Background
Methods
Narrative review
Chart review
Interview surveys
Focus groups and one to one interviews
Development of a PPM plan
Analyses
Results
Narrative review
Studies and interventions | Region/ Country | Program content | Specialist delivered the interventions | Centres | Results |
---|---|---|---|---|---|
Northern Island/UK | The importance of planning pregnancy and the role of contraception. | A diabetes specialist- nurse and -midwife, a dietitian, a GP, a clinical health Psychologist, an obstetrician, a nutritionist | 1 [10]: Two national health services 2 [13]:At their centre 4 [24]: At their centre | 1 [10]: The DVD significantly improved self-efficacy and reduced perceived barriers. Knowledge of pregnancy planning and pregnancy-related risks increased (P < 0.001). 2 [13]: The development process and outcome evaluation are an important point of reference for future educational programs 3 [23]: The viewed-DVD subgroup had lower first visit HbA1c (P < 0.001; increased planned pregnancy (P < 0.001); increased folic acid preconception (P = 0.001); and had improved HbA1c preconception (P < 0.001). 4 [24]: the development of an e-learning continuing professional development resource within the website. | |
Leaflets, structured audit with benchmarking, poster formal and informal patient education programs | East- Anglia/ UK | Planning a pregnancy and contact details for local PPC coordinator | Diabetes physician, specialist nurse, midwife or obstetrician | Primary-care teams in community settings, women with T1D: by specialist teams in hospital settings. Joint clinics. | 5 [5]: Women with PPC presented earlier (P = 0.001), were more likely to take 5 mg preconception folic acid (P = 0.0001) and had lower HbA1c (P = 0.0001). They had fewer adverse pregnancy outcomes P = 0.009). Lack of PPC was independently associated with adverse outcome (OR = 0.2; 95% CI 0.05–0.89). 6 [9]: Understanding PPC (90%); optimal glycaemic control (80%); risks of malformation (48%) and macrosomia (35%). 70% were not regularly using contraception (70%), stopped deliberately (45%), become less rigorous (28%) or experienced side effects (14%). |
EASIPOD 2a [19]: websites, workshops for HCP, Leaflets, structured audit with benchmarking, poster formal and informal patient education programs; GP software flags, online education program for HCPs | East- Anglia/UK | Planning a pregnancy and contact details for local PPC coordinator | Diabetes physician, specialist nurse, midwife or obstetrician | Primary-care teams in community settings, women with T1D: by specialist teams in hospital settings. Joint clinics. | 7 [19]: In those withT1D: improved gestational age at booking (7.6 vs 8.4 weeks), and in women with T2D: high rate of first HbA1c of < 6.5% < 48 mmol (58.5% vs 44.4%) and higher rate of preconception 5 mg folic acid (41.8% vs 23.5%) |
READY-Girls | Pittsburgh/USA | Presents the effects of diabetes on reproductive health, puberty, sexuality, and pregnancy and the benefits of PPC and includes skill-building exercises for healthy decision making and communication with HCPs. | Specialised nurses and GPs | Major university-based diabetes clinics | 8 [20]: Improved knowledge about family planning and reproductive health issues. 9 [12]: Increased in knowledge after the first visit (P < 0.001) and being sustained for 9 months (P < 0.05). preconception counselling barriers decreased over time (P < 0.001), and intention and initiation of preconception counselling and reproductive health discussions increased (P < 0.001). 10 [21]: Stronger knowledge about PPC (P = 0.003) and seek PPC when planning a pregnancy\ (P = 0.02) |
Leaflets and posters in out-patient waiting room [22] | Ireland | Patient education, a full medication review, assessment & treatment of diabetes-complications and thyroid status, commencement of folic acid 5 mg/d and focus on intensive glucose monitoring | Specialist and general practitioners | Antenatal care by Primary care clinicians, local endocrinologist, diabetes nurse specialist and dietitian | Attendees were more likely to take preconception folic acid (P < 0.001) and less likely to smoke (P = .03). Attendees had lower glycated haemoglobin levels (P < .001; third trimester HbA1c (P = 0.001), and their offspring had lower rates of serious adverse outcomes (P = 0.007) |
