Preconception care and women with or at risk for diabetes: implications for community intervention

A Scoping Review of Barriers and Facilitators for Preconception Care: Lessons for Global Health Policies and Programs

Preconception care (PCC) encompasses a set of actions taken before pregnancy to support the health and well-being of women before conception to improve maternal and child health (MCH) outcomes. The utilization of PCC services is influenced by multifaceted factors that can either enable or impede women's capacity to access and utilize them effectively. This scoping review examined the barriers and facilitators influencing the utilization of PCC services among women of reproductive age (15-49 years) at both individual and community levels. Through an extensive review of published articles from 2004 to 2021, including peer-reviewed sources, barriers and facilitators were identified. At the individual level, barriers included limited knowledge about PCC, neglect of self-health, and financial constraints. Community-level barriers encompassed insufficient supply of supplements, restricted access to health care, high health care costs, and setbacks due to delayed delivery of MCH services. Conversely, individuals reported that credible sources of information, such as friends, family, and community health volunteers, facilitated their engagement with PCC services. At the community level, facilitators included government-regulated supply chains for supplements and the involvement of community workers in health monitoring. Understanding and addressing these factors can help improve the utilization of PCC services among women of reproductive age (WRA) and improve MCH outcomes.

Reproductive care in Thai women with diabetes mellitus: a descriptive cross-sectional study

BACKGROUND

Pre-existing diabetes mellitus (DM) is a challenging pregnancy complication as poor glycemic control is associated with adverse maternal and fetal outcomes. In this study, we aimed to investigate DM-related knowledge, attitudes, preconception care practices, and contraceptive prevalence in women with DM.

METHODS

This descriptive cross-sectional survey was conducted among reproductive-aged Thai women receiving DM treatment at King Chulalongkorn Memorial Hospital between August 1, 2021, and June 30, 2022. Patients with DM who were not pregnant or trying to conceive and could be contacted via the phone were included and a validated self-administered questionnaire was distributed electronically.

RESULTS

A total of 238 participants were included in the final analysis, yielding 69.4% response rates. The mean (standard deviation) score for knowledge of pregnancy planning and pregnancy-related risks was 6.8 (3.5) out of 15. Only about half of the participants had discussed pregnancy planning with their physicians. Multivariable analysis showed that younger age at DM diagnosis, non-Buddhism, married, higher education, and medical personnel were significantly associated with higher knowledge scores. Women aged > 45 years and those with higher practice scores had significantly higher adjusted odds of using highly effective contraception; the most common methods included male condoms and combined oral contraceptive pills. There was an unmet need for contraception in 9.5% of women with DM.

CONCLUSIONS

Although highly effective contraception is safe for patients with DM, only about half of our participants used tier one or two contraceptives or had received consultation regarding preconception planning. There was a notable gap in care coordination among specialists; integrating reproductive healthcare into DM therapy would improve access to preconception care.

Influence of red blood cell indices on HbA1c performance in detecting dysglycaemia in a Singapore preconception cohort study

Abnormalities of red blood cell (RBC) indices may affect glycated haemoglobin (HbA1c) levels. We assessed the influence of haemoglobin (Hb) and mean corpuscular volume (MCV) on the performance of HbA1c in detecting dysglycaemia among reproductive aged women planning to conceive. Women aged 18-45 years (n = 985) were classified as normal (12 ≤ Hb ≤ 16 g/dL and 80 ≤ MCV ≤ 100 fL) and abnormal (Hb < 12 g/dL and/or MCV < 80 fL). The Area Under the Receiver Operating Characteristic (AUROC) curve was used to determine the performance of HbA1c in detecting dysglycaemic status (prediabetes and diabetes). There were 771 (78.3%) women with normal RBC indices. The AUROCs for the normal and abnormal groups were 0.75 (95% confidence interval 0.69, 0.81) and 0.80 (0.70, 0.90), respectively, and were not statistically different from one another [difference 0.04 (- 0.16, 0.08)]. Further stratification by ethnicity showed no difference between the two groups among Chinese and Indian women. However, Malay women with normal RBC indices displayed lower AUROC compared to those with abnormal RBC indices (0.71 (0.55, 0.87) vs. 0.98 (0.93, 1.00), p = 0.002). The results suggest that the performance of HbA1c in detecting dysglycaemia was not influenced by abnormal RBC indices based on low Hb and/or low MCV. However, there may be ethnic variations among them.

