seen as a time to have a break from body image driven behaviours such as dieting and exercise. It was reported by a health worker that some women with GDM made an active choice to use insulin as a tool to eat the foods they desired, instead of using it as a last resort method to control blood sugar. Additionally, it was also suggested that body image may prevent women from undertaking actions that might protect against the development of type 2 diabetes after childbirth (e.g. exercise and breastfeeding). These attitudes and practices towards food suggest there is a lack of understanding of GDM, its severity and lifelong implications. The severity of GDM can also be played down through little understanding of the cause of this condition which was observed among most people in the Braybrook community. It was indicated that it is sometimes believed the baby itself causes GDM. This belief is reinforced by factors that: GDM is only diagnosed during pregnancy, is usually only present for the time of gestation, and often women cease to have diabetes almost immediately after giving birth. Thus it can be logically perceived that GDM comes and goes with the baby. Associating the GDM episode with the likelihood of developing diabetes later in life may therefore be low. As a result postnatal testing in Australia is low. An Australian study found there was no difference in postnatal testing regardless of whether a woman was born in or outside Australia (Nielsen et al 2014). Essentially there is a lack of testing amongst all women. This gap in the system and lack of support, combined with an immense lifestyle change makes type 2 prevention much harder. Issues such as time, affordability and newly found focus on the baby may cause a new mother to neglect her own health. Essentially socio-cultural beliefs, opportunities and lack of knowledge impact on preventative behaviours and optimal care of GDM. There is a particular expectation that women need to eat high volumes of food in order to produce a healthy baby. Women can also face other social barriers in the community such as lack of support or isolation. Women receive much medical attention during their gestational period, and after birth this attention can become diminished. Women go back into the community and receive less support, especially for their own health; the focus of services understandably shifts toward the new baby. It was identified by many experts that there is a gap in services for women in the postnatal period; proof of this is in low postnatal screening rates. It seems as through testing is not vigorously pursued by both health professionals and women themselves, as post testing is time consuming and difficult. 14

15 Section Two: Ethnographic and Environmental Context of Gestational Diabetes Mellitus 15

16 As mentioned previously, ethnicity can be a strong indicator for the development of diabetes. The determinant of ethnicity should be analysed in several ways including associated cultural behaviours and perceptions of health and wellbeing8, in addition to biomedical concepts. The role of culture within the ethnic premise is critical as it explains beliefs that govern behaviours, not biological make-up. This needs to be considered carefully when attempting to understand diabetes prevalence among particular ethnic groups. As discovered in the previous sections the Vietnamese and Burmese communities have the highest representation of GDM in Braybrook across two data sets. It is thought that Asia contributes 60% of the global population of diabetes sufferers (Ramachandran et al 2012). The prevalence of diabetes is growing faster in South East Asia than in the Western Pacific Region (WHO 2015). Vietnam has one of the fastest growing diabetes prevalences, which is large in comparison to both the South East Asian and Western Pacific Region (WHO 2015). Among people of Asian backgrounds diabetes can occur at lower BMIs than European peoples; BMI=23> compared to BMI=25> respectively (Ramachandran et al 2012). The following section will examine the prevalence of diabetes in Vietnamese and Burmese contexts. Cultural concepts of health and family will also be examined among the Vietnamese and ethnic groups of Burma to determine the role of culture in diabetes prevalence and management. Vietnam and Diabetes It is estimated that 5.3% of the Vietnamese population in 2014 were living with diabetes, compared to 5.1% of the Australian population (IDF 2014b). This shows that diabetes prevalence is quite similar between the two countries and may translate proportionately between countries. The Vietnamese community are the largest ethno-cultural community in Braybrook making about a quarter of the Braybrook population. Due to being such a large community, it is unsurprising that the Vietnamese community would experience high rates of diabetes. Vietnamese Culture and Pregnancy Balance is a particular feature of Vietnamese health beliefs. To live well and be healthy all must be balanced. As in most cultures food, in relation to pregnancy plays an important role in Vietnamese culture. These beliefs specify the appropriate variety of foods as well as specific amounts. It is recommended that women not eat too much during pregnancy for fear the baby will become too big and make labour more difficult. Certain foods are promoted to be better for pregnancy. Vietnam Burma Figure 14. Globally Recorded Diabetes Rates (IDF 2014b) See also appendix 7 global diabetes mortality rates. 8 Specific cultural norms and practices can contribute to diabetes; such as the maintenance of family relationships through mediums such as food (Ito 1985). 16

