Community-based pre-pregnancy care programme improves pregnancy preparation in women with pregestational diabetes

Abstract

Aims/hypothesis Women with diabetes remain at increased risk of adverse pregnancy outcomes associated with poor pregnancy preparation. However, women with type 2 diabetes are less aware of and less likely to access pre-pregnancy care (PPC) compared with women with type 1 diabetes. We developed and evaluated a community-based PPC programme with the aim of improving pregnancy preparation in all women with pregestational diabetes. Methods This was a prospective cohort study comparing pregnancy preparation measures before and during/after the PPC intervention in women with pre-existing diabetes from 1 June 2013 to 28 February 2017. The setting was 422 primary care practices and ten National Health Service specialist antenatal diabetes clinics. A multifaceted approach was taken to engage women with diabetes and community healthcare teams. This included identifying and sending PPC information leaflets to all eligible women, electronic preconception care templates, online education modules and resources, and regional meetings and educational events. Key outcomes were preconception folic acid supplementation, maternal HbA 1c level, use of potentially harmful medications at conception and gestational age at first presentation, before and during/after the PPC programme. Results A total of 306 (73%) primary care practices actively participated in the PPC programme. Primary care databases were used to identify 5075 women with diabetes aged 18-45 years. PPC leaflets were provided to 4558 (89.8%) eligible women. There were 842 consecutive pregnancies in women with diabetes: 502 before and 340 during/after the PPC intervention. During/after the PPC intervention, pregnant women with type 2 diabetes were more likely to achieve target HbA 1c levels ≤48 mmol/mol (6.5%) (44.4% of women before vs 58.5% of women during/after PPC intervention; p = 0.016) and to take 5 mg folic acid daily (23.5% and 41.8%; p = 0.001). There was an almost threefold improvement in 'optimal' pregnancy preparation in women with type 2 diabetes (5.8% and 15.1%; p = 0.021). Women with type 1 diabetes presented for earlier antenatal care during/after PPC (54.0% vs 67.3% before 8 weeks' gestation; p = 0.003) with no other changes. Conclusions/interpretation A pragmatic community-based PPC programme was associated with clinically relevant improvements in pregnancy preparation in women with type 2 diabetes. To our knowledge, this is the first community-based PPC intervention to improve pregnancy preparation for women with type 2 diabetes. Data availability Further details of the data collection methodology, individual clinic data and the full audit reports for healthcare professionals and service users are available from https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/ourclinical-audits-and-registries/national-pregnancy-in-diabetes-audit.

Pregnancy outcomes for women with pre‐pregnancy diabetes mellitus in Australian populations, rural and metropolitan: A review

“…Neonatal intensive care admission was close to 10% in recent moderately sized Australian cohorts . When including special care admission, the rate was 58% in Australia, and close to 50% in other parts of the world …”

“…Type 2 DM is increasingly recognised as an important risk factor for poor pregnancy outcomes and is becoming more common. Diabetes type for women giving birth between 2007 and 2017 was type 2 for 12 787 participant women and type 1 for 23 664 participant women; thus, more than one in three women had type 2 DM . The comparable numbers of participant women with type 1 and type 2 DM were 15 407 and 1662 for publications about births between 1987 and 2006; thus in this earlier era, fewer than one in ten women with diabetes were reported as having type 2 .…”

“…Only two studies report greater than the expected 10% of infants have birthweight <10th centile (SGA): 15.9% and 12.9% . Eighteen other studies showed SGA at expected or lower than population rates …”

“…Pre pregnancy care has been variably defined by asking women if the pregnancy was planned, whether they had consulted a general or specialist health practitioner or achieved other aspects of optimal preparation . The majority of papers included HbA1c as a measure of preconception glycaemic control . Others relied on clinical notes about the purpose of outpatient consultations or whether a pregnancy was planned .…”

“…Markedly, high rates of pregnancy planning have been reported for some European women with type 1 DM: 66% in Finland and 84% in the Netherlands . In contrast, prior to implementation of a preconception community care program in the north of England, only 5.8% of women with type 2 DM were considered to have optimal pregnancy preparation, defined as taking folic acid, not taking harmful medications (such as angiotensin converting enzyme inhibitors or statins), optimal first trimester HbA1c and pregnancy booking at less than eight weeks of amenorrhoea …”