1 in 10 Moms and Babies Impacted. ??Are we missing the mark on Family Planning?

Welcome back to 'Health at Work & People'! Continuing our mission to empower employees to advocate for their health at work and to build healthier workplaces, we explore the convergence of top Health Risk issues, Mental Fitness, Wellbeing, and Business Growth, reinforcing our commitment to impactful health strategies.

?? At the end of this 'Health at Work' edition, I invite you to join me on a purpose-driven trip. Will you? ??

'Health at Work & People' collaborations aim to equip employees with data insights and tools to advocate for their health in the workplace, while also helping employers incorporate best practices for a healthier workforce and sustainable business.

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I encourage all interested parties to contribute to this dynamic resource. Whether you’re an expert in your field, a health advocate, or a forward-thinking employer, join us in enhancing workplace wellbeing and sustainability.
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Following our 'Diabetes at Work ' edition, and ‘Busyness & our relationship with and behavior towards food ’ – we invite you on a bumpy 9 months journey – from preconception (family) planning to post-partum. ?? We explore cultural norms, misconceptions about eating when planning for a new baby, unmet needs and the perverse impact of our lifestyle habits on pregnant individuals and their babies, drawing wisdom from trusted global sources on healthy pregnancy, eating, diabetes prevention and behavior.

Have you noticed?

When talking about supporting women at work with preconception planning, the ‘trying to get pregnant’ chat usually goes straight to fertility help – IVF and Fertility medications, and making work hours a bit more flexible – all essential topics!?

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But there’s a huge piece of the puzzle that’s barely mentioned - our relationship with food , and its role in getting women's bodies & mind ready for a baby.

Beyond the old wives tales, like eating oysters, don't eat sushi, or popping some extra vitamins, we’re missing out on the opportunity to talk about family history, preventive checks on glucose levels, or seeing food as a big player in setting mom and baby up for success from preconception, reducing the risk of developing gestational diabetes (GDM).

And honestly, it’s about time that changed. ??We are the change!

We’re diving into this complex, generational challenge because prevention of GDM as a key component of preconception planning has been flying under the radar for too long.??

Our research has identified a critical issue: women diagnosed with gestational diabetes often encounter significant gaps in functional knowledge, consistent monitoring, and emotional support. Moreover, the link between gestational diabetes mellitus (GDM) and mental health issues is increasingly concerning, highlighting the problems associated with fragmented (per body parts) care.

Addressing this fragmentation is crucial, as the absence of integrated care escalates risks such as mental health challenges and gestational complications. Keeping status quo means that approximately 50% of GDM cases progressing to type 2 diabetes after childbirth.

This edition of 'Health at Work' is based on my HMS GHLP capstone project and research on the mind-body aspects of care coordination for GDM.

I have joined forces with my HMS GHLP capstone partner Suguna Chunduri , thought provoking leaders, and brilliant health experts to raise awareness, ?education and offer actionable steps towards promoting healthier workplaces, mitigating incidence and impact of gestational diabetes.

Our project assessed the unmet needs of populations at risk for or affected by gestational diabetes mellitus (GDM). This includes conducting surveys and interviews with women who have experienced pregnancy to understand their specific challenges and needs related to GDM.

Additionally, the research seeks to explore research gaps and how GDM impacts individuals across different races and ethnicities, identifying any disparities in prevalence or outcomes.

By engaging with chief medical officers and experts in diabetes and women's health, I evaluated viable solutions and interventions that can address these unmet needs effectively.

Based on these comprehensive assessments, the research will propose a strategic path forward to enhance care and support for individuals at risk of developing or dealing with GDM.

What is covered on this edition?

1?????? Family Planning, Nutrition, & Mental Wellness. ??

2?????? What affects 1 in 10 pregnancies? And what about newborns?

3?????? What You Told Us? Unmet Women’s Health Needs & The Prevalence of Gestational Diabetes

4?????? Care Coordination: What does it mean? Is it an effective solution?

5?????? Employers, Families, and Healthcare System in Action

One of the perks of authentically pursuing my purpose of building 'Health at Work' as a tool for employee self-advocacy and corporate sustainability is the chance to collaborate with amazing leaders dedicated to closing key gaps in health equity. Dr. Kofi Essel, MD, MPH, FAAP , is one of these exceptional leaders.

Other than sharing meaningful insights, calling attention to the concept of "food as medicine", Dr. Essel highlighted tools like medically tailored meals or groceries to support mothers and mentioned health equity programs like FreshRx .

1:? Family Planning, Food, & Mental Fitness

Pregnancy brings about profound changes in a woman's body, one of which is increased insulin resistance. On average, a woman experiences up to a 50%- 60% drop in insulin sensitivity during her pregnancy journey. This natural adaptation can sometimes tip the balance too far, leading to elevated blood glucose levels without a prior diabetes diagnosis.

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Suguna and I share our pregnancy journeys, hoping this resonates with many and highlights misconceptions and shed a light on unmet needs of women during pregnancy, bringing attention to families, friends and spouses.

?? Jaqueline: Throughout my three pregnancies, I experienced a variety of outcomes: a miscarriage in the US, a challenging birth in the UK, and the ultimate joy of welcoming two wonderful children into the world.

Interestingly, the health and leave benefits I have crafted for my clients were not available to me 17 years ago when I was navigating the early stages of motherhood. I found myself returning to work just three months after my first child was born—a story for another 'Health at Work' discussion.

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In the early stages of preconception, my focus was narrow: take vitamins, avoid certain foods, and somewhat track fertility windows. The notion of checking glucose levels, and rethinking my food for a healthier pregnancy was not top of mind, nor was it a topic of discussion among healthcare providers, friends, or family. The primary aim was straightforward: be fertile, get pregnant and ensure the baby's health through pre-natal checks.

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Once the pregnancy news was out, congratulations poured in alongside cheerful advice like "Now you can eat for two!" and "Got any cravings?" I even received amusing warnings about taking a break from exercise, with the memorable caution, "Don't bend over"—as if picking a piece of paper from the floor could somehow push the baby out. I wasn't sure whether to laugh or cry. ???

Indulging in comfort food and embracing a more sedentary lifestyle seemed not just acceptable but almost celebrated, a well-deserved treat for the monumental task of nurturing a new life.

But was this really the case?

Our relationship with food influence not only our healthcare management but also our emotional wellbeing. And, for individuals with diabetes, this relationship may be even louder and definitely more complex.

What would I share with my younger self?