17 These include poultry, fish, pork, most ripe fruits and vegetables, plain rice, eggs and ginseng. Other foods recommended for avoidance during pregnancy include hot foods such as alcohol, coffee, unripe fruit, red meat, spicy soups, garlic, ginger and red chillies. While cold foods recommended for avoidance include ice cream, ice water, bananas, oranges and gelatines; these hot and cold foods promote imbalance to a pregnant woman. An Australian study found that following this traditional diet does not inhibit the birth-weight of a baby (Bodo and Gibson 1999). Other behaviours in addition to food recommendations are promoted to aid labour and assist in the development of a healthy child. One such recommendation discourages physical inactivity during pregnancy. It is suggested that laying and sitting for too long is not optimal; pregnant women are encouraged to be active up until the time they give birth. It is also believed that inactivity will contribute to a larger baby making labour more difficult (Bodo and Gibson 1999). Vietnamese culture in Australia Vietnamese people have migrated to Australia in waves, some of these waves have been in the context of conflict, reuniting with family and also for marriage. The Vietnamese community today is well established in Melbourne s west, particularly in Braybrook. It is known that this community is able to maintain their food culture, eating much of the same foods as they themselves or their families did in Vietnam. It was noted by Tran (2003) that many Vietnamese that came to Australia out of conflict and those who came to reunite with their families have more community and family support, as well as more experience in dealing with government and the public health systems. It was noted however that there is a wave of less supported immigrants coming out of Vietnam with the intention of marrying in Australia. These women are often of childbearing age and are more vulnerable, as they do not have family support and are often isolated and reliant on their husband. This can make having a baby and experiencing care in the public health system a startling one, especially because pregnancy and childbirth are considered women s business in Vietnamese culture (Tran 2003). It is thought that in the period just after arriving in a new country that traditional customs may be more intensely practiced to compensate for loss of identity (Bodo and Gibson 1999). If this is the case traditional diets and practices (particularly around pregnancy) may act as a protective factor for diabetes. However environmental and cultural contexts are not the same in Australia and Vietnam. In Australia, while traditional Vietnamese foods are available there may not be the accessibility or time to cook or prepare them. Life may also be more inactive than in Vietnam due to different working hours and conditions. The desire to assimilate into Australian culture may also play an integral role in the development of diabetes. Tran (2003) noted that many Vietnamese believe that western ways of feeding children are more advanced. A case study where a mother of a new born expressed the desire for her baby to eat lamb, despite not being able to stand the smell of it, may be a method of assimilation (Tran 2003 p.7). Other foods such as chocolate and Coca-Cola were thought to be for the rich among the Vietnamese, making these food items high in symbolic value (Budd et al no date). The availability, affordability and the perception of these items still held in Australia may encourage their consumption in order to elevate personal and family status. The desire to assimilate into Australian culture may also play an integral role in the development of diabetes. 17

