Pre-pregnancy care strategically targets a woman’s health before conception. Through prevention and management, pre-pregnancy care aims to identify and modify biomedical, behavioural and social healthcare risks.^1,2 The provision of this is care also strives to ensure that the woman is aware of any potential hazards, so that she can make an informed decision about pregnancy and her modifiable and non-modifiable risks. 

Pre-pregnancy care is essentially an opportunity to optimise future pregnancy outcomes, particularly in the presence of known risk factors.  

Diabetes and pre-pregnancy care 

Diabetes is one of the most common medical conditions affecting pregnancy and is associated with adverse maternal, foetal and infant outcomes.³ The risk of congenital malformation in the infants of women with diabetes is twice that of the background population, there is a five-fold increase in stillbirth, and a three-fold increased risk in perinatal mortality.^3,4,5,6 Pre-existing diabetes exerts an influence on all stages of pregnancy, consequently these pregnancies are considered high-risk.  

The first trimester of pregnancy is particularly crucial as this is the period of organogenesis, and it is known that exposure to hyperglycaemia and many of the medications prescribed for the treatment of diabetes can be hazardous during this early developmental phase.^6,7,8,9 Indeed the negative impact of these can be realised even before the woman is aware she is pregnant.¹⁰

To reduce these risks, women with diabetes need effective pre-pregnancy care, either to prevent pregnancy or to reduce diabetes-related risk factors prior to conception.¹¹ It is therefore essential that women have an awareness of their need for pre-pregnancy care and know how to access it. Internationally, clinical guidance recommends that a focus on pre-pregnancy care be incorporated into diabetes consultations with women from adolescence and throughout their reproductive years.^3,12,13

Pre-pregnancy guidance 

The key elements of pre-pregnancy care for women with diabetes include, the need to optimise their glycaemic control (HbA1c < 48mmol/mol); appropriate medication management to prevent foetal exposure to teratogenic agents; the introduction of high dose folic acid (5mg); and screening for and treatment of diabetes complications.^3,13

Individualised dietary advice is advocated and where necessary women should be supported to achieve a heathy weight. Importantly, reliable contraception is essential and this should only be discontinued once the woman has attained the recommended targets and is ready to conceive.^3,13 Furthermore, once pregnant, women with diabetes are advised to attend antenatal care as early as possible in their pregnancy, ideally before eight weeks gestation.

Pregnancy preparation

The importance of pre-pregnancy care for women living with diabetes has been appreciated for several decades, and the positive results of this care have been replicated in many studies.^{14,15,16,17,18} Generally, these studies have demonstrated that women who have received pre-pregnancy care are more likely to have optimised their glycaemic control prior to conception; have an increased uptake of high-dose folic acid; and are less likely to be taking medications unsuitable for pregnancy around the time of conception compared with those who have not received it.  Recipients of pre-pregnancy care are also more likely to attend for antenatal care at an earlier gestation than those who have not received it. Nevertheless, despite these benefits the majority of women with diabetes still do not receive pre-pregnancy care.  

 In a recent large national cohort study in the UK (n = 3,036) during 2016 only 14% of women with type 1 diabetes and 37% of those with type 2 diabetes achieved the recommended glycaemic control target of 48mmol/mol prior to pregnancy.  During the same period the uptake of 5mg folic acid was similarly disappointing at 46% among those with type 1 and 23% of women with type 2 diabetes.¹⁹ The Irish national diabetes in pregnancy audit data during 2015, although having a much smaller number of participants (n = 185) were somewhat better as almost 20% of those with type 1 and 46% of those with type 2 diabetes had a first trimester HbA1c of < 48mmol/mol and the uptake of 5mg folic acid was almost 45% and 34% for those with type 1 and type 2 diabetes respectively.²⁰

Significantly, the UK cohort study revealed for the first time that there were as many women with pre-existing type 2 diabetes in pregnancy as those with type 1 diabetes.  In the last decade the number of women with type 2 diabetes prior to pregnancy has greatly increased, while in the CEMACH report 2007 only a third of those included had type 2 diabetes.²¹