Pause, take time to journal your experiences, and enjoy the ride! When you eat, step away from the computer, slow down and listen to your body's hunger cues. Notice how different foods affect your energy and wellbeing. When visiting your doctor, bring your questions about food, exercise, pregnancy journey, and preventive checks. Ask for help and be curious! ? Be kind to yourself, and remember that emotions, life experiences, and cultural norms can influence how you eat.

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Suguna: My journey into pregnancy commenced in 1995 when I was 25 years old, having been married for 2.5 years.

Excited reactions from family and friends surrounded me, yet the reality of impending motherhood hadn't quite sunk in until my first official checkup. Guided by a doctor who was a friend of my dad's, I received prenatal care and advice to cherish every moment of the journey. Despite the initial joy, doubts crept in during an educational class on motherhood, where the weight of responsibility hit me hard. Morning sickness added to the physical toll, accompanied by unexpected challenges like food aversions and weight loss.

As weeks passed, concerns arose, including elevated A1c levels indicating potential gestational diabetes. Despite reassurances, I felt uninformed and anxious about the unknowns. Weekly ultrasounds monitored declining amniotic fluid levels, leading to a decision for induction at 36 weeks due to dangerously low levels. With my husband's timely presence in Singapore for Christmas break, the induction process began on December 27th, accompanied by a whirlwind of emotions and uncertainty.

The absence of my primary obstetrician led to the care of Dr. Chan, who handled my case personally. Exhausted and frustrated after hours of labor, I opted for an epidural to rest. Meanwhile, my worried parents, including my recently surgically treated mom, were urged to go home and rest by Dr. Chan, promising updates if anything changed.

However, fate intervened, and just as they reached home, a call summoned them back urgently. The baby's distress and plummeting amniotic fluid levels demanded immediate action. Rushing back to the hospital, they arrived just in time for my daughter's premature birth at 12:59 am on December 28th.

Coming to consciousness, I found Dr. Chan by my side, assuring me of my daughter's well-being despite her premature birth and jaundice. Though overwhelmed with love for her, a sense of apprehension lingered, exacerbated by difficulties with breastfeeding and feelings of inadequacy. The journey into motherhood had begun, marked by challenges and unexpected twists, but also imbued with profound love and devotion for my newborn daughter.

Every day brought new challenges, yet I sensed a gradual improvement. If only someone had prepared me for the realities of being a new mom. At my first postpartum check-up, when asked how I felt, I hesitated to admit feeling overwhelmed. Was it selfish to acknowledge my own struggles? No one reassured me it was acceptable.

Six months later, our move to CT/USA marked the beginning of my unraveling. Despite being surrounded by people, loneliness gripped me, and tears flowed inexplicably. Seeking solace, I visited the doctor for a routine check-up, only to find myself swiftly diagnosed with depression and prescribed antidepressants. This plunged me deeper into despair as I questioned my worth as a mother.

Simultaneously, I received the news of being diagnosed with type 2 diabetes. It felt as though my world was crumbling around me, compounded by the fact that I received no prior education or support regarding either condition. At just 25, I found myself grappling with immense challenges with no guidance to navigate them.

Looking back, I had solid overall support, but still found it challenging to balance everything. If education, empathy, and attentive physicians had been part of my experience, I believe it would have made my pregnancy journey much smoother and more enjoyable.

What I learned from that experience became valuable lessons for subsequent pregnancies. Additionally, customs and culture significantly influence whether our experiences are positive or negative. One prevailing issue I've noticed is the lingering guilt mothers feel if anything deviates from the norm during pregnancy and beyond. It's crucial for our societies to rally behind mothers, providing comprehensive support and advocating for healthy lifestyles, leading to exceptional experiences for moms, their children and family.

I felt that throughout, I had to advocate for myself and for my own wellbeing.

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Risk factors ??

Gestational Diabetes Risk Factors

• Age: Being over 25 years old - basically, many women planning to get pregnant.
• Overweight or obesity, especially when combined with low physical activity.
• History of gestational diabetes or delivering a baby weighing over 4 kg (8.8 lbs) (macrosomia) in previous pregnancies.
• High blood pressure or a history of heart disease.
• Diagnosis of polycystic ovarian syndrome (PCOS), a condition affecting hormone levels, reproductive, and overall health.
• Prediabetes, where blood glucose levels are elevated above normal but not high enough for a diabetes diagnosis.
• A family history of diabetes in close relatives (parent, sibling).
• Belonging to certain racial or ethnic groups, including Black, American Indian or Alaska Native, Asian, Hispanic/Latino, or Pacific Islander populations, which show higher diabetes prevalence.

The condition - GDM - stems from an inadequate insulin response, often due to pregnancy-specific factors like the action of a pregnancy-specific hormone, human placental lactogen, on insulin receptors, which disrupts normal glucose regulation.

?2:? What medical condition impacts 1 in 10 pregnancies?

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Gestational diabetes mellitus (GDM) is a type of diabetes that develops during pregnancy. It's more common than most think, affecting over 16 million pregnancies globally each year.

In the United States alone, around 8.3% of all pregnancies in 2021 were affected by GDM, representing a significant rise of 38% since 2016. This translates to about 298,800 American pregnant women and their offspring being affected by gestational diabetes. The increase in gestational diabetes was observed across all maternal age groups. However, mothers aged ≥40 years had a gestational diabetes rate of 15.6%, nearly six times higher than the rate for mothers aged <20 years, which was 2.7% (CDC ).

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GDM represents the most common medical challenge in pregnancy, with a notably higher risk among women who develop overweight or obesity. Yet, it's not exclusive to them; even women without a diagnosis of overweight or obesity can find themselves navigating this unexpected turn.

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2.1: Why should women, families, health advocates, government and employers care?

The stakes are high! GDM is linked to several adverse outcomes, including increased risks of hypertension, preeclampsia, cesarean delivery, and labor complications for the mother. Women with gestational diabetes (GDM) face heightened risks , not only during pregnancy but also postpartum including:

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• Long-term maternal risks include a 30%–70% GDM recurrence.

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• About 50% of women with gestational diabetes go on to develop type 2 diabetes within the first 15 years from childbirth. If you experienced gestational diabetes during your pregnancy, think of it as an important alert.

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GDM offers a golden opportunity to proactively protect your health against type 2 diabetes during the crucial early years after giving birth.        

