The Gestational Diabetes Group Program

Development and Implementation of an Integrated Model of Perinatal Diabetes Education and Management to Improve Maternity Outcomes and Health Equity

Diabetes mellitus (DM) confers unique risks during the perinatal period, contributing to maternal, fetal, and neonatal morbidity and mortality. Integrating DM education and management services with obstetrical care offers key advantages for birthing individuals. The purpose of this study is to describe the development and implementation of a perinatal DM program at a large ambulatory practice serving a diverse population. Understanding this approach and program workflow may facilitate adoption of similar services in other care settings.

Diabetes Group Prenatal Care: A Systematic Review and Meta-analysis

OBJECTIVE

To estimate the effect of diabetes group prenatal care on rates of preterm birth and large for gestational age (LGA) among patients with diabetes in pregnancy compared with individual diabetes prenatal care.

DATA SOURCES

We searched Ovid Medline (1946-), Embase.com (1947-), Scopus (1823-), Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov.

METHODS OF STUDY SELECTION

We searched electronic databases for randomized controlled trials (RCTs) and observational studies comparing diabetes group prenatal care with individual care among patients with type 2 diabetes mellitus or gestational diabetes mellitus (GDM). The primary outcomes were preterm birth before 37 weeks of gestation and LGA (birth weight at or above the 90th percentile). Secondary outcomes were small for gestational age, cesarean delivery, neonatal hypoglycemia, neonatal intensive care unit admission, breastfeeding at hospital discharge, long-acting reversible contraception (LARC) uptake, and 6-week postpartum visit attendance. Secondary outcomes, limited to the subgroup of patients with GDM, included rates of GDM requiring diabetes medication (A2GDM) and completion of postpartum oral glucose tolerance testing (OGTT). Heterogeneity was assessed with the Cochran Q test and I2 statistic. Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean differences.

TABULATION, INTEGRATION, AND RESULTS

Eight studies met study criteria and were included in the final analysis: three RCTs and five observational studies. A total of 1,701 patients were included in the pooled studies: 770 (45.3%) in diabetes group prenatal care and 931 (54.7%) in individual care. Patients in diabetes group prenatal care had similar rates of preterm birth compared with patients in individual care (seven studies: pooled rates 9.5% diabetes group prenatal care vs 11.5% individual care, pooled RR 0.77, 95% CI, 0.59-1.01), which held for RCTs and observational studies. There was no difference between diabetes group prenatal care and individual care in rates of LGA overall (four studies: pooled rate 16.7% diabetes group prenatal care vs 20.2% individual care, pooled RR 0.93, 95% CI, 0.59-1.45) or by study type. Rates of other secondary outcomes were similar between diabetes group prenatal care and individual care, except patients in diabetes group prenatal care were more likely to receive postpartum LARC (three studies: pooled rates 46.1% diabetes group prenatal care vs 34.1% individual care, pooled RR 1.44, 95% CI, 1.09-1.91). When analysis was limited to patients with GDM, there were no differences in rates of A2GDM or postpartum visit attendance, but patients in diabetes group prenatal care were significantly more likely to complete postpartum OGTT (five studies: pooled rate 74.0% diabetes group prenatal care vs 49.4% individual care, pooled RR 1.58, 95% CI, 1.19-2.09).

CONCLUSION

Patients with type 2 diabetes and GDM who participate in diabetes group prenatal care have similar rates of preterm birth, LGA, and other pregnancy outcomes compared with those who participate in individual care; however, they are significantly more likely to receive postpartum LARC, and those with GDM are more likely to return for postpartum OGTT.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021279233.

CenteringPregnancy: A Review of Implementation and Outcomes

Importance

CenteringPregnancy (CP) is a model for group prenatal care associated with improved perinatal outcomes for preterm birth and low birthweight, increased rates of breastfeeding, and higher rates of patient and clinician satisfaction.

Objective

The study aims to review the literature related to perinatal outcomes associated with CP, benefits and barriers to implementation, and utility of the model.

Evidence

An electronic-based search was performed in PubMed using the search terms "CenteringPregnancy" OR "Centering Pregnancy," revealing 221 articles.

Results

The CP model improves patient centeredness, efficiency, and equality in prenatal care. Challenges include administrative buy-in, limited resources, and financial support. Multisite retrospective studies of CP demonstrate improved maternal, neonatal, postpartum, and well-being outcomes, especially for participants from minority backgrounds; however, prospective studies had mixed results. CenteringPregnancy is feasibly implemented with high tenet fidelity in several low- and middle-income settings with improved perinatal outcomes compared with traditional care.

Conclusions

CenteringPregnancy is feasible to implement, largely accepted by communities, and shows positive qualitative and quantitative health outcomes. This body of literature supports CP as a potential tool for decreasing racial inequalities in prenatal access, quality of care, and maternal mortality. Further investigation is necessary to inform obstetric clinicians about the potential outcome differences that exist between group and traditional prenatal care.

Health Care Providers' Utilization of and Perspectives on Mobile Health Technology for Diabetes and Pregnancy Support

OBJECTIVE

Mobile health (mHealth) technology can be an effective tool to deliver behavioral interventions to improve health outcomes for individuals with diabetes. However, there is limited evidence on mHealth for pregnant women managing diabetes or for the role of health care providers (HCPs) in delivering mHealth tools. To prepare for the development of a pregnancy-specific mHealth intervention for diabetes, we sought to understand HCPs' acceptance, utilization, and design recommendations for how mHealth technology can best be used to support the management of diabetes during pregnancy.

METHODS

Focus groups and individual interviews were conducted with clinical HCPs (obstetricians, nurses, diabetes educators, dietitians, and lactation counselors) who care for low-income pregnant women with diabetes. Data were analyzed using the constant comparative method.

RESULTS

Participants (n = 29) generated five themes and 14 subthemes. Knowledge and acceptance themes included utilization of mobile resources and barriers to HCPs' adoption. Knowledge of popular pregnancy applications (apps) dominated, while familiarity with and use of diabetes apps varied by profession and proximity to continued education. Technology adoption barriers included lack of credibility, dependence on Internet resources, and reliance on knowledge networks. Design themes addressed user-centered design, responsive and practical education, and clinical integration. Clinicians recommended patient-participatory design, customizable features, data-tracking features, motivational feedback, and bidirectional communication capabilities.

CONCLUSION

Although HCPs strongly embraced mHealth tools as an adjunct to obstetric care for women with diabetes, they also expressed limited knowledge and apprehension about patient engagement. HCP recommendations and concerns must critically inform the development of meaningful tools for this population.