18 Burma and Diabetes Burma is one of the most ethnically diverse countries in the world with 130 different groups (McGinnis 2012). The largest ethnic groups in Burma are Burma, Shan, Karen, Arakan, Chin, Mon, Kachin and Kayah/ Karenni who are all distinct from one another. In Braybrook the Karen and Chin are the most prevalent groups to come from Burma. The peoples of Burma have been arriving in Australia since 2003 (Lane et al 2013). Burma has a long history of conflict and people have suffered violence, displacement, food insecurity and hunger (McGinnis 2012). In 2014 the diabetes rate in Burma was recorded at 5.79%, which again is comparable to Australia and Vietnam (IDF 2014). However these rates are questionable as seeking medical advice was said to be uncommon in Burma. Cultures of Burma and Pregnancy Due to the importance of family across Burmese cultures, pregnancy is considered a crucial part of a woman s life. As in Vietnamese culture, there are specific practices around pregnancy to protect the health of the mother and baby. Certain practices relating to food, physical activity and temperature as well as postnatal rituals are implemented accordingly (McGinnis 2012). Due to the importance of family across Burmese cultures, pregnancy is considered a crucial part of a woman s life. Particular foods and cooking methods are often thought to have qualities that enhance or inhibit the health of mother and child. Burmese women in America indicated that restricting certain foods during pregnancy was believed to promote health9. Particular types of fruit, vegetables and meats were recommended to be avoided. Other items such as alcohol and cigarettes were also mentioned by the Kayah and Kayaw as items to avoid during pregnancy. The Karen women however, were the only group to discuss foods that were recommended during pregnancy, which included oranges, lemons, mangoes, warm soup, rice and milk (McGinnis 2012). Physical activity is another crucial aspect to women in pregnancy; there are many beliefs about the function and effects on a pregnant woman s body. It was agreed amongst all groups interviewed that physical activity and strenuous work was harmful to a pregnant woman and her baby. Many of the groups specifically mentioned heavy lifting as being a particular task pregnant women should not undertake. The Kayah were the only group to mention that physical activity or hard labour was considered acceptable to undertake in the first trimester; after this period it would be considered dangerous. Many women expressed the ideal for a pregnant women to rest, and allow her husband to do all her normal duties (McGinnis 2012). Food and physical activity are more obvious variables of health in pregnancy, however there are others that are considered just as important. All Burmese groups interviewed expressed the importance of temperature, particularly among women during pivotal points in their lives. It was suggested by most groups that women need to be warm, especially during the menstruation, pregnancy and the postnatal periods. Most women agreed that being cold especially in these times are not good for a woman s health or her pregnancy. The Karen women mentioned that the cold may give a woman future health problems and may cause medicines not to work. While the Kayah women mentioned that the cold may harm the unborn baby; it was recommended particularly that women should not use cold water in the postnatal period. (McGinnis 2012). Interestingly the time allocated for the postnatal period was not consistent among the groups interviewed. The Karen women suggested that it should last between 2 months and 1 year. 9 This data was collected by an American Anthropologist who interviewed women from Burmese cultural groups discussing reproductive beliefs and practices in the USA. The ethnic groups spoken to for this study were: Karen, Chin, Kayah and Kayaw women (McGinnis 2012). 18

19 While Chin women suggested that this period was up to 2 months, but could end earlier depending on the woman s ability (McGinnis 2012). This period may be important as there may be rituals that have significance in this timeframe, such as the food and temperature restrictions listed above. Common issues for pregnancy and childbirth in Burma were having limited food and food choices, financial burdens and few women had access to hospitals (McGinnis 2012). It was reported that a person would only see a doctor or go to a hospital in Burma if something is seriously wrong. Women of Burma in America and Australia Although the Burmese cultural groups experience mental health problems, language barriers and feelings of homesickness in new homelands, there are also positive experiences including food security and quality medical care (McGinnis 2012). As the Burmese peoples are experiencing new aspects of life in America and Australia, to a large extent they are still able to maintain some of their culture. Manual labour is one point of difference in both Australia and America than in Burma. A Kayaw women expressed that she felt she was able to get more rest (in pregnancy and postpartum) because women don t have to work the way they did in Burma (McGinnis 2012). Food is another crucial element of difference in America as in Australia, there is a wide variety and abundance of food which is easily accessible. All groups said they were able to source culturally appropriate foods from Asian grocers (McGinnis 2012). The Kayah women reported that in America there was no need for food restrictions, as there was in Burma. This may be because there are so many options that food restrictions are not as burdensome as they once were. This comment suggests that eating restrictions are not necessary in America not only because of food security and wide range of foods, but also because there is medicine available to relieve ailments. Throughout McGinnis (2012) thesis there is a common theme of trust in the US medical system, particularly noting the care given and the ability to relieve pain during pregnancy. In Melbourne s west it was found however that people of Burmese cultures had mixed feelings about the public health system. Firstly it was expressed that a trip to a GP can be a traumatic experience. Often patients can wait for long periods of time without being seen by a doctor (reportedly it is said that the patients name is called out, and then the patient list is moved on). When a patient had an appointment with a GP often an interpreter was not included (as it may have taken them too long to wait for them to arrive or to engage with them). Additionally the appointment only lasts a few minutes which does not satisfy the needs of Burmese patients. Hospitals on the other hand were considered a trustworthy place because medical professionals could spend more time, provide more perceived care and also the use of interpreters are more common. It was said that the use of GPs in Burma is seldom. Western medication on the other hand is considered important and trustworthy. It was reported that in Burmese communities in Australia, western medication is desired and trusted; which was the same finding in the American study (McGinnis 2012). According to a bicultural worker in Melbourne, medication is obtained and taken with a sense of pride. Having medications (which sometimes is reportedly not needed) provides peace of mind and the thought that health will be restored. There seems to be a strong psychological element and socio-cultural symbolism that medication represents among Burmese communities. We did not eat some foods [in Burma and Thailand], but [we do] in America. There s a vegetable, they bring it from Thailand so it is [available in the US]. When you live in [Burma there is] no medicine so you can t eat [the vegetable], but [Karen women] will eat [this in the US] because they can drink the medicine if they feel bad. [But] I don t know what the medicine is Karen woman aged 50 (McGinnis 2012 p72) 19