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• Mental Health and Mental Fitness: GDM is linked to increased risks of depression and anxiety. The physiological changes including insulin resistance can affect the brain’s stress response system, potentially leading to symptoms of depression. Engaging in regular physical activity, adopting a healthy diet tailored to your needs, and accessing stress management resources are key strategies for mitigating these risks.

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• Complications during pregnancy and delivery. Poorly controlled gestational diabetes can lead to risks like preterm birth, C-sections, and high birth weight for the baby.

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• Hospital Readmissions. Certain complications such as high blood pressure, preeclampsia, and the need for cesarean delivery (C-section), which can lead to more hospital visits or readmissions.

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Amazingly sad but true: about 98 million American adults—1 in 3—have?prediabetes. 

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What’s more, more than 8 in 10 of people with prediabetes don’t know they have it.

American Diabetes Association        

2.2: What about the children? How are they affected by gestational diabetes and the associated lifestyle factors?

The implications of GDM extend to the next generation, with children born to mothers with GDM facing higher risks of macrosomia, obesity, insulin resistance, and eventually, T2DM in later life - with several studies showing they are at least five times more likely to develop impaired glucose tolerance. Specifically:

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• Obesity: Research indicates that children born to mothers with gestational diabetes are more likely to have obesity during childhood and adolescence. A study published in the journal “Diabetes Care” highlighted that by the age of 5 to 7 years, children of mothers with GDM had a 50% higher risk of obesity compared to those whose mothers did not have GDM.

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• Type 2 Diabetes: The risk of these children developing type 2 diabetes is also significantly elevated. The American Diabetes Association notes that the offspring of women with GDM face a substantially higher risk of developing type 2 diabetes, with studies suggesting that these children are almost six times more likely to develop type 2 diabetes themselves compared to children whose mothers did not have GDM.

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These risks are attributed to several factors, including the intrauterine environment influenced by high blood glucose levels during pregnancy, which can affect the baby’s metabolism and predispose them to these conditions. Moreover, genetic predispositions and shared lifestyle factors between parents and children, such as nutritious food availability, eating behaviors and physical activity levels, also play a crucial role.

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The HAPO Study , a landmark investigation involving over 25,000 women, highlighted a continuous increase in the risk of adverse maternal, fetal, and neonatal outcomes alongside rising maternal hyperglycemia levels, even within what was previously considered normal ranges.

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Gestational Diabetes is a pervasive condition that necessitates prevention. Empowering families with education and actionable strategies during family planning is essential.

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Dr. Boham highlights the alarming prevalence of GDM, emphasizing its significant transgenerational impact. “Actually, they say up to 10% of women have gestational diabetes,” she notes, underlining the condition’s commonality. She explains the direct consequences for both the baby and the mother, stating,

“Those offspring often have an increased risk of insulin resistance and diabetes and weight gain when they are adults ...it makes it harder for that baby to maintain a healthy weight when they’re an adult.”

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Investing in the prevention of gestational diabetes mellitus (GDM) is crucial. 

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Healthcare initiatives aimed at preventing GDM should start from preconception or even earlier, by incorporating relevant education into the curriculum.         

Because of its silent nature, often presenting without noticeable symptoms, GDM requires screening as a critical component of prenatal care. It’s aimed not just at managing hyperglycemia to improve outcomes but also at identifying women at heightened risk of developing type 2 diabetes later in life.

The diagnostic journey can begin with either the one-step oral glucose tolerance test (OGTT) recommended by the WHO after 24 weeks of gestation, or a two-step approach involving an initial oral glucose challenge test (OGCT). 

Mayo Clinic | 2024        

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Once diagnosed, the management of GDM focuses on medical nutrition therapy, glucose level checks, physical activity, and, usually depending on the pre-gestational BMI, weight management. “Blood glucose monitoring plays a vital role in the treatment and management of women who have developed gestational diabetes. Healthcare professionals use blood glucose values to check and adjust the effect of treatments, such as the effectiveness of diet and exercise and the dosage of medications.”? Regular blood glucose monitoring enables timely adjustments to treatment, aiming for specific fasting and postprandial glucose targets.

As gestational diabetes mellitus (GDM) rates rise globally, the importance of secondary prevention has become clear. Recognized health organizations such as the FIGO (International Federation of Gynecology and Obstetrics) highly recommend postpartum screenings. These screenings, advised 6–12 weeks after childbirth and periodically thereafter, help monitor for diabetes and cardiovascular risks in women who have had GDM.

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Additionally, secondary prevention also focus on the health of the offspring, aiming to prevent obesity and diabetes, highlighting the need for a proactive approach to family health.

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2.3: Health Equity, SODH, Races & Ethnicities

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Race, ethnicity, and obesity emerge as the most potent, independent risk factors in the development of gestational diabetes mellitus (GDM), revealing a complex interplay of genetic predispositions, environmental influences, and lifestyle choices. Recognizing these influences is key to developing precise prevention and management strategies.

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By the numbers:

• BMI alone is not an indicator of higher risk for GDM. The prevalence of GDM rises with an increase in BMI across all racial and ethnic groups. However, Asian and Filipina women exhibit a notably higher prevalence of GDM at lower BMI ranges compared to other groups.

• Even at lower BMI ranges (19.0–21.9 kg/m2), the prevalence of GDM is more than three times higher among Asian and Filipina women compared with non-Hispanic white and African American women.

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• Food culture plays a significant role in dietary habits, which can impact the risk of gestational diabetes mellitus (GDM). Diets high in refined sugars and carbohydrates, prevalent in some cultures, can increase the likelihood of obesity and GDM.

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• Strategies should prioritize early screening and emphasize addressing social determinants of health, which disproportionately affect the prevalence and impact of GDM among certain populations, including African American and Hispanic women.

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?? Recent research by Dr. Kartik K. Venkatesh and his team, published in JAMA , provides a detailed analysis of gestational diabetes (GDM) and its impact on pregnancy across different racial and ethnic groups in the U.S. from 2014 to 2020.

This study highlights the increased risk among Black and American Indian individuals with GDM, who are more likely to face severe complications such as preeclampsia, gestational hypertension, and the need for cesarean delivery compared to their White counterparts. ?? It also emphasizes how social determinants of health, such as access to quality healthcare, socioeconomic status, discrimination, bias, and neighborhood conditions, contribute to the higher rates and severity of adverse pregnancy outcomes observed among these populations.

Having access to nutritious food, engaging in physical activity, and receiving quality healthcare are key factors in managing health. The differences in gestational diabetes mellitus (GDM) rates among various racial and ethnic groups go beyond genetic predisposition.

