Between pregnancies: how health visitors can spot and act on diabetes risk
Every contact after birth is a chance to revisit a risk that can otherwise go unnoticed. Health visitors can help women understand the long-term impact of gestational diabetes and the steps that reduce it, but only if the information reaches them.
Anulika Ifezue has been a nurse since 1990 and a health visitor since 2006, and she now leads on perinatal and infant mental health at Manchester Local Care Organisation, part of Manchester University NHS Foundation Trust. She is on the NIHR Senior Research Leader Programme. She no longer delivers universal home visits, but she shapes the workforce that does. When she thinks about the cases that have stayed with her, she thinks first of eclampsia: a woman whose blood pressure had been slowly rising since discharge, no flag raised, no urgent follow-up arranged, until she seized and was admitted to intensive care. The type of crisis that demands speed, and where speed can make the difference. But there is another category of risk entirely, one with no dramatic moment to catch, no sudden deterioration to act on, just a slow accumulation across months and years that by the time it surfaces has already done its damage.
Type 2 diabetes developing after gestational diabetes is that risk. And the window to interrupt it is exactly the window in which a health visitor is present.
One in two women who have gestational diabetes will go on to develop Type 2 diabetes within five years, according to NICE guideline NG3 on diabetes in pregnancy. But what Diabetes Africa has found, in focus groups with women across South East London, is that it rarely reaches the women themselves in a way that changes behaviour. The blood sugar was fine at the last check. They were discharged. They got on with having a baby. “They were told the blood sugar was fine, and that was it,” Anulika says. “They don’t go back.”
Bernadette Adeyileka-Tracz, Executive Director of Diabetes Africa, frames the gap this way: “The moment a woman is discharged after gestational diabetes, she enters a space that nobody owns. Her midwife has moved on. Her diabetes team considers the episode resolved. Her GP has a record but no prompt. And she has a baby, and exhaustion, and a body she was told is back to normal. The information exists. What is missing is someone who speaks her language.”
Why does this matter for health visitors specifically? Because the consequences of an unprepared pregnancy with Type 2 diabetes are serious. Research shows that women with diabetes face a two to five times greater risk of congenital anomaly, stillbirth and neonatal death compared with the general maternity population. A woman who does not know she has moved from gestational diabetes to Type 2 cannot prepare.
There are two things a health visitor can do with that knowledge, and neither requires specialist diabetes training. The first is signposting to the Healthier You NHS Diabetes Prevention Programme, a free nine-month behaviour change programme available to any woman with a history of gestational diabetes, with no blood test result required to access it, and with a dedicated group teleconferencing pathway specifically for women post-GDM. Women can self-refer. They just need to know it exists. The second is planting a seed about future pregnancy: if a woman does go on to develop Type 2 diabetes, a future pregnancy will need specific preparation, and starting that conversation now, before she is pregnant again, is the moment that matters. “You don’t have to have all the answers,” as Oluwaseun Labisi, Consultant Midwife for Public Health at Lewisham and Greenwich NHS Trust, puts it. “You just have to open the door.”
For Black women, the gap is wider and the stakes are higher. Nationally, around 6 to 7% of Black women living with diabetes are well prepared for pregnancy, where well prepared means taking 5mg folic acid, achieving an HbA1c below 48 mmol/mol, and completing a medication review before conception. The reasons are multiple, but one of them is the long stretch between a gestational diabetes diagnosis resolving and Type 2 developing, a stretch in which a woman is technically healthy, not flagged by any system, and seen regularly by one professional: her health visitor.
Make sure the information reaches you
The structural problem, as Oluwaseun Labisi sees it, is that the information simply does not travel. “If a woman had gestational diabetes and that isn’t flagged to the health visitor at handover, then the health visitor is walking into that home without the one piece of information that would change what questions she asks.” The transfer notification contains birth weight, Apgar score, gestational age. It rarely contains the maternal health history: whether the woman had gestational diabetes, was admitted, or left with a monitoring instruction she has already half-forgotten. Anulika is direct about the consequence: if the history is not on the system as a flag, health visitors cannot be expected to go looking for it. If you are not receiving this information at handover, it is worth raising with your midwifery colleagues. The ask is a flag, not a full case history.
Know what you may encounter in the conversation
Knowing the risk exists and having the information in front of you does not mean the conversation will be straightforward, and it is worth being prepared for that.
Anulika places this in a broader context: across health services, she observes, there is a significant shift underway towards understanding people’s cultural traditions, their heritage, their religious beliefs, as part of care. Health visiting is a universal service, which has always meant the same offer to everyone. What is changing is the expectation that everyone delivering it understands that people are different. That shift matters here, because when a health professional raises the prospect of Type 2 diabetes with a woman of Black African or Caribbean heritage, the response can stop the conversation before it has properly begun: “I reject it.”
Not denial, not avoidance, but something more specific: in many Pentecostal and evangelical communities across Britain, speaking illness into existence gives it power, and the response reflects that.
Okay, you reject it. That’s good. You have a positive mindset. But what do you need to do to make sure it doesn’t come?”
Anulika Ifezue
What Anulika has learned over decades of working with those communities is that the rejection is not the end of the conversation. It is the beginning of a different one. “Okay, you reject it. That’s good. You have a positive mindset. But what do you need to do to make sure it doesn’t come? If you fold your hands, then it becomes a risk.” The framing moves from threat to agency, and what follows is practical: the foods, the lifestyle, the GP appointment, the blood test.
“Be conscious about your own biases,” Anulika says. “What you think is a norm might not be the norm for somebody else. If somebody says I reject it, that’s not denial. That’s belief. And if you understand where that comes from, you can work with it.” She is not asking health visitors to become cultural experts. She is asking for curiosity. “Be open. Show genuine interest. You already know how to do this.”
The mental health of a woman in that postnatal window is part of the same picture. Whether she books the GP appointment, whether she follows up the blood test, whether she makes the changes that would reduce her risk, all of it is shaped by how she is doing emotionally, and whether she feels safe enough to say so. “The more we bring it up,” Anulika says, “the more people embrace it and begin to work around their emotional wellbeing.” The question about her own health is not separate from the question about the baby. It is the same question.
“First of all, I need to understand you,” Anulika says. “And then create a space to work with you.” The window between pregnancies is not empty time. It is the most important window there is.
Diabetes Africa is working with the Institute of Health Visiting to develop content on diabetes and pregnancy preparedness for health visiting training, with a particular focus on culturally sensitive approaches for Black women.
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