Chart-review
Variables | T1D | T2D | P-value* | T1D Melbourne | Background population in NSWd (2010) [28] |
---|---|---|---|---|---|
Age (years), mean (SD) | 28.6 (5.6) | 32.9 (5.2) | < 0.001 | 29.3 (5.3) | 30.8 |
n = 99 | n = 53 | n = 46 | |||
BMIa (Kg/m2), mean (SD)c | 25.8 (5.2) | 35.4 (8.1) | < 0.001 | 27.3 (5.0) -- | |
n = 93 | n = 48 | n = 45 | |||
Gravida, n (SD)** | 2.6 (2.2) | 3.1 (2.2) | 0.17 | – | |
n = 98 | n = 53 | n = 45 | |||
Parity, n (SD)** | 1.0 (1.2) | 1.5 (1.4) | 0.09 | – | |
n = 98 | n = 53 | n = 45 | |||
Country of birth, n (%)** | 0.07*** | ||||
Australia | 13 (35.1) | 8 (19.1) | 95 (89) | 67.3% | |
European descent | 16 (43.2) | 12 (28.6) | – | – | |
India/Bangladesh | 1 (2.7) | 5 (11.9) | – | 3.5% | |
Aboriginal | 2 (5.4) | 5 (11.9) | – | 3.3% | |
Others | 5 (13.5) | 12 (28.6) | – | 25.9% | |
n = 79 | n = 37 | n = 42 | |||
Family history of diabetes, n (%)** | 20 (66.7) | 30 (83.3) | 0.30 | – | – |
n = 66 | n = 30 | n = 36 | |||
Third-trimester HbA1c** | – | – | |||
% | 7.0 (1.8) | 6.5 (1.4) | 0.4 | ||
mmol/mol (SD) | 53.0 (19.7) | 47.5 (15.3) | |||
n = 76 | n = 39 | n = 37 | |||
Folic acid, n (%)** | 0.4*** | ||||
Nil | 13 (36.1) | 9 (30.0) | |||
< 5 mg | 7 (19.4) | 8 (26.7) | |||
5 mg | 8 (22.2) | 10 (33.3) | |||
Yes (dosage unknown) | 8 (22.2) | 3 (10.0) | |||
n = 66 | n = 36 | n = 30 | |||
Treatment before pregnancy, n (%)** | < 0.001*** | ||||
Diet alone | 0 | 4 (9.4) | |||
Tablets | 0 | 11 (26.2) | |||
Metformin | 0 | 8 (19.0) | |||
Gliclazide | 0 | 3 (7.1) | |||
Janumet (Metformin + Sitagliptin) | 0 | 1 (2.4) | |||
Insulin | 51(96.2) | 16 (38.1) | |||
Insulin + Metformin | 2 (3.8) | 7 (16.7) | |||
Nil | 0 | 4 (9.4) | |||
n = 95 | n = 53 | n = 42 | |||
Treatment during pregnancy, n (%)** | 0.003*** | ||||
Insulin | 38 (92.7) | 32 (78.1) | |||
Metformin | 1 (2.4) | 2 (4.9) | |||
Insulin & metformin | 1 (2.4) | 5 (12.2) | |||
CSIIb | 1 (2.4) | 0 | |||
Insulin only at labour | 0 | 1 (2.4) | |||
Total | 41 (100) | 40 (97.6) | |||
n = 82 | n = 41 | n = 41 | |||
Retinopathy screening, n (%)** | 0.06*** | ||||
Yes | 18 (64.3) | 9 (39.1) | |||
No | 10 (43.5) | 14 (60.9) | |||
n = 55 | n = 29 | n = 26 | |||
Thyroid disease, n (%)** | 0.8*** | ||||
Yes | 6 (12.0) | 5 (11.9) | |||
No | 42 (84) | 36 (85.7) | |||
n = 89 | n = 48 | n = 41 | |||
Delivery methodsb, n (%)** | 0.005*** | ||||
Vaginal | 12 (24.5) | 18 (41.9) | |||
Elective CSc | 17 (34.7) | 13 (30.2) | |||
Emergency CSc | 11 (22.5) | 9 (20.9) | |||
Vacuum | 3 (6.1) | 4 (9.3) | |||
n = 87 | n = 43 | n = 44 | |||
Pregnancy outcomesϕ, n (%)** | |||||
Neonatal Hypoglycaemia | 9 (36.0) | 3 (12.5) | 0.12 | – | – |
n = 49 | n = 25 | n = 24 | |||
Any congenital malformations | 4 (9.1) | 7 (15.6) | 0.25 | 4 (4) | 775 (0.8) |
Major | 4 (9.1) | 4 (8.9) | 0.55 | – | – |
Minor | 0 | 4 (8.9) | – | – | – |
n = 89 | n = 44 | n = 45 | |||
Hypertension | 11 (24.4) | 10 (22.2) | 0.25 | 2 (2) | 6357 (6.7) |
n = 90 | n = 45 | n = 45 | |||
Pre-eclampsia | 6 (12.2) | 4 (10.3) | 0.84 | 5 (5) | – |
n = 88 | n = 49 | n = 39 | |||
Macrosomia (birthweight> 4000 g) | 17 (34.7) | 11 (24.4) | 0.50ϒ | 47 (44) | – |
n = 94 | n = 49 | n = 45 | |||
Stillbirth | 0 | 0 | – | 7 (7) | 555 (0.6) |
n = 88 | n = 48 | n = 40 | – | – | |
Miscarriage | 4 (8.0) | 0 | – | ||
n = 94 | n = 50 | n = 44 |
Qualitative results (from interview surveys, focus groups and one to one interviews)
Patients
HCPs
Gaps (requirements) | Intervention programs used in the literature/ suggested by HCP’s/women/partners | Actions required to implement the interventions |
---|---|---|
Lack of time for women/patients to attend diabetes clinic | Websites, leaflets, contact details of local HCPsa [5], social media | 1) Providing after- hours clinics 2) Providing other educational resources (e.g. webpages, social media, and apps) 3) Reaching out to all patients and mailing them leaflets and information sheets on a regular basis |