20 The Burmese populations are essentially familiar and comfortable with western medicine (McGinnis 2012). It can be sensed through such comments below, that there is a great trust in the American medical system and perhaps a limited understanding from a biomedical perspective. In Burma when you are pregnant we still have to work and we cannot find the food like we can in America. We have to go to the farm and carry a lot of stuff like rice, corn We don t have to work like the way we work in Burma and we can find more food In the US I feel, I envy of [pregnant women] because they feel lucky. They medicate and they have regular check- ups with the doctor and check the health. They are very lucky. Chin woman aged 35 (McGinnis 2012 p. 97) Cultural beliefs and practices were reported to be minimising because of cultural clashes. For example the postnatal rituals which take place amongst the Karen people are becoming shorter in America, and are reportedly changing due to environmental opportunities in Australia. Rituals that would have been implemented to heal a woman in the postnatal period are being replaced with western medicine: one Karen woman reporting they have enough medicine here (McGinnis 2012 p.72). Another example was seen amongst the Chin women who suggested that traditional bodily cleaning practices with warm or hot water that take place after birth are changing. Chin women who give birth in the US place their trust in doctors and their medicines (McGinnis 2012). It was also reported that some of these traditional behaviours such as washing hair during menstruation was not practiced in Burma because only cold water was available. However in Australia hot water is available all the time, thus this ritual is ignored because it is overcome by modern technologies. Essentially the cultural concept remains, but different environments allow varied ways to carry out particular rituals. In interviews conducted with the Burmese groups in America and information sought from a bicultural worker in Melbourne s west, it was uncovered that pregnancy and birth are easier in America and Australia. Conclusion There are cultural aspects of both the Vietnamese and the groups of Burma that relate specifically to family and pregnancy. Although these promoting and prohibiting cultural beliefs and practices are open to interpretation, it is important to note that these cultures uphold a critical concept of optimal care specific to pregnant women. The Vietnamese however appear to have the most protective cultural beliefs and behaviours that relate to GDM in the Australian context; the promotion of movement and healthy eating in small portions is particularly notable (Bodo and Gibson 1999). While many cultures of Burma had less protective factors which include prohibiting physical activity particularly (McGinnis 2012). While these practices were probably well adapted to the environment and life in their home country; their implementation into Australian society may be problematic. Stress about overworking and food availability was relieved once the Burmese people arrived in America and Australia It was indicated that worry and stress about overworking and food availability was relieved once the Burmese people arrived in America and Australia10. This may contribute to behaviours that promoted the presence of GDM. Essentially there are no food restrictions, no need to do physical work and western medicine is available. It maybe the assumption that if a woman develops GDM medication will take care of this. 10 According to a Victorian Burmese Bicultural worker, food was actually described more in a celebratory sense; in that food was abundant but also flavoursome and affordable. It was noted that within the first 1-2 months arriving in Australia that a range of foods were eaten, that were not necessarily health promoting. 20