Worryingly, while there is a growing population of women with type 2 diabetes during pregnancy, this group continue to be much less well-prepared for pregnancy compared with women with type 1 diabetes.  Women with type 2 diabetes tend to present for antenatal care at a later gestation than women with type 1 diabetes (by which time the foetus may have already been compromised); women with type 2 diabetes are also less likely to have taken appropriate folic acid supplementation prior to conception, and are more frequently taking teratogenic medications.^14,17,22,23

A synthesis of the experiences of women with type 2 diabetes and healthcare professionals has suggested that the uptake of pre-pregnancy care is informed by several elements including: 

• The personal orientation of women towards their own reproductive healthcare needs
• How well women interact with their healthcare providers
• How they are supported to navigate care within the healthcare system
• The awareness and understanding of healthcare professionals about the need for this care. 
• Essentially, how women are facilitated to have an awareness of and access to pre-pregnancy care impacts the uptake of it.²⁴

Pre-pregnancy care studies

Studies from Ireland and the UK have used a regional approach to the provision of pre-pregnancy care to women with diabetes. These groups have proactively identified women from their diabetes databases and provided postal information about the availability of pre-pregnancy care services, together with an invitation to participate.^5,17,18

A common feature of these studies was the dual approach to concentrate on both the healthcare professionals and the women living with diabetes. The interventions for healthcare professionals predominantly comprised of education sessions, development of specific clinical practice guidelines, clinical practice proformas and information leaflets for women with diabetes.  The provision of pre-pregnancy care tended to be in specialist centres within these select geographical regions.  

While the impact of the individual elements of these interventions were not evaluated, collectively they did show the positive influence on the maternal and foetal outcomes among those women with diabetes who received pre-pregnancy care. However, these targeted interventions have also exemplified that enhancing the uptake of pre-pregnancy care is challenging as the overall uptake was reported as 27% of participants in the UK study¹⁷ and 36% in the Irish study.²³

Community-based pre-pregnancy care

More recently, a community-based approach to pre-pregnancy care has been evaluated.²⁵ This mode was adjunct to an existing regional service providing pre-pregnancy care via secondary care in the UK.¹⁷ Within this study, 422 primary care centres were identified of which almost 73% (n = 306) agreed to participate and collectively they distributed 4,558 information leaflets to women with diabetes, aged 16-45 years.  Online education modules for healthcare professionals were provided along with regional meetings and data collection supports.  

This approach demonstrated favourable results with women attending for antenatal care earlier than previously with over 67% (n = 138) of women with type 1 and 40% (n = 53) of those with type 2 diabetes booking prior to eight weeks gestation.  They also showed an increase in women with both type 1 and type 2 diabetes reaching the recommended glycaemic control targets, taking high-dose folic acid and a reduction in the use of teratogenic medications.   

This community-based approach saw significant improvements in individual elements of pre-pregnancy care such as 50% of women taking folic acid prior to conception. Collectively however, only 16.3% of women with type 1 and 15.1% of those with type 2 diabetes were considered optimally prepared for pregnancy, which was defined as when a woman attained all the elements of pre-pregnancy care (initial HbA1c ≤ 48mmol/mol [6.5%], taking folic acid 5mg daily prior to last menstrual period; booking to antenatal care at ≤ eight weeks gestation; and not taking any teratogenic medications prior to last menstrual period).

Therefore, while we have a comprehensive understanding of what care is needed, and when this should be delivered, the challenge remains about how best to enhance the uptake of pre-pregnancy care for women with diabetes.  

Technology and pre-pregnancy care 

Alternative strategies to facilitate behaviour change and improve pregnancy outcomes are emerging.  There is a more recent increase in studies which have focused on the use of multimedia technologies, namely interactive CD-ROM and DVDs.^26,27

These approaches have resulted in significant improvements in knowledge and perceived benefits of pre-pregnancy care,^28,29 reduced barriers to seeking this care and increased intention to initiate a discussion about pre-pregnancy care with healthcare professionals^28,30 and an increase in the perceived benefits and attitudes to contraceptive use.^29,30 Although data on the impact of these resources are limited, women were more likely to have prepared for pregnancy following exposure to DVDs about pre-pregnancy care.³¹