Lack of communication (miscommunication) between HCPs and patients | Workshops, newsletters, online learning resources,regular meetings and education programs [46] | 1) Reminding HCPs about online resources and workshops 2) Adding techniques for communication to the existing learning materials |
Lack of knowledge about PPM and contraception methods in women and their partners | Leaflets, posters, DVDs, PPM education programs and peer support | 1) Developing a wide range of educational resources (e.g. posters, apps) 2) Increasing the accessibility of educational resources 3) Translating educational resources in most common languages |
Disparities of preferences in receiving knowledge about PPM and contraception options | Use of a wide range of interventions (e.g. online resources, social media, leaflets and posters) | Raising awareness among patients and their partners about the ranges of interventions |
Development of the plan
Interventions | Content/ details | Places (to be implemented) | Pros | Cons | Included |
---|---|---|---|---|---|
Workshops for HCPsa | Interpersonal techniques for communicating with other HCPs and patients (including CALDb women), and PPMc | Primary and secondary care services | Motivational, Enhancing skills and knowledge | Lack of flexibility in time, expensive | Yes |
DVD | ‘Risk of unplanned pregnancy, and effective contraception methods’, ‘local support team’, ‘blood glucose targets, hypos and ketoacidosis’, ‘diet, delivery’ and ‘post-birth’ | Primary and secondary care services including pharmacies | Easily accessible and convenient | High cost, not sustainable (can be lost/or scratched) | No |
Web-based education program | PPM information, links to pre-existing YouTube channels in multiple languages e.g. Arabic and Vietnamese | Websites and social media | Easily accessible and convenient, no limits in content | Passive | Yes |
Courses for patients and their partners | The importance of PPM (e.g. glycaemic control, smoking cessation and physical activity) and use of effective contraception | Primary and secondary care services, women’s health clinics | Motivational, they can ask questions | High cost, lack of flexibility in time | No |
Posters presentation /T.V screen advertisement | The importance of PPM with information about available local services (contact details for local HCPs) | Waiting rooms of primary and secondary care services, pharmacies, women’s health and fertility clinics | Easily visible, encourage an active response | Limited content | Yes |
Peer support/web chat | Sharing experiences about diabetes in pregnancy and services they have used | DCAPP social media | Easily accessible and convenient | Possibility of inaccuracy (Vulnerable to (cognitive) biases) | Yes |
Text message reminders | Links to the important websites, available resources (e.g. local pre-pregnancy clinics, social media) | Will be sent from the GP practices on regular bases (every six weeks) | Easily accessible and convenient | High cost | No |
Leaflets | Links to useful websites, potential risks of unplanned pregnancy and risk factors for potential complications | Primary and secondary care services, mail, pharmacies and women’s health clinics | Easy to access | High cost (if mailed), lack of interest (so common) | Yes |
Apps | ‘Risk of unplanned pregnancy, and effective contraception methods’, ‘local support team’, ‘blood glucose targets, hypos and ketoacidosis’, ‘diet, delivery’ and ‘post-birth’ | DCAPP website and social media, leaflets, and posters | Systematic approach, no cost to design (already existed) | Only available to smart-phone users | Yes |
Social media | Useful websites (e.g. NDSSd), updates/posts on the importance of PPM and contraception, and YouTube channel | Online (i.e. Facebook and Instagram) | High chance of being visited regularly | Only available to DCAPP social media followers | Yes |
Checklist software for general practitioners | Medication review, contraception advice, weight management strategies, importance of having optimal glycaemic control | GP surgeries | Systematic approach | High cost of design Needs to articulate with existing software | No |
Interventions | Content/ details | Places (to be implemented) | Pros | Cons | Included |
---|---|---|---|---|---|