21 Section Three: Interventions and Research Programs 21

22 Areas for Intervention In America it is predicted that intervention in GDM would prevent or delay 16% of type 2 diabetes in the female population (Chasan-Taber 2014). Essentially it is fair to say that GDM can act as a gateway to type 2 diabetes. Women with GDM are an effective diabetes prevention audience, as they are diagnosed and engaged in the appropriate services. Thus GDM should not be underdiagnosed like other types of diabetes (Lee et al 2007). These factors make GDM sufferers an effective target audience in the overall prevention of type 2 diabetes. GDM is often targeted by programs and actions in the following ways: Promoting women to be fit for pregnancy; preparing the body (prevention) Promotion of healthy eating during pregnancy (management) Promotion of breastfeeding in the postnatal period (management and prevention) Fit for Pregnancy The concept of fitness for pregnancy encourages women to get healthy and fit for the birth itself as well as pregnancy. This is a preventative measure for GDM, and can be aimed at a more general audience (those who may become pregnant in the future). This type of intervention relies on behaviour change in terms of physical activity and eating in the prenatal period. This type of intervention could focus more on physical activity- strengthening muscles and pelvic floor for birth and better recovery, and importantly control weight gain. This type of initiative would ideally have a flow on effect, normalising and alleviating previous anxiety about exercise. The benefit of promoting physical activity, is there are many cost effective and free ways to be physically active. One of the negatives about this type of intervention is that opportunities, motivation and an obesogenic environment may hinder the willingness to be physically active. Fit For Pregnancy Increasing fitness through exercise and healthy food in preparation for gestation and birth: form of weight control Promote Healthy Eating Preventing excessive weight gain during gestation Prenatal Pregnancy Healthy Eating Promotion The promotion of healthy eating and weight management during pregnancy can help to prevent an increase of adipose tissue and also diabetes. If this initiative was successful GDM levels may decrease, additionally type 2 diabetes may also be prevented. This type of initiative could also have a flow on effect informing and allowing the practice of healthy eating, which can be carried on for life. However healthy eating messages do not take into account the environment and the opportunity to action prescribed behaviour change. Additionally healthy eating messages saturate our culture with little effect. Promote Breastfeeding Influence weight loss and improved insulin sensitivity Postnatal 22

23 Breastfeeding Promotion Studies have shown that women who breastfeed in the postnatal period lower their risk of type 2 diabetes (Owen et al 2006, Stuebe et al 2005). Breastfeeding has been shown to assist in weight loss, as well as improve insulin sensitivity and glucose tolerance, all of which are factors for diabetes. Additionally it is shown that babies who are breastfed are less likely to be obese as adults, and are also less likely to develop type 2 diabetes (Gunderson 2007, Gabbe et al 2012, Owen et al 2007). The duration recommended for breastfeeding for maximum health promoting effects for mother and baby is 6 months (exclusive breastfeeding), up to one year or more. However studies have shown that longer duration of breastfeeding has also been associated with lower maternal weight gain years post pregnancy (Gunderson 2007). Additionally it has been shown that infants who were breastfed for 12 months or longer had a reduced risk of developing type 2 diabetes compared to children who were not breastfed at all (Gunderson 2007). Thus breastfeeding has protective measures against diabetes for both mother and baby. Breastfeeding is also cost effective; the ability to breastfeed is not defined by social class, opportunity or resources. It is known that breastfeeding rates in Melbourne s west are low11; the choice to breastfeed is often influenced by cultural and economic factors (Stuebe et al 2005). Cultural Case Study A study comparing Australian (presumably of Anglo-Saxon heritage), Turkish and Vietnamese women s attitudes and practices of breastfeeding in Melbourne in 1999, found that Vietnamese women had the lowest rate of breastfeeding initiation (75% compared to Australian 84% and Turkish 98%). In fact 40% of Vietnamese mothers gave their newborn formula in the hospital. Vietnamese women also perceived that their partners felt negatively about breastfeeding, and did not value the health benefits of colostrum to the same extent as the other two groups (McLachlan and Forster 2006). Interestingly most women in Vietnam breastfeed for at least one year. However studies have shown that women born in Vietnam who have migrated to a new country have lower breastfeeding rates. Vietnamese women in this study were likely to be married, older and on a lower family income than Australian women and were less likely to smoke prior to pregnancy. McLachlan and Forster (2006) also stated that Vietnamese women may not breastfeed due to convenience, perceptions of diminished quality of breast milk, economic reasons (needing to return to work), insufficient social support and perceptions that more affluent families do not breastfeed, and additionally wanting to conform to this perceived norm (McLachlan and Forester 2006). Cultural Perceptions of Breastfeeding Breastfeeding initiation in Australia is around 83%, however there are variations between groups. Australian studies have found that women are more likely to breastfeed if they are older, have more education, have higher income and social support (McLachlan and Forester 2006). There were also differences seen amongst ethnic and cultural groups. Studies have shown that women who breastfeed in the postnatal period lower their risk of type 2 diabetes 11 In the financial year of , 46% of six month old babies attending Maternal and Child Health Services at Maribyrnong City Council were being breastfeed the ideal recommended amount (Maribyrnong City Council no date). 23