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Social determinants of health, such as economic status, healthcare accessibility, and educational attainment, play a crucial role in these variations. For example, a lack of available nutritious food or prenatal healthcare services can increase the likelihood of developing GDM.

"Food insecurity is also associated with increased risk for developing gestational diabetes, greater gestational, weight gain, and pregnancy complications."

The White House  ????
B L U E P R I N T  F O R  A D D R E S S I N G T H E  M A T E R N A L  H E A L T H C R I S I S
2022        

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Why is this relevant?

Understanding these trends and disparities is crucial for developing better ways to manage GDM and improve outcomes for all pregnant individuals, especially considering the increasing diversity in the U.S. and global populations.

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Clinicians should be aware that the BMI thresholds for increased risk of GDM varies by racial/ethnic group and that the risk is high even at relatively low BMI cutoffs in Asian and Filipina women. ?? Asian women may benefit from different prevention strategies in addition to weight management.

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Current GDM care standards apply universal screening and diagnostic criteria across all racial and ethnic groups, despite evidence suggesting racial and ethnic disparities in GDM prevalence and pathogenesis. ??

How might healthcare outcomes change if it truly considered everyone's unique backgrounds and unmet needs?

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Let me introduce you to Dr. Miriam Zylberglait (Dr.Z) ?? , affectionately known as Dr. Z. As a physician who began her career in Peru, Dr. Z has made significant strides in the medical field, both in her home country and in the United States. triple Board-Certified Physician in Internal Medicine, Geriatrics, and Obesity Medicine and the Founder of Virtual Wellbeing MD - Dr. Z .

Her journey is marked by resilience and dedication, particularly during her residency training when she discovered she was pregnant with her first child at 40. Despite facing the dual challenge of a demanding medical career and a diagnosis of gestational diabetes, Dr. Z balanced her responsibilities with grace and determination. It's this blend of professional excellence, integrity, compassionate care, and personal resilience that makes Dr. Z an inspiring figure in the world of medicine.

3: What You Told Us?

3.1: GDM Impact | Unmet Women’s Health Needs when Having a Child

So far, our capstone research has involved review of American Diabetes Association Standards of Care , and more than 30 difference medical studies, as well as conversations with industry leaders, chief medical officers, surveys and interviews individuals personally affected by gestational diabetes.

More than 50 women responded to our survey or 1:1 interview, most of them were working during their pregnancy journey. We are grateful and honored to listen and learn from their pregnancy stories, providing comprehensive insights on the unmet needs and challenges encountered during the journey of gestational diabetes.? Through interviews, survey and external clinical studies, we uncovered care gaps in women’s physical, emotional, and mental healthcare lived experiences.?

Key unmet needs insights from our recently conducted multi-regional survey and interviews, as well as statistically significant surveys from reliable sources, are as follows:

1?? Medical, Care Coordination, Eating and Lifestyle:

• Prevention of GDM and type 2 diabetes is challenged by a lack of relevant mind-body healthcare knowledge from preconception to postpartum.

• Lack of standardized treatment protocols leads to some women being untreated post-diagnosis.

• Gaps in care coordination include delayed referrals and long intervals between consultations as well as postpartum abandonment .

• Dietary misconceptions and lack of guidance add to the challenges in managing GDM.

• Care Coordination: A notable gap in integrated mind-body care is evident in the survey respondent feedback, and multi-country studies. Women report delayed referrals and difficulty in coordinating care with specialists, disregard to their emotions, alongside long intervals between medical consultations.

• Lifestyle and Food: Dietary management is crucial for GDM prevention and care. Misconceptions about nutrition during pregnancy and information overload without adequate guidance on managing GDM, including dietary recommendations and potential complications of increasing carbohydrate intake during pregnancy.

While 78% of respondents agree or strongly agree that they felt supported by healthcare professionals throughout pregnancy, only 62% believe they had consistent healthcare support throughout the entire pregnancy journey, including postpartum care.

86% of respondents agree or strongly agree that having a care coordinator for mental health monitoring, nutritional guidance, diabetes management, and overall care consistency would be desirable and expected to improve their family's mind-body health.

43% would be willing to pay for a personalized care plan and integrated services.

2?? Mental Fitness & Emotions:

• Emotional Support Needs: Women experience neglect of mental health throughout gestation stages. When mental health was neglected, anxiety, fear, guilt, and feelings of being unsupported are common.

• The absence of regular mental health and fitness check-ins, lack of emotional support, and safe spaces for emotional expression exacerbate diabetes-related distress. Mental fitness care must be a standard component of prenatal and postpartum care.

• Higher risk of postpartum depression reinforces advantages of offering integrated body-mind health support.

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• Cultural and Racial Sensitivity: Instances of insensitivity impacting care quality, lacking culturally appropriate care co-designed with communities.

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Consequences ascribed to GDM-specific discrimination and stigma by the women include avoidance of screening/testing, both during and after pregnancy; not reporting on blood glucose readings; disordered eating; not wanting more children; stress; social isolation; loneliness and not prioritizing own health after pregnancy.


Extracted from 'The stigma associated with gestational diabetes mellitus: A scoping review'

Emma Davidsen, Helle Terkildsen Maindal, Morten Hulvej Rod,Kasper Olesen, Molly Byrne,Peter Damm,and Karoline Kragelund Nielsena.        

• Most women reported feeling thrilled and joyful at the beginning of their pregnancy. The unmet care comes as the pregnancy evolves, whereas initial positive emotions about pregnancy often give way to fear when GDM is present.

Women often demonstrate remarkable resilience, with 47% of surveyed women stating they were able to maintain their professional goals and performance despite the emotional challenges - with only 14% heavily impacted. ?

3?? Physical Activity:

• Lack of engagement in physical activity is noted among many patients with GDM, either due to a lack of established habits, cultural norms, or complications associated with pregnancy.

Many women reported using mindfulness, meditation, and physical activity as pathways to help them cope with the emotional roller coaster experienced during pregnancy, also helping them to build connections for life.

Practices like yoga, dance, and walking were commonly reported as effective methods to manage stress and maintain emotional balance.        

Meet Dr. Lisa Flexner, PT, DPT, FAAOMPT , our collaborator for this 'Health at Work' edition. I asked Lisa for her insights on physical activity as part of GDM prevention and management. Lisa is a physical therapist and consultant in Oregon and a fellow in the American Academy of Orthopedic and Manual Physical Therapy. She previously taught as a clinical assistant professor at Oregon State University of Health in the Doctor of Physical Therapy and Kinesiology and Exercise Science programs.