Development and validation of a clinical model for preconception and early pregnancy risk prediction of gestational diabetes mellitus in nulliparous women

Implementation of dietary and lifestyle interventions prior to and early in pregnancy in high risk women has been shown to reduce the risk of gestational diabetes mellitus (GDM) development later in pregnancy. Although numerous risk factors for GDM have been identified, the ability to accurately identify women before or early in pregnancy who could benefit most from these interventions remains limited. As nulliparous women are an under-screened population with risk profiles that differ from their multiparous counterparts, development of a prediction model tailored to nulliparous women may facilitate timely preventive intervention and improve maternal and infant outcomes. We aimed to develop and validate a model for preconception and early pregnancy prediction of gestational diabetes mellitus based on clinical risk factors for nulliparous women. A risk prediction model was built within a large California birth cohort including singleton live birth records from 2007-2012. Model accuracy was assessed both internally and externally, within a cohort of women who delivered at University of Iowa Hospitals and Clinics between 2009-2017, using discrimination and calibration. Differences in predictive accuracy of the model were assessed within specific racial/ethnic groups. The prediction model included five risk factors: race/ethnicity, age at delivery, pre-pregnancy body mass index, family history of diabetes, and pre-existing hypertension. The area under the curve (AUC) for the California internal validation cohort was 0.732 (95% confidence interval (CI) 0.728, 0.735), and 0.710 (95% CI 0.672, 0.749) for the Iowa external validation cohort. The model performed particularly well in Hispanic (AUC 0.739) and Black women (AUC 0.719). Our findings suggest that estimation of a woman's risk for GDM through model-based incorporation of risk factors accurately identifies those at high risk (i.e., predicted risk >6%) who could benefit from preventive intervention encouraging prompt incorporation of this tool into preconception and prenatal care.

47-Fold rise of diabetes in childbearing age Chilean women: Markov model and cost-effectiveness of prevention of birth defects

AIM

Prevalence of type 2 diabetes mellitus (T2DM) during childbearing age in Chile had a 47-fold rise in 7 years, reaching 120 844 women, half of which are unaware of their condition. We aimed to project pregnancies and births among Chilean women of childbearing age (WCBA) with T2DM and report the incidence of birth defects and the associated years of life lost and lifetime costs.

METHODS

Markov model of cohort of WCBA with T2DM (WCBA-DM) with a 20-year time horizon (2018-2037), using data from previous studies. Two scenarios were assessed: scenario A: no universal detection of T2DM and scenario B: universal screening of T2DM using glycosylated hemoglobin levels. Both lifetime costs and disability-adjusted life years (DALY) were calculated with a 5% discount rate (US$ of 2017).

RESULTS

In scenario A, 12 163 infants with birth defects could be born among the analyzed cohort, resulting in 243 260 years of life lost, 296 652 DALY and in lifetime costs of US$ 1 957 657 966. In scenario B, the first three figures could be reduced by 70.4% to 3599 infants with birth defects, 71 980 years of life lost and 87 794 DALY. Due to the addition of diabetes screening and new patient costs to scenario B, there would be a lesser reduction (67.3%) in total lifetime costs, to US$ 640 669 296.

CONCLUSION

Screening of diabetes in WCBA would yield a 20-year reduction of 70.4% in the number of infants with birth defects, years of life lost and DALY. Total lifetime costs could be reduced by 67.3%.

Opportunities to Reduce Diabetes Risk in Women of Reproductive Age: Assessment and Treatment of Prediabetes within a Large Integrated Delivery System

BACKGROUND

Preventing diabetes before pregnancy may be important to improve maternal and infant outcomes. Although the preconception period is a crucial time to focus on chronic disease prevention, little is known about preventive services for reproductive-aged women at risk of developing diabetes.