24 Previous Projects Addressing GDM: Hospital based education programs- behaviour modification. The National Gestational Diabetes Register (NDSS) - this service provides testing reminders to both the woman and her nominated doctor post birth, in addition to lifestyle, diet and health-related information in order to minimise risk of developing type 2 diabetes. You2connect- Diabetes QLD connect newly diagnosed pregnant women with GDM, with mothers who have in the past experienced GDM in their pregnancies. MAGDA (Mothers After Gestational Diabetes in Australia) - is a controlled trial, known as the GDM Diabetes Prevention Program (GDM-DPP) with a structured lifestyle modification group intervention for women who have had GDM. GooD4Mum Collaborative Project- aims to improve the diabetes prevention care provided to women with a history of gestational diabetes in participating Victorian general practices over a 12 month period. Programs to promote breastfeeding have included: - Structured education programs - Education programs with support - Peer support or counselling programs - Baby Friendly Hospital Initiatives (Centre for Community Child Health 2006). Important Findings from Previous Studies Women are often poorly prepared for GDM, and may not know anyone who has had it Many people in the wider community do not know what GDM is. It does not have the same recognition or understanding as type 1 and type 2 diabetes New mothers expressed experiencing challenge with engaging and maintaining healthy lifestyles in the postnatal period Women have shown low adherence to recommended lifestyle in the postnatal period Intensive lifestyle interventions have proven effective for prevention of type 2 diabetes generally, younger women with infants and children may have more difficulty maintaining a new regime due to restrictions on their time and energies (Khangura 2010) Women underestimated their risk of developing T2D post GDM (Khangura 2010) 2007 Canadian trial of a dietary intervention for women with GDM showed that, while adherence was maintained through pregnancy, it was not maintained through 6 months postnatal. Authors conclude that: Women with GDM made changes in eating patterns during pregnancy, but these were not maintained postpartum. Further intervention is recommended during the postnatal period for women with GDM to sustain changes made during pregnancy (Khangura 2010, p.9) The distribution of written material has been ineffective in increasing breastfeeding rates. The distribution of commercial discharge packages, containing samples of artificial formula or promotional material for artificial formula given to mothers, has increased the likelihood of formula being used over breast milk (Centre for Community Child Health 2006) Structured education programs and combined education and support programs have demonstrated good results (Centre for Community Child Health 2006) Written material alone cannot be relied upon to encourage women to breastfeed (Centre for Community Child Health 2006) Evidently there are many strategic and suitable areas and times to implement GDM projects. However, what is most useful for the community must be determined by Braybrook statistics, sociocultural and environmental variables, and importantly the Braybrook community itself. 24