Let's debunk myths about exercising during pregnancy.

Lisa emphasizes that exercise—whether it's cardio, strength training, or a combination of both—can significantly improve blood sugar levels, which is particularly relevant for women at risk of or with GDM, and may reduce or even eliminate the need for insulin.

??How can family members, friends and spouses actively support and join regular exercise during pregnancy to ensure better health outcomes for both the mother and the baby??

4?? Workplace:

• There were mixed responses regarding employer support suggesting an opportunity to rethink pregnancy-friendly workplace policies.

?? Employers be curious about why high performing talents - pregnant women and new parents are not returning to work, or returning but soon becoming disengaged or isolated.

• Workplace Pressures: Amidst interview and survey responses we noticed a pattern: pressure from employers about returning to work postpartum and the challenges of balancing work demands with the desire to be with the baby emphasize the need for flexible and supportive workplace policies.

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5?? Financial, Practical and Social Support:

• The willingness to pay for personalized care plans indicates a sensitivity to cost, hinting at the role of insurance coverage in improving care access and coordination.

• The strong agreement on the benefits of a coordinated care platform suggests a demand for integrated care solutions that encompass mental health resources and care coordination.

• Family Dynamics and Education: The lack of support and understanding from family members about postpartum depression and GDM management underscores the importance of family education on postpartum support and ongoing education for mothers on managing their health postpartum.

• Community and Financial Support: Establishing and nurturing community relationships can offer additional support and resources for new mothers.

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Addressing these unmet needs requires a holistic, culturally sensitive approach that encompasses patient education, emotional and mental health support, practical assistance, and adaptations in the workplace and healthcare settings.

And, by tailoring body-mind integrated support to meet these diverse needs, healthcare providers can improve outcomes for women at risk of or with GDM, enhancing both maternal and neonatal health.

3.2: Insights from industry leaders and health experts.

Similar to uncovering unmet patient needs, when exploring the concept of integrated care coordination through discussions with industry leaders and healthcare experts, I identified gaps and roadblocks that helped refine the approach:

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1?? Care Coordination Needs: Stakeholders agree that more focus is needed on lifestyle adjustments and clinical check-ups from the outset of preconception to prevent GDM. Mental health support and further research into GDM care pathways are also critical.

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2?? Nutritional Guidance Debate & Research Gaps: There's a call for revisiting the dietary recommendations , especially around carbohydrate intake levels. ? By revisiting and potentially revising dietary recommendations, keeping up with new technologies to monitor how each patient responds to different foods, healthcare providers can offer more effective, personalized guidance for managing GDM.

Other research gaps include: impact of adding mental health support as part of care coordination for gestational diabetes, variation of risk factors per race and ethnicity impacting strategies to test and diagnose GDM , as well as effectiveness and safety of various GDM medications (e.g., comparing oral agents to insulin) and delivery management strategies (e.g., induction vs. expectant management) to identifying risk factors and strategies for preventing type 2 diabetes in women with a history of GDM.

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3?? Early Intervention: The rising GDM cases , paralleled with an uptick in obesity and insulin resistance – impacting mom and babies was highlighted during conversations with healthcare experts. They emphasize the importance of preventive and prompt measures, starting from pre-pregnancy stages.

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4?? Profitability vs. Necessity: Care coordination, especially in diabetes care, is more than a necessity—it's a strategic choice that can save costs significantly.

While not always lucrative upfront, care coordination averts the need for expensive medical treatments. Since diabetes management costs are about 2.6 times higher than for those without diabetes, focusing on integrated care not only benefits health outcomes for mothers and children but also represents a financially savvy approach to employer and healthcare stakeholders.

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5?? Payment and Integration Challenges: Incorporating new services into existing healthcare systems is not just complex but also struggles with sustaining interest amidst "point solution fatigue" — a growing weariness towards isolated healthcare solutions. A focused strategy on seamless tech integration, especially with EMRs, can alleviate operational challenges and refresh interest by offering comprehensive, user-friendly solutions.

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6?? Community Engagement: There's a significant gap in building supportive communities within existing healthcare solutions due to concerns about monitoring exchange of misinformation, and sustainability.

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Our response to these challenges involves developing a care plan framework that addresses these unmet needs and obstacles, setting the stage for strategic partnerships and holistic digital platform development that fits within existing ecosystems for family planning, diabetes prevention and women’s health. These strategies aim to enhance patient engagement, ensure privacy and security, and harness AI's potential for predictive care.

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?? Strategic Partnerships: Collaborating across the healthcare spectrum can offer personalized care and align with quality-centric healthcare models, despite potential coordination complexities.

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?? Holistic People-Centric Platform: A digital solution could offer a comprehensive view of patient health and foster community, though according to industry leaders, it requires overcoming tech-savviness barriers and securing data privacy.

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?? Empowering Care: Education and collaboration with providers and family engagement, empower women, supporting preventive care strategies to minimize hospital revisits and uncontrolled glucose levels.

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To truly make an impact, our strategies will focus on dynamic monitoring, empowering patients with knowledge, and ensuring a network of support is always communicating and within reach. ?? This approach is not without its barriers, including data privacy concerns, cultural stigmas , and the need for broad buy-in and engagement across all stakeholder groups.

Among amazing purpose-driven entrepreneurs in women's health, I had the privilege of talking with Joe Connolly , CEO of Visana Health , and their CMO, Barbara Levy, MD, FACOG, FACS . Dr. Levy shared her vast wisdom and challenged me to look beyond the pregnancy stages when scoping coordinated care for GDM, starting from preconception.

And, Joe and I have been collaborating for a while, and for this edition of 'Health at Work' he shared,

We've had patients discover they are pre-diabetic or diabetic when they come to Visana looking to get pregnant. Identifying and treating insulin resistance and pre-diabetes before pregnancy is crucial to preventing gestational diabetes.

4: Care Coordination for Gestational Diabetes

What does it mean? Our HMS GHLP capstone, a novel approach.

With 16 million pregnancies worldwide impacted by gestational diabetes (GDM) annually, the urgency for effective care coordination across the healthcare continuum becomes evident. This concept, fundamental in enhancing patient experiences and outcomes, transcends beyond mere teamwork and technology integration. It's about forging a path where patient preferences enlighten care delivery, backed by the sharing of knowledge and establishing accountability among healthcare providers, women, and potentially family members.

