Improving systems of care during and after a pregnancy complicated by hyperglycaemia: a protocol for a complex health systems intervention

MacKay, D., Kirkham, R., Freeman, N., Murtha, K., Van Dokkum, P., Boyle, J., Campbell, S., Barzi, F., Connors, C., O'Dea, K., Oats, J., Zimmet, P., Wenitong, M., Sinha, A., Hanley, A.J., Moore, E., Peiris, D., McLean, A., Davis, B., Whitbread, C., McIntyre, H.D., Mein, J., McDermott, R., Corpus, S., Canuto, K., Shaw, J.E., Brown, A., Maple-Brown, L., and , Diabetes Across the Lifecourse Partnership (2020) Improving systems of care during and after a pregnancy complicated by hyperglycaemia: a protocol for a complex health systems intervention. BMC Health Services Research, 20 (1). 814.

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Background: Many women with hyperglycaemia in pregnancy do not receive care during and after pregnancy according to standards recommended in international guidelines. The burden of hyperglycaemia in pregnancy falls disproportionately upon Indigenous peoples worldwide, including Aboriginal and Torres Strait Islander women in Australia. The remote and regional Australian context poses additional barriers to delivering healthcare, including high staff turnover and a socially disadvantaged population with a high prevalence of diabetes.

Methods: A complex health systems intervention to improve care for women during and after a pregnancy complicated by hyperglycaemia will be implemented in remote and regional Australia (the Northern Territory and Far North Queensland). The Theoretical Domains Framework was used during formative work with stakeholders to identify intervention components: (1) increasing workforce capacity, skills and knowledge and improving health literacy of health professionals and women; (2) improving access to healthcare through culturally and clinically appropriate pathways; (3) improving information management and communication; (4) enhancing policies and guidelines; (5) embedding use of a clinical register as a quality improvement tool. The intervention will be evaluated utilising the RE-AIM framework at two timepoints: firstly, a qualitative interim evaluation involving interviews with stakeholders (health professionals, champions and project implementers); and subsequently a mixed-methods final evaluation of outcomes and processes: interviews with stakeholders; survey of health professionals; an audit of electronic health records and clinical register; and a review of operational documents. Outcome measures include changes between pre- and post-intervention in: proportion of high risk women receiving recommended glucose screening in early pregnancy; diabetes-related birth outcomes; proportion of women receiving recommended postpartum care including glucose testing; health practitioner confidence in providing care, knowledge and use of relevant guidelines and referral pathways, and perception of care coordination and communication systems; changes to health systems including referral pathways and clinical guidelines.

Discussion: This study will provide insights into the impact of health systems changes in improving care for women with hyperglycaemia during and after pregnancy in a challenging setting. It will also provide detailed information on process measures in the implementation of such health system changes.

Item ID: 66740
Item Type: Article (Scholarly Work)
ISSN: 1472-6963
Keywords: Aboriginal, diabetes in pregnancy, gestational diabetes, health services, health systems, healthcare delivery, Indigenous Australian, mixed methods evaluation, Torres Strait Islander, type 2 diabetes in pregnancy
Copyright Information: © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Funders: National Health and Medical Research Council (NHMRC)
Projects and Grants: Global Alliance for Chronic Diseases Grant 1092968
Date Deposited: 05 Jul 2022 23:05
FoR Codes: 42 HEALTH SCIENCES > 4203 Health services and systems > 420311 Health systems @ 100%
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