25 Section Four: Recommendations 25

26 This report has demonstrated the relatively high prevalence and severity of GDM in the Braybrook community. Although the number of people with GDM is significantly lower than that of type 2 diabetes, it can be argued that this type of diabetes has greater far reaching affects than any other type. Addressing GDM is effectively taking a preventative approach to type 2 diabetes in women and children. Additionally women with GDM are a captive audience as they are already highly engaged in the health care system. Thus interventions to alleviate issues experienced by women with GDM or the prevention of GDM is critical to the health of women and children in Braybrook as well as the west. To address GDM in Braybrook the following areas should be taken into account: Areas needed for intervention Health Literacy - knowledge of GDM, its severity and future consequences appears to be alarmingly low. It was observed that knowledge of GDM was lower than any other type of diabetes within the Braybrook community. Acknowledgement of Cultural Perceptions - relating to general health (particularly during pregnancy) and pregnancy may interfere with recommended medical advice and preventative behaviours. This contributes to lack of preventative behaviours for the development of type 2 diabetes. Social Isolation- women who are isolated from social networks may be at increased risk of underutilising vital health and social services (contributing to poor health literacy and health outcomes). Support - women may have little support to help with care of the baby, lifestyle changes, emotional support etc. during pregnancy and postnatal period which may act as a barrier to seeking medical or social services. Postnatal Care - women are highly engaged in the medical and possibly social system during pregnancy; this focus often shifts predominantly to the baby s health after birth. This shift in focus may act as a barrier for women acting on their own health. Obesogenic Environment - limited access to healthy food, low walkability, perceived safety, sedentary conditions (workplace) etc. contribute to unhealthy choices. The healthy choice is more often not the easiest choice. (See Responding to Diabetes in Braybrook for more details). Recommendations for Future Projects Recommendation 1. Work with specific ethnic groups to subdue GDM rates As noted above newly arrived Vietnamese women and women from Burma experience higher known rates of GDM than other groups in Braybrook. Strategically the Vietnamese community represent the largest population group of Braybrook, and accordingly have a proportionately high rate of diabetes. The Karen and Chin only represent a small proportion of Braybrook, but also represent a high proportion of those who experience GDM. Working with these particular groups and bicultural workers would be a strategic way to influence the rate of GDM in Braybrook. Project interventions could include: Address cultural and assimilated practices that can impact the development of GDM (physical inactivity, perception of the role and ability of western medicine, low rates of breastfeeding) presented a community education-preventative approach. Work with services that provide health care and social support to these groups to increase knowledge of traditional cultural practices and current barriers to service uptake and provision. Work with migration agencies providing information about particular health problems within migrant populations and provide tools and advice on how to navigate the health care system. Recommendation 2. Promote and enable diabetes postnatal testing It is agreed by health care professionals that postnatal testing is low. There are a variety of reasons for this: little time and support, child care, unpleasant experience, perception and understanding of GDM. This proposal advocates an umbrella approach to better manage GDM in all women. Project interventions could include: Promote the seriousness of GDM and the increased potential for diabetes in women of childbearing age in a community educationpreventative approach Address barriers to postnatal testing; advocate for testing in child care centres or childcare in testing centres 26

27 Promote the use of HbA1c level testing for women in the postnatal period (this method has been approved for use in this period). Compliance with this test is much higher than fasting tests. Recommendation 3. Improve system support for women post pregnancy Postnatal period is an important period for diabetes management in women. There is much information around on what to do, but perhaps more information needs to be given on how it can be achieved in a particular environment. A project could be conducted to investigate the barriers to women in Braybrook accessing services while also analysing the perceptions of health in this period. Project interventions could include: Map out services used by women during pregnancy and in the post-natal period; understanding the gaps and barriers in healthcare provision for pregnant women Develop a system planning tool that can assist women in the postnatal period to access needed services and educate them on the importance of postnatal health care. Incorporate care and health promotion for mother into paediatric services Recommendation 4. Lifestyle Intervention- Prevention Programs Physical activity and healthy eating could be incorporated into social community groups aimed at Burmese and Vietnamese women (church groups, Community Health, Neighbourhood House). The aim of such groups would be to instil good practices, provide access and information to these groups prior to pregnancy. Such groups would provide interventions for prevention, but also could be used as a support for women during and post pregnancy. Recommendation 5. Breastfeeding Promotion The promotion of breastfeeding will have upstream and downstream elements that will impact diabetes rates in the community. Breastfeeding helps to control blood glucose, which is important for the management of GDM, while also preventing conditions that will produce type 2 diabetes in the future. Additionally breastfed children have a lower risk of both type 1 and 2 diabetes as well as a decreased risk of obesity. Initiation rates for breastfeeding are quite high in Australia, however maintenance rates of breastfeeding are low, particularly in Melbourne s west. Thus an important element to address is the ongoing breastfeeding of infants. Recent Australian research has shown that education among women regarding breastfeeding does not result in increased ongoing breastfeeding rates. Additionally it was also shown that the fathers have an influential impact on whether a child is breastfeed. Interestingly the research also showed that skin on skin contact was found to promote initiation and duration of breastfeeding (Amir et al 2010). Project interventions could include: Promoting breastfeeding as a cultural norm Selecting particular groups such as the Vietnamese which evidence suggests have lower rates of breastfeeding Increasing breastfeeding friendly environments (workplaces, public spaces) Education of the benefits of breastfeeding among male groups (new fathers- incorporate into Sons of the West and other men s health programs). Project interventions could include: Increase the awareness of pivotal members in the community who have access and influence over target groups that experience high levels of GDM Develop healthy eating, pregnancy or exercise classes with existing community groups Embed healthy eating, physical activity and health service information into existing groups, assisting existing services to become more health literate and aware of GDM. 27