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Adopting a holistic lens, similar to managing non-communicable diseases (NCDs), GDM's management necessitates a vigilant eye on both mental and physical health aspects. Leveraging design thinking principles, our approach to crafting high-tech, high-touch care solutions for those at risk of GDM begins with understanding the journey from preconception through to postpartum.

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How to start?

To craft an effective high-tech, high-touch care model for individuals at risk of gestational diabetes, I have harnessed design thinking principles, breaking down the process into clear, actionable steps:

1?? Stakeholder Mapping: Identify everyone involved - patients, doctors, insurers, and family members. Understand what they need and expect from the care process.

2?? Problem Identification: Pinpoint challenges across the care journey, from preconception to post-partum. Use interviews and surveys to gather deep insights from stakeholders.

3?? Solution Linking: Match problems with potential solutions for comprehensive care. For instance, if patients express difficulty tracking glucose levels, consider a user-friendly app solution.

4?? Solution Evaluation: Assess if the solutions are viable, feasible, and desirable. Ensure they align with stakeholders' needs.

5?? Market Assessment: Rank solutions based on their market impact and relevance, assess gaps. Focus on high-value options.

6?? Service Scope Evaluation: Examine and refine care stages, ensuring a seamless journey from pre-pregnancy to postpartum.

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An "Aha" moment led me to rethink the service scope, starting from pre-conception, or even earlier if considering high-school settings. ?? The profound potential of preventing GDM from the outset—for the wellbeing of both mother and child—cannot be overstated.

Empowering women through dynamic and personalized education, mental-physical fitness, and comprehensive social and clinical support during preconception stages is crucial for their overall wellbeing and successful pregnancy outcomes.

7?? Service Categorization: Group coordinated services by care stages for better management. This helps in organizing the solutions based on where they fit in the patient's journey.

In conversations with Dr. Margarita R. Ochoa-Maya, MD , a leading expert in the field of endocrinology and diabetes management. With a robust background in clinical practice and a passion for integrating modern technology with traditional healthcare methods, Dr. Ochoa-Maya is dedicated to improving patient outcomes through innovative approaches.

When considering the prevention of gestational diabetes, digital transformation can enhance the doctor-patient relationship by providing timely information, education, and care coordination to improve outcomes,[...]

Dr. Margarita R. Ochoa-Maya, MD highlights that devices like Continuous Glucose Monitors (CGMs) offer real-time glucose level data, crucial for detecting and managing GDM at its onset. Additionally, technologies such as the ōURA Ring monitor physical activity, sleep, and stress, contributing to a comprehensive health profile. Dr. Ochoa-Maya emphasizes,

"Integrating CGMs into care plans not only improves the doctor's ability to manage GDM but also heightens patients' awareness of their daily health choices."

She concludes that the goal is...

"to empower patients, enhance communication with providers, and utilize every available tool to ensure a healthy pregnancy and beyond."

8?? Set Personalized Care Standards: Create a framework for care that's tailored to individual needs.

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9?? Develop and Test Solutions: Prototype services or tools, then refine them based on user feedback. Begin with a small group test to refine concepts efficiently.

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1??0?? Ensure Compliance: Address legal and regulatory requirements to protect patient data.

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1??1?? Seamlessly Integrate: Make sure the new model fits smoothly into existing healthcare systems.

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1??2?? Plan for Implementation: Draft a detailed rollout strategy, including provider training.

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1??3?? Measure Impact: Define metrics to assess quality, access, experience, effectiveness of care, building upon evidence-based approach, and use this data for continuous improvement.

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1??4?? Assess Finances: Evaluate the financial viability and explore revenue models, such as insurance partnerships.

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1??5?? Build Community: Establish a support network with resources and peer groups for patient empowerment.

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1??6?? Prepare for Scale: Develop a plan to broaden the model's impact, aiming to improve maternal and women's health on a larger scale.

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Our vision for advancing women's health includes a tech-enhanced, whole-person dynamic care coordination service for GDM, built on three pillars: ? personalized care plans tailored to individual GDM care needs, ? supportive community networks, and ? empowering dynamic educational initiatives.

These pillars are designed to cater to the unmet needs of individuals at risk for GDM, fostering a holistic, value-based care model.

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Key participants in this journey include patients, caregivers, healthcare professionals, pharmaceutical entities, health insurers, and esteemed organizations like the American Diabetes Association . Our foundational strategy emphasizes personalized GDM management that integrates mental health resources and leverages advanced technology, including AI and predictive analytics, to address mental health challenges proactively associated with diabetes.

I'm thrilled to introduce Dr. Ana Luísa Neves , a remarkable physician from 英国帝国理工学院 who became a cherished friend. Ana and I were classmates in the Harvard Medical School Global Healthcare Leader Executive Program, where we bonded as part of the Portuguese-speaking team. Her insights and expertise have always been invaluable, and she recently shared a thoughtful perspective on managing gestational diabetes.

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5: Path Forward: Employers & Healthcare solutions

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Decision makers play a critical role in advocating for their employees' health. Targeted and evidence-based support can address financial and non-financial multigenerational risks of gestational diabetes mellitus through integrated programs that address dynamic knowledge sharing, and mind-body care coordination for prevention and treatment.

All women need access to high-quality care in preconception, pregnancy, and during and after childbirth. Implementing an integrated approach, as discussed in prior chapters, involves actionable steps for employers and healthcare providers that go beyond technological advancements in fertility. Here are some best practices:

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Awareness ??

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?? Identifying At-Risk Employees: Employers can influence healthcare stakeholders—including TPAs, PBMs, payers, and providers—to utilize health analytics for launching targeted mind-body health intervention nudges and campaigns.

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?? Health Screenings Advocacy: Launch campaigns promoting regular health screenings that include tests for pre-diabetes, especially for employees planning a family.

These initiatives may focus on employees planning to have children, postpartum with GDM, and those at higher risk for GDM, emphasizing early interventions and routine screening for GDM risk factors. Factors to consider include family history, BMI, age, and previous history of GDM. Additionally, the approach should address the relationship with food and incorporate personalized body-mind care pathways.

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?? Tech-Enabled Health Monitoring: Consider partnering with vendors that integrate health apps and wearables for continuous health monitoring, targeting preconception and prenatal periods for early detection and management of GDM.

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Actionable Education ??

?? Family Planning offerings to empower employees - all genders - with actionable insights to prevent and care for GDM.