Mobile health (mHealth) technology is another important strategy. It has been estimated that 90% of the world’s population has access to mobile networks, with smartphones accounting for a substantial proportion of mobile devices^32,33,34,35 that have the capacity to run applications (apps).  These advances have resulted in a proliferation of healthcare education, decision-making support, and self-care monitoring apps.³⁴

In relation to pre-pregnancy care the potential reach of this technology has important implications for awareness-raising and engagement with this care.  An evaluation of the awareness and use of a locally developed Danish pregnancy in diabetes app reported that of the 139 pregnant women included, while almost all had a smartphone, 75% had downloaded an app, with almost half of women having actively engaged with the functionality of it before pregnancy.³⁶ Therefore, seizing on this shift towards technology, awareness raising about pre-pregnancy care has advanced.  

Despite the overwhelming evidence supporting the benefits of pre-pregnancy care and the creative methods used to enhance the delivery and uptake, we have not succeeded in significantly engaging and activating women with diabetes to prepare for pregnancy. Therefore, we need to consider a robust programme for awareness-raising and education for women living with diabetes and healthcare professionals, so that there is a systematic integration of pre-pregnancy care into the routine care for all women with diabetes during their reproductive years.  

This article is based on Rita Forde’s presentation at the recent Diabetes in Pregnancy Study Day held by Diabetes Ireland in the Crowne Plaza Hotel, Dublin