METHODS

Using electronic health record data from patients at Kaiser Permanente Northern California, we identified 21,965 nonpregnant women aged 18 to 44 with incident prediabetes (PDM; fasting plasma glucose [FPG] = 100-125 or glycated hemoglobin A1c = 5.7%-6.4%) between 2007 and 2010. We looked for evidence of a "clinical response" to PDM in the 6 months after laboratory testing, defined as retesting of blood glucose levels, referral or attendance to health education, diagnosis of PDM, metformin initiation, or a clinical note of discussion of PDM. Multilevel models were used to examine the relationship between patient characteristics and clinical response, and to assess provider-level variation.

RESULTS

Fewer than one-half of women had a documented clinical response to the PDM-range laboratory result. Women with higher FPG values and body mass indexes were more likely to have a PDM diagnosis (FPG 120-125 vs. 100-119: OR, 1.96; 95% CI, 1.78-2.17; body mass index, 30-34 kg/m² vs. <25 kg/m²: OR, 1.30; 95% CI, 1.13-1.48) and have 'PDM' recorded in the notes (FPG 120-125 vs. 100-119: OR, 1.15; 95% CI, 1.06-1.26; body mass index: 30-34 kg/m² vs. <25 kg/m²: OR, 1.58; 95% CI, 1.44-1.74). Provider-level variation was modest, except for metformin initiation (intraclass correlation coefficient, 0.8; p < .01).

CONCLUSIONS

Low clinical response to PDM among women of reproductive age suggests there are missed opportunities for diabetes prevention among this vulnerable population.

Fifteen-year trends and predictors of preparation for pregnancy in women with pre-conception Type 1 and Type 2 diabetes: a population-based cohort study

AIMS

To investigate trends in indicators of preparation for pregnancy in women with Type 1 and Type 2 diabetes and explore their predictors.

METHODS

Data on 2293 pregnancies delivered during 1996-2010 by women with Type 1 (n = 1753) and Type 2 (n = 540) diabetes were obtained from the Northern Diabetes in Pregnancy Survey. Multiple logistic regression was used to analyse the relationship between potential predictors and three indicators of inadequate pregnancy preparation: non-attendance for pre-conception care; no pre-conception folate consumption; and peri-conception HbA(1c) ≥ 53 mmol/mol (≥ 7%).

RESULTS

Overall, 40.3% of women with diabetes attended pre-conception care, 37.4% reported pre-conception folate consumption, and 28.2% had adequate peri-conception HbA1c . For all patients, pre-conception folate consumption improved over time, while peri-conception glucose control did not. Attendance for pre-conception care for women with Type 1 diabetes significantly declined. Residence in deprived areas, smoking and younger maternal age (for women aged < 35 years) were independently associated with all three indicators of inadequate preparation for pregnancy. Additional predictors of inadequate peri-conception HbA(1c) were: Type 1 diabetes (adjusted odds ratio 5.51, 95% CI 2.71-11.22), longer diabetes history (adjusted odds ratio 1.16, 95% CI 1.09-1.23 per year increase for those with < 15 years' diabetes duration), non-white ethnicity (adjusted odds ratio 3.13, 95% CI 1.23-7.97) and higher BMI (adjusted odds ratio 1.05, 95% CI 1.01-1.09 per 1-kg/m(2) increase). Non-attendance for pre-conception care was additionally associated with Type 2 diabetes (P = 0.003) and multiparity (P < 0.0001).

CONCLUSIONS

There are socio-demographic inequalities in preparation for pregnancy among women with diabetes. Women with Type 2 diabetes were less likely to attend pre-conception care. Pre-conception services need to be designed to maximize uptake in all groups.