Facilitate access to dynamic knowledge via AI empowered tools validated by your healthcare provider, as well as education sessions and workshops incorporating reducing the risk of GDM, and management as part of family planning, integrating medical checkups, mindful and intuitive eating behaviors, nutritional and physical activity guidelines tailored for preconception, pregnancy and postpartum.

?? Peer Support and Expert-Led Groups: Create support groups moderate by healthcare providers to foster a community of learning and mutual support among employees, specifically addressing the challenges of GDM.

?? Integrative Mental Health Solutions: Incorporate education on the interplay between diabetes and mental health, highlighting the importance of emotional support and providing access to counseling services.

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What if?

We prioritized selecting mental healthcare professionals based on their expertise in guiding individuals through the full spectrum of maternal health—from pre-conception to postpartum, including managing obesity and diabetes?

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?? Tailored Nutrition Plan and Education: Offer specialized experiential-learning programs that address the unique dietary needs of individuals at risk of or with gestational diabetes.

Understanding the impact of certain foods by monitoring glucose levels in response to eating is essential for effectively managing gestational diabetes.

Collaborate with Health Plans and Diabetes/Mental Health Solutions. Partner to offer interactive workshops on intuitive and mindful eating for women planning to conceive, especially those at risk for or affected by GDM.

• Tailored Content for GDM: Address the unique needs of those impacted by gestational diabetes.
• Utilize AI-empowered Knowledge: Provide personalized, AI-driven educational resources.
• Focus on Emotional and Psychological Aspects: Highlight the emotional and psychological facets of eating.
• Practical Tools for Informed Action: Equip participants with actionable strategies for healthy eating behaviors.

These dynamic educational efforts aim to empower women with the knowledge and skills to manage their dietary needs confidently, improving mental and physical health during pregnancy and beyond.

?? Employee-Centric Communication. Make it easy for employees to find out what is available to address specific needs of those being impacted by Diabetes. This includes adopting intentionally inclusive language .

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When it comes to supporting women through the complexities of pregnancy, Dr. Mohammad Mahboob Siddiqui's diverse and multi-cultural expertise is invaluable. As the founder and director of Health Coaching and Innovative Consultancy (HCIC) Vision Inc., Dr. Siddiqui brings over 25 years of diverse experience in healthcare, including roles as a physician, radiologist, clinical educator, and product manager.

His passion for health and wellness coaching was evident during our conversations, Dr. Siddiqui’s insights highlight the importance of education and early intervention. By raising awareness and providing personalized support, we can ensure a healthier future for both mothers and their children. His unique approach combines medical expertise, coaching techniques, and corporate insights, all aimed at guiding individuals toward optimal wellbeing.

Support and Care ??

?? Pregnancy-friendly workplace policies & Flexible Work Arrangements: Beyond paid family leave, consider offering hybrid or remote work options. This can help employees prevent and manage GDM by giving them easier access to healthier choices, exercise, and stress management strategies. Companies are acknowledging that, aside from the medical aspect, new parents' entire life has changed.

Women at risk of developing GDM often require additional medical appointments which may necessitate flexible working hours and time off from regular working hours. Employers should accommodate these needs to ensure both employee and child's health are prioritized, and in return, observe higher engagement and lower attrition rate.

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During the COVID-19 pandemic, I was empowered by our CHRO Diane Gherson , along with Nickle LaMoreaux and Joanna Daly , to address the unmet needs of parents within our workforce. We went beyond traditional leaves, flexibility, fertility care, and healthcare by implementing comprehensive caregiving services for both children and parents. Additionally, we rethought our communication strategies to focus on employees' life experiences and unmet needs, rather than merely sharing information about available offerings.

One of the most gratifying outcomes was learning that our people-centric approach resonated even with those who didn't directly use the services. For example, a new hire engineer expressed pride in joining IBM because of our efforts, despite not needing the services herself. Remarkably, our employee engagement survey scores rose by 4 basis points, even amidst the challenges of the pandemic. "These initiatives brought me joy," I recall, "seeing the positive impact on our employees' lives and wellbeing."

?? Tailored Health Benefits: Enhance family building offerings and broader health plans to include comprehensive evidence-based coverage for gestational diabetes mellitus (GDM) – prevention and treatment.

Offer actionable preventive support and testing and treatment that encompasses the continuum from during family planning through postpartum, ensuring mothers and newborns are set up for success, and keeping their health in check.

This should involve personalized monitoring of integrated care plans, specialized counseling in mind-body nutrition, and access to endocrinologists and GDM-trained health coaches, along with other essential specialists. Workplace support for continued care and monitoring is essential.

• Simplify the monitoring of biomarkers by adopting wearable technology that seamlessly integrates relevant data into the care coordination system.

• For women with GDM or pre-existing diabetes, pre-conception counseling and planning are crucial and should be supported by employers to ensure better health outcomes in pregnancies.

• Post-delivery, women should monitor risk and receive support for breastfeeding, which has been shown to reduce the progression from GDM to type 2 diabetes.

• After childbirth, it's important for women to continue with health monitoring, mindful eating, and exercise to manage GDM's long-term risks.

?? What is the financial cost of developing diabetes?

Care for people diagnosed with diabetes accounts for 1 in 4 health care dollars in the U.S., 61% of which are attributable to diabetes. 


Economic Costs of Diabetes in the U.S. in 2022

Emily D Parker , Janice Lin, Troy Mahoney, Nwanneamaka Ume, Grace Yang, Robert A Gabbay , Nuha A ElSayed , Raveendhara R Bannuru        

?? Affordable Care Solutions: The cost is a barrier to accessing care, as indicated survey respondents. Employers that provide and clearly communicate coverage for GDM-related services to families at risk can significantly enhance access to essential mind-body preventive care.

How can employers make diabetes prevention and care more affordable, perhaps by offering subsidies or discounts for essential care products, food and medications? Why prioritize? The American Diabetes Association reports that people with diabetes incur an average of $19,736 per year in medical expenses, with about $12,022 attributed directly to diabetes care?

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?? Access to Specialized Care: Ensure employees have access to telemedicine and specialized care for GDM, making it easy for them to receive timely consultations and interventions while avoiding commuting time.

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?? Healthy Workplace Environment: Create a conducive environment for health, offering on-site and virtual spaces for relaxation, mindfulness, mindful and intuitive eating practices along with targeted insights on nutrition, and physical activity that can aid in GDM management.

?? Inclusive Nutrition Options: Ensure that workplace food options include GDM-friendly choices, and using best practices in mindful and intuitive eating encourage healthy eating habits that support blood sugar management.