28 28 Appendices

29 Appendix 1 Appendix 2 Sunshine Braybrook West Footscray Avondale Heights NDSS Registrants Men Women The above table shows the percentage of NDSS registrants in each suburb, as well as the percentage of the male and female population per suburb (Diabetes Australia 2010). 29

30 Appendix 3 Medical services for pregnant women in Braybrook include: Organisation Location GP Cohealth Churchill Avenue, Braybrook Central West Medical Centre Braybrook Medical Centre Ashley Street Medical Centre Wests Road Medical Centre Medical One The Gathering Place Health Service Ballarat Road Family Medical Centre Barkly St Medical Clinic Rosamond Medical Centre 67 Ashley Street, Braybrook 154 Churchill Avenue, Braybrook 88 Ashley St, Footscray 25 Wests Rd, Maribyrnong Sunshine Plaza Shopping Centre 324 Hampshire Rd, Sunshine Unit Hampstead Rd, Maidstone Shop 4, 303 Ballarat Road, Footscray 602 Barkly Street, West Footscray 111 Rosamond Road, Maidstone Obstetrics Western Health 148 Gordon Street, Footscray Dr. Thao (Tara) Le 17 Stanlake Street, Footscray Midwifery Western Health Sunshine Hospital Coheatlh (Wednesdays) Paisley Street, Footscray Maternal and Child Maribyrnong City Council Churchill Avenue, Braybrook Health Dietetics Cohealth Churchill Avenue, Braybrook Central West Medical Centre 67 Ashley Street, Braybrook Joslin Clinic 571 Barkly Street West Footscray Durham Road Clinic 141 Durham Road, Sunshine ISIS Primary Care 122 Harvester Road, Sunshine The Gathering Place Unit 5, Hampstead Road, Maidstone Diabetes Educator Cohealth Churchill Avenue, Braybrook Central West Medical Centre 67 Ashley Street, Braybrook ISIS Primary Care Sunshine Campus 122 Harvester Road, Sunshine Sunshine Ultimate Care Clinic 127 Durham Road, Sunshine This table illustrates services in and near Braybrook (green writing indicates services inside Braybrook). As can be seen in the above table, Braybrook has most services that women need while in the gestational period; the only services not provided for are midwifery and obstetrics which are often hospital based services. There are also dedicated women s health clinics (or clinics that advertise this as part of their work scope) such as Completely Well Women which has services such as GP, Birth, breastfeeding, family planning, pregnancy, pregnancy tests etc. and is located in Yarraville. 30

31 There are also specific community groups and services that provides support and physical activity for women: Services specifically for women (green writing indicates Braybrook location) Exercise Support Organisation Location Cost Mummy Tummy s Dance/ Maribyrnong Community $10 per session Exercise Class Centre, 9 Randall Street, Maribyrnong Women s Only Yoga Maidstone Community $5 per session Centre, 21 Yardley Street Maidstone Pram Walking Group West Footscray Neighbourhood House, 539 Barkly Street, West Footscray Braybrook Maternal and Child Health Service BMNH Playgroup Parent Information Sessions Churchill Avenue, Braybrook 113 Melon Street, Braybrook Community Services Building, Civic Offices, Corner of Hyde and Napier Streets, Footscray. Free Free Free Appendix 4 Age of women in Victoria giving birth in 2011 (Li et al 2013) 31

32 Appendix 5 Percentage of women from their country of birth who have given birth in Australia (Li et al 2013) Appendix 6 BMI of women who gave birth in Victoria (Li et al 2013) 32

33 Appendix 7 Diabetes Global Mortality Rates (WHO 2014a) 33

34 34 References