The challenges and future considerations regarding pregnancy-related outcomes in women with pre-existing diabetes

Ineffective management of blood glucose levels during preconception and pregnancy has been associated with severe maternal and fetal complications in women with pre-existing diabetes. Studies have demonstrated that preconception counseling and pre-pregnancy care can dramatically reduce these risks. However, pregnancy-related outcomes in women with diabetes continue to be less than ideal. This review highlights and discusses a variety of patient, provider, and organizational factors that can contribute to these suboptimal outcomes. Based on the findings of studies reviewed and authors' clinical and research experiences, recommendations have been proposed focusing on various aspects of care provided, including improved accessibility to effective preconception and pregnancy-related care and better organized clinic consultations that are sensitive to women's diabetes and pregnancy needs.

Differences in pregnancy planning between women aged 18-44, with and without diabetes: behavioral risk factor surveillance system analysis

AIM

Assess differences in pregnancy planning and behavioral risk factors among women of reproductive age, by diabetes status.

METHODS

A secondary analysis of cross-sectional data from the Behavioral Risk Factor Surveillance System (2002 and 2004) was conducted. Subjects were 18-44-year-old, non-pregnant, fertile women, grouped into two categories: non-diabetes (n=57,436), and diabetes (n=2929). Multivariable logistic regression was used to estimate adjusted prevalence odds ratios and 95% confidence intervals.

RESULTS

Approximately 93% of women of reproductive age with or without diabetes are not intending a pregnancy, and yet among them, women with diabetes are 22% more likely not to use any birth control at all. Women with diabetes are 3.4 times more likely to be obese, 1.4 times more likely to be overweight, 35% less likely to drink any alcohol, and 27% less likely to binge drink alcohol, than women without diabetes. There were no differences in risk factors between women with diabetes that were and were not intending a pregnancy.

CONCLUSIONS

Birth control nonuse for women with diabetes not intending a pregnancy and lack of behavioral change for women with diabetes intending a pregnancy, combined with an increasing prevalence in diabetes, will likely result in significant economic and social tolls on society.

Pre-pregnancy predictors of diabetes in pregnancy among Aboriginal and Torres Strait Islander women in North Queensland, Australia

To identify pre-pregnancy risk factors for diabetes in pregnancy among a cohort of Australian Indigenous women. Data on 1,009 Indigenous women of childbearing age who participated in a 1998-2000 health screening program in far north Queensland were linked to Queensland hospitalisations data. Women who attended hospital after their health check for a pregnancy-related condition were identified. The data on women who were hospitalised for birth were also linked to Queensland perinatal data. Of 220 women who gave birth, 23 had diabetes in the pregnancy following their health check. A strong predictor of having a subsequent pregnancy affected by diabetes was suboptimal glucose control before conception. The presence of the metabolic syndrome predicted over a threefold increase in risk among non-diabetic women after adjustment for age and ethnicity (PR, 3.50; 95% CI, 1.54-8.00). For each 1-cm increase in waist circumference, there was an age-adjusted increase in risk of 4% for diabetes in pregnancy (1.04; 1.01-1.06). For each 1-mmHg increase in blood pressure (systolic and diastolic), there was an age-adjusted increase in risk of 3% (1.03; 1.01-1.05 and 1.03; 1.00-1.07, respectively). Associations between hypercholesterolaemia and dyslipidaemia and diabetes in the subsequent pregnancy were diminished after adjustment for age and ethnicity. The risk for women with "hyper-triglyceridaemic waist" phenotype before pregnancy was diminished by adjustment for age, ethnicity and baseline fasting glucose. Alcohol intake, smoking, level of physical activity and red cell folate showed little effect. Identification of women at particularly high risk for future diabetes in pregnancy, given their pre-pregnancy health, is important so that they can manage their risks and where overweight or obesity is a factor, interventions aimed at weight management should be implemented.

Pregnancy planning and diabetes: a qualitative exploration of women's attitudes toward preconception care

INTRODUCTION

Seeking preconception care is recognized as an important health behavior for women with preexisting diabetes. Yet many women with diabetes do not seek care or advice until after they are pregnant, and many enter pregnancy with suboptimal glycemic control. This study explored the attitudes about pregnancy and preconception care seeking in a group of nonpregnant women with type 1 diabetes mellitus.