? Click HERE to access a comprehensive view of 'Diabetes at Work' solutions that have been successfully implemented in corporate settings.

Go to '3?? Proactive Employers & Healthcare Solutions'

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? Click HERE to access a comprehensive view of 'Women’s Health’ solutions that have been successfully implemented in corporate settings.

Go to 'Health-Equity: Employers can take measurable action'?

? Click HERE to access a comprehensive view of 'Mental Fitness’ solutions that have been successfully implemented in corporate settings.

Have you ever wondered how holistic care can transform the management of gestational diabetes? I had the privilege of discussing this with Robin Martinez, FNP-BC, CDCES , the dedicated force behind Axis Holistic Care. Robin is not only a board-certified Family Nurse Practitioner but also a Certified Diabetes Care and Education Specialist (FNP-BC, CDCES). Our conversation covered her extensive experience, stories, and the profound impact of a multidisciplinary approach on improving health outcomes for those diagnosed with gestational diabetes.

Robin also highlighted the importance of early intervention, stating,

A brief assessment of pregnancy plans during the history and physical followed by a few minutes of patient education would begin the process. For example, 'Do you plan to become pregnant within the next 6 months or year?' If the answer is yes, and the patient has risk factors for GDM, such as obesity or family history, this is the opportunity for the provider to discuss healthy eating patterns and health risks associated with obesity and GDM during pregnancy.

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What comes to mind when you think about pregnancy? For many, the answer is fertility. Yet, gestational diabetes often remains overlooked in discussions about pregnancy. Its impact can be daunting for both mothers and their babies, affecting long-term health outcomes.

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Consider the story of one woman from our interviews and survey responses. She was overjoyed when she discovered she was pregnant, but that joy quickly turned to worry with her GDM diagnosis. She felt overwhelmed, shamed, and unsupported, unable to access meaningful help. ?

Her spouse was not included in the family education and was not onboarded on new eating and exercise habits that could benefit both mom and baby. Years after childbirth, she developed type 2 diabetes, and their offspring struggles with obesity.

Does this resonate? Her experience is a stark reminder of the gaps in our current healthcare system and societal norms.

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Women diagnosed with GDM often encounter significant gaps in functional knowledge, consistent monitoring, and emotional support. This fragmentation in per body-parts care escalates risks such as mental health challenges and gestational complications. Without integrated care, approximately 50% of GDM cases will continue to progress to type 2 diabetes after childbirth. And, their children to be at a significantly increased risk for obesity and type 2 diabetes, with a fivefold greater likelihood of developing impaired glucose tolerance.?

In sum, our capstone research identified several actionable steps for individuals, healthcare payers, providers, and employers to address the challenges of GDM. These include advocating for early screening, integrated, and personalized care. Nutritional and lifestyle education, focusing on intuitive and mindful eating adapted to specific needs of individuals at risk of developing GDM, physical activity, and glucose monitoring, can empower women to manage their health. Integrating mental fitness resources into prenatal and postpartum care is crucial for emotional support. Additionally, leveraging AI-powered tools and wearable technologies like CGMs or ōURA Rings can provide continuous body-mind health monitoring and personalized feedback.

To help prevent or manage GDM, employers have a crucial role in supporting pregnant employees by fostering a pregnancy-friendly workplace culture. This includes being aware of the risks associated with GDM, advocating for personalized education and early health screenings, providing access to nutritional -body-mind integrated health resources, and ensuring flexible work arrangements.

Thank you for being part of this vital journey! Imagine a world where every pregnant woman has access to these resources. A world where no woman has to navigate the complexities of GDM alone. How will we, as a community, rise to the challenge of transforming these insights into actions that not only support pregnant women but also ensure healthier outcomes for mothers, families and their children?

A heartfelt thank you to all collaborators on this edition of 'Health at Work,' and especially to the women whose stories of navigating GDM have sparked our curiosity and compassion. Your experiences motivated us to dig deeper to uncover unmet needs, evaluating solutions that lead to a more integrated and targeted coordinated care model.

I deeply admire the strength and determination that women show in balancing their personal and professional lives during the complexities of pregnancy. But they are not alone. ? With proactive support from spouses, friends, family, employers, and society, women can find the safe spaces they need to care for themselves and their families, allowing them to truly thrive.

The consequences on women's wellbeing and mental health, and baby's health were at the core of much of this 'Health at Work'. With your support, we are ready to transform this novel integrated care approach into action, championing a future where every mother receives the coordinated, meaningful, effective, and compassionate care she truly deserves.

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Call for Action ?

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Here is the link to the Trekking For Kids, Inc. page for Mozambique ????

https://www.trekkingforkids.org/trekker_resources.php?id=905

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Sources ??

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1. American Diabetes Association: Gestational Diabetes Mellitus (GDM) .
2. Centers for Disease Control and Prevention (CDC): Diabetes During Pregnancy
3. Mayo Clinic. Gestational Diabetes
4. A scoping review of gestational diabetes mellitus healthcare: experiences of care reported by pregnant women internationally
5. The stigma associated with gestational diabetes mellitus
6. Gestational Diabetes Mellitus: Long-Term Consequences for the Mother and Child Grand Challenge: How to Move on Towards Secondary Prevention?
7. Pregnancy as an opportunity to prevent type 2 diabetes mellitus: FIGO Best Practice Advice
8. Gestational Diabetes and Postpartum Care California Department of Public Health
9. Women with gestational diabetes mellitus want clear and practical messages from credible sources about physical activity during pregnancy : a qualitative study
10. Bridging Gaps and Understanding Disparities in Gestational Diabetes Mellitus to Improve Perinatal Outcomes
11. Risk of Adverse Pregnancy Outcomes Among Pregnant Individuals With Gestational Diabetes by Race and Ethnicity in the United States, 2014-2020
12. Racial/Ethnic Disparities in the Prevalence of Gestational Diabetes Mellitus by BMI
13. Management of Diabetes in Pregnancy: Standards of Care in Diabetes—2024 and Gestational Diabetes Standards
14. A Comprehensive Review of Gestational Diabetes Mellitus: Impacts on Maternal Health, Fetal Development, Childhood Outcomes, and Long-Term Treatment Strategies
15. The top 10 research priorities in diabetes and pregnancy according to women, support networks and healthcare professionals?

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Disclaimer ??

This is a non-exhaustive list of health solutions. If you would like to discuss potential solutions tailored to your population, please get in touch.

All information posted on this article is merely for educational and informational purposes. It is not intended as a substitute for health professional advice.

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