Workshops for HCPsa and pharmacies [48] | Available contraceptive methods for women with diabetes and insertion techniques for IUDb | Primary and secondary care services and pharmacies | Potentially motivates HCPs, updates their knowledge | Lack of flexibility in time, High cost | Yes |
Courses for patients and their partners | The importance of planning for pregnancy and available contraception options for women with diabetes | Primary and secondary care services and pharmacies | Potentially motivates patients and their partners, they can ask questions | Lack of flexibility in time, High cost | No |
Accessibility of contraception | Providing free condoms in health-care services (especially primary care centres) | Primary and secondary care services, dental clinics, women’s health clinics, NDSSc | Easily visible, encourages people to use contraception | High cost | No |
Leaflets women and their partners’ awareness [49] | Importance of planning pregnancy and contraception uptake in women with diabetes | Primary and secondary care services, women’s health clinics and NDSSc | Minimises potential conflicts which could exist within the couples | High cost if mailed | Yes |
Mass-media, community and interpersonal channels [50] | Benefits of IUD, wide range of available contraception options, importance of optimised diabetes management prior to pregnancy | Primary and secondary care services, pharmacies and women’s health clinics | Repetitions, accessible to the majority of population group | High cost, not usable/usable for CALD women | No |
Web-based program including YouTube channel | The importance of planning for pregnancy and role of contraception, education of contraception options | The app will be addressed on leaflets, posters | Accessible anytime, pre-existed | Needs internet connection | Yes |
Checklist software for HCPs | Contraception advice | The link will be available on leaflet and posters | Potentially motivates HCPs, updates their knowledge | High cost Needs to articulate with existing software | No |
Why conception with poor glucose control and/or unsafe medications should be avoided | |
Contraception and family planning advice, with emphasis on the most effective contraception options (e.g. Long Acting Reversible Contraception and emergency contraception) to prevent unplanned pregnancies. | |
Emphasising the importance of glycaemic control using safe medications at least three months prior to conception | |
5 mg folic-acid uptake at least three months prior to pregnancy. | |
Avoidance/replacement of teratogenic drugs particularly for hypertension and dyslipidaemia | |
Importance of retinal, renal and vascular complication screening prior to conception | |
The risk of smoking during pregnancy | |
Online educational resources (e.g. National Diabetes Supply Scheme, Facebook and Instagram pages) | |
Contact details of local health services |
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Pharmacists will be asked to approach those picking up diabetes prescriptions.
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GP surgeries, private fertility and public diabetes clinics will be requested to make a list of the women with T1D/T2D of reproductive age and provide the coordinator with this number. This may be facilitated by using practice software. The hospital clinics have been provided with BIOGRID database/software [25] to facilitate this process. A clinic/practice member will be identified as the contact person to provide/receive further information. General practice and diabetes clinic staff who see the women will be asked to record if a leaflet has been provided, and their assessment of whether the woman is
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planning to become pregnant (and therefore warrant pre-pregnancy management/referral to the pre-pregnancy clinics or private care)
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not planning to become pregnant and identify the form of contraception in place including abstinence or not required (e.g. hysterectomy, confirmed menopause)
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neither and listing reason including informed decision, religious reasons, not currently sexually active.