References 

1. Seshadri S, Oakeshott P, Nelson-Piercy C, Chappell LC. Prepregnancy care. BMJ. 2012;344
2. van Voorst S, Plasschaert S, de Jong-Potjer L, Steegers E, Denkta S. Current practice of preconception care by primary caregivers in the Netherlands. The European Journal of Contraception & Reproductive Health Care. 2016:1-8
3. National Institute for Health and Care Excellence (NICE). Diabetes in pregnancy: management from preconception to the postnatal period. London: NICE; 2015
4. Egan AM, Murphy HR, Dunne FP. The management of type 1 and type 2 diabetes in pregnancy. QJM: An International Journal of Medicine. 2015;108(12):923-7
5. Dunne FP, Avalos G, Durkan M, Mitchell Y, Gallacher T, Keenan M, et al. ATLANTIC DIP: pregnancy outcome for women with pregestational diabetes along the Irish Atlantic seaboard. Diabetes Care. 2009;32(7):1205-6
6. Macintosh MC, Fleming KM, Bailey JA, et al. Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study. Br Med J. 2006;333(7560):177
7. Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med. 2006;354(23):2443-51
8. Godfrey LM, Erramouspe J, Cleveland KW. Teratogenic risk of statins in pregnancy. Ann Pharmacother. 2012;46(10):1419-24
9. Berry DC, Boggess K, Johnson QB. Management of pregnant women with type 2 diabetes mellitus and the consequences of fetal programming in their offspring. Current Diabetes Reports. 2016;16(5):36
10. Toivonen KI, Oinonen KA, Duchene KM. Preconception health behaviours: A scoping review. Prev Med. 2017;96:1-15
11. Murphy HR, Bell R, Dornhorst A, Forde R, LewisBarned N. Pregnancy in Diabetes: challenges and opportunities for improving pregnancy outcomes. Diabet Med. 2018;35(3):292-9
12. American Diabetes Association. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes – 2018. Diabetes Care. 2018;41(Supplement 1):S137-S43
13. HSE. Guidelines for the Management of Pre-gestational and Gestational Diabetes Mellitus from Pre-conception to the Postnatal period. 2010
14. Willhoite MB, Bennert Jr HW, Palomaki GE, et al. The impact of preconception counseling on pregnancy outcomes: The experience of the Maine diabetes in pregnancy program. Diabetes Care. 1993;16(2):450-5
15. Fuhrmann K, Reiher H, Semmler K, Fischer F, Fischer M, Glockner E. Prevention of congenital malformations in infants of insulin-dependent diabetic mothers. Diabetes Care. 1983;6(3):219-23
16. Temple RC, Aldridge V, Stanley K, Murphy HR. A study of the effect of glycaemic control and prepregnancy care on risk of pre-eclampsia in women with type 1 diabetes. Diabetologia. 2005;48:A315-A
17. Murphy HR, Roland JM, Skinner TC, et al. Effectiveness of a regional prepregnancy care program in women with type 1 and type 2 diabetes: benefits beyond glycemic control. Diabetes Care. 2010;33(12):2514-20
18. Owens LA, Avalos G, Kirwan B, Carmody L, Dunne F. ATLANTIC DIP: Closing the Loop A change in clinical practice can improve outcomes for women with pregestational diabetes. Diabetes Care. 2012;35(8):1669-71
19. Murphy HR, Bell R, Cartwright C, et al. Improved pregnancy outcomes in women with type 1 and type 2 diabetes but substantial clinic-to-clinic variations: a prospective nationwide study. Diabetologia. 2017;60(9):1668-77
20. Dunne F. The Irish National Diabetes in Pregnancy Audit. Presented at The management of diabetes in pregnancy: a multidisciplinary team approach; 2018; Dublin, Ireland
21. Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer-2003-2005.  The seventh report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. CEMACH. London 2007
22. National Health Service (NHS) Digital. National Pregnancy in Diabetes (NPID) Audit Report 2016. 2017
23. Egan AM, Danyliv A, Carmody L, Kirwan B, Dunne FP. A prepregnancy care program for women with diabetes: effective and cost saving. Journal of Clinical Endocrinology Metabolism. 2016;101(4):1807-15
24. Forde R, Patelarou EE, Forbes A. The experiences of prepregnancy care for women with type 2 diabetes mellitus: a meta-synthesis. International Journal of Women’s Health. 2016;8:691
25. Yamamoto JM, Hughes DJF, Evans ML, et al. Community-based pre-pregnancy care programme improves pregnancy preparation in women with pregestational diabetes. Diabetologia. 2018;61(7):1528-37
26. Charron-Prochownik D, Hannan MF, Sereika SM, Becker D, Rodgers-Fischl A. How to Develop CD-ROMs for Diabetes Education: Exemplar “Reproductive-Health Education and Awareness of Diabetes in Youth for Girls” (READY-Girls). Diabetes Spectrum. 2006;19(2):110-5
27. Spence M, Harper R, McCance DR, et al. The systematic development of an innovative DVD to raise awareness of preconception care. European Diabetes Nursing. 2013;10(1):7
28. Fischl AF, Herman WH, Sereika SM, et al. Impact of a preconception counseling program for teens with type 1 diabetes (READY-Girls) on patient-provider interaction, resource utilization, and cost. Diabetes Care. 2010;33(4):701-5
29. Holmes VA, Spence M, McCance DR, Patterson CC, Harper R, Alderdice FA. Evaluation of a DVD for women with diabetes: impact on knowledge and attitudes to preconception care. Diabet Med. 2012;29(7):950-6
30. Charron-Prochownik D, Sereika SM, Becker D, et al. Long-term effects of the booster-enhanced READY-girls preconception counseling program on intentions and behaviors for family planning in teens with diabetes. Diabetes Care. 2013;36(12):3870-4
31. Hamill L, McCance D, Deery M, et al. Impact of a preconception counselling resource (DVD) on preconception folic acid intake in women with diabetes. Proc Nutr Soc. 2014;73:E64
32. Silva BMC, Rodrigues JJPC, de la Torre Díez I, López-Coronado M, Saleem K. Mobile-health: A review of current state in 2015. Journal of Biomedical Informatics. 2015;56(Supplement C):265-72
33. Derbyshire E, Dancey D. Smartphone Medical Applications for Women&#x2019;s Health: What Is the Evidence-Base and Feedback? International Journal of Telemedicine and Applications. 2013;2013:10
34. Klasnja P, Pratt W. Healthcare in the pocket: Mapping the space of mobile-phone health interventions. Journal of Biomedical Informatics. 2012;45(1):184-98
35. International Telecommunication Union. The world in 2010: ICT facts and figure [Available from: https://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2010.pdf 
36. Reinhardt Mathiesen E, Ladefoged Nichum V, Barfred C, Juul HM, Secher AL, Ringholm L, Damm P. The smartphone application “Pregnant with Diabetes” communicates antenatal health information and reaches pregnant women with diabetes and those planning pregnancy.  European Association for the Study of Diabetes; Lisbon 2017