METHODS

In-depth semistructured interviews were completed with 14 nonpregnant women with type 1 diabetes.

RESULTS

Analysis of the interview data revealed 4 main themes: 1) the emotional complexity of childbearing decisions, 2) preferences for information related to pregnancy, 3) the importance of being known by your health professional, and 4) frustrations with the medical model of care.

DISCUSSION

These findings raise questions about how preconception care should be provided to women with diabetes and highlight the pivotal importance of supportive, familiar relationships between health professionals and women with diabetes in the provision of individualized care and advice. By improving the quality of relationships and communication between health care providers and patients, we will be better able to provide care and advice that is perceived as relevant to the individual, whatever her stage of family planning.

A qualitative study of perceived barriers to management of diabetes among women with a history of diabetes during pregnancy

BACKGROUND

Uncontrolled diabetes during pregnancy can cause adverse maternal and infant outcomes. This study explored barriers to glycemic control before, during, and after pregnancy and describes knowledge, attitudes, and behaviors among pregnant women with pregestational diabetes (PGDM) or gestational diabetes (GDM).

METHODS

Focus groups were conducted in the Atlanta area among white, black, and Hispanic women who had diabetes during a recent pregnancy. Participants were a convenience sample drawn from a variety of sources. Nine focus groups were held with women who had GDM, and seven focus groups were held with women who had PGDM.

RESULTS

Participants identified five main areas of barriers to management of diabetes during pregnancy: financial barriers and difficulties accessing care, barriers to maintaining a healthy diet and exercising, communication difficulties, lack of social support, and barriers related to diabetes care. Participants with GDM had general awareness of possible diabetes complications but frequently could not name specific effects of diabetes on the woman or child during and after pregnancy. Most were unaware of their risk for developing type 2 diabetes later. Participants with PGDM expressed concern about the increased risk of adverse outcomes for the baby; most knew the importance of maintaining glycemic control during pregnancy. Low rates of pregnancy planning were reported in both groups. Pregnancy planning was not identified as a strategy to ensure a healthy baby.

CONCLUSIONS

The barriers to achieving glycemic control during pregnancy identified in this study could help inform future efforts to assist women in achieving optimal prepregnancy and intrapregnancy glycemic control.

Integrating preconception care for women with diabetes into primary care: a qualitative study

BACKGROUND

National guidelines emphasise the need to deliver preconception care to women of childbearing age. However, uptake of the services among women with diabetes in the UK is low. Questions arising include how best to deliver preconception care and what the respective roles of primary versus secondary caregivers might be.

AIM

To explore the perspective of GPs and secondary care health professionals on the role of GPs in delivering preconception care to women with diabetes.

DESIGN OF STUDY

Qualitative, cross-sectional study.

SETTING

A London teaching hospital and GP practices in the hospital catchment area.

METHOD

Semi-structured interviews with GPs and members of the preconception care team in secondary care. Thematic analysis using the framework approach.

RESULTS

GPs and secondary care professionals differ in their perception of the number of women with diabetes requiring preconception care and the extent to which preconception care should be integrated into GPs' roles. Health professionals agreed that GPs have a significant role to play and that delivery of preconception care is best shared between primary and secondary care. However, the lack of clear guidelines and shared protocols detailing the GP's role presents a challenge to implementing 'shared' preconception care.

CONCLUSION

GPs should be more effectively involved in providing preconception care to women with diabetes. Organisational and policy developments are required to support GPs in playing a role in preconception care. This study's findings stress the importance of providing an integrated approach to ensure continuity of care and optimal pregnancy preparation for women with diabetes.

Preconception planning: are we making progress?

According to the American Diabetes Association, unplanned pregnancies in women with diabetes could lead to abnormal metabolic control, which causes fetal and maternal complications. Preconception planning can decrease these risks. This article reports on the progress in preconception planning over the past 2 years.