Preconception care in managed care: The translating research into action for diabetes study

doi:10.1016/j.ajog.2004.06.105

American Journal of Obstetrics and Gynecology

Volume 192, Issue 1, January 2005, Pages 227-232

https://doi.org/10.1016/j.ajog.2004.06.105 Get rights and content

Objectives

This study was undertaken to examine the rates of preconception counseling in managed care for women with diabetes and associated patient and physician characteristics.

Study design

Participants included women aged 18 to 45 years enrolled in a study of diabetes care in managed care. Women were asked if they recalled discussions regarding glucose control before conception (n = 236) and use of family planning until glucose control was achieved (n = 227). Hierarchical logistic regression models accounted for patient and physician characteristics.

Results

Fifty-two percent of women recalled being counseled about glucose control and 37% recalled family planning advice. In adjusted models, patient age (years) (odds ratio [OR] 0.91, 95% CI 0.86-0.96) and body mass index (BMI) (kg/m²) (OR 0.96, 95% CI 0.93-0.99) remained significant predictors of glucose control counseling. Similarly, patient age (years) (OR 0.94, 95% CI 0.89-0.99) and BMI (kg/m²) (0.96, 95% CI 0.93-0.99) remained significant predictors of family planning counseling.

Conclusions

Preconception counseling rates for diabetic women are low and associated with younger age and lower BMI.

Section snippets

Study setting and population

The TRIAD study has been previously described.¹⁵ In brief, 6 Translational Research Centers (TRCs) collaborate with 10 managed care health plans and 68 provider groups that serve approximately 180,000 people with diabetes. The health plans are geographically and ethnically diverse (Hawaii, California, Texas, Indiana, Michigan, New Jersey, and Pennsylvania). TRIAD's study population consisted of a stratified, random sample of adults with diabetes. The study protocol was reviewed and approved by

Results

The unadjusted characteristics of participants by their recall of preconception counseling are shown in Table. Twenty-four percent of women were aged 18 to 34 years, 26% were 35 to 39 years, and 50% were 40 to 45 years. Approximately half of the women recalled discussions regarding the importance of attaining good glucose control and a little more than a third recalled discussions regarding the importance of family planning. Women who were younger, with lower weight and longer duration of

Comment

Although multiple measures of the quality of diabetes care have improved over the past decade, this improvement has not extended to preconception care. TRIAD has previously reported increased rates of dilated eye examination, lipid measurement, influenza vaccination, foot examination, Hb_A1C measurement, and blood pressure measurement compared with earlier studies.¹⁰ This report demonstrates low preconception counseling rates persist from previous reports that noted approximately a third of

Acknowledgments

We thank the TRIAD participants who made this study possible. We also thank Kathy Welch for her assistance in the statistical analysis.

References (22)

C. Weisman et al.
Contraceptive counseling in managed care: preventing unintended pregnancy in adults
Womens Health Issues
(2002)
S. Gabbe et al.
Management of diabetes by obstetrician-gynecologists
Obstet Gynecol
(1998)
Centers for Disease Control and Prevention
Diabetes prevalence among American Indians and Alaska Natives and the overall population—United States, 1994-2002
MMWR Morb Mortal Wkly Rep
(2003)
M. Engelgau et al.
Use of services by diabetes patients in managed care organizations
Diabetes Care
(1998)
M.B. Willhoite et al.
The impact of preconception counseling on pregnancy outcomes
Diabetes Care
(1993)
B. Rosenn et al.
Pre-conception management of insulin-dependent diabetes: improvement of pregnancy outcome
Obstet Gynecol
(1991)
A. Elixhauser et al.
Cost-benefit analysis of preconception care for women with established diabetes mellitus
Diabetes Care
(1993)
ACOG technical bulletin
Preconceptional care. Number 205-May 1995. American College of Obstetricians and Gynecologists
Int J Gynaecol Obstet
(1995)
American Diabetes Association
Preconception care of women with diabetes
Diabetes Care
(2002)
N. Janz et al.
Diabetes and pregnancy: factors associated with seeking pre-conception care
Diabetes Care
(1995)

E. Holing et al.

Why don't women with diabetes plan their pregnancies?

Diabetes Care

(1998)

Cited by (33)

Effect of implementation of a preconception counselling resource for women with diabetes: A population based study
2017, Primary Care Diabetes
To evaluate the effect of regional implementation of a preconception counselling resource into routine diabetes care on pregnancy planning indicators.
A preconception counselling DVD was distributed to women by diabetes care teams and general practices. Subsequently, in a prospective population-based study, pregnancy planning indicators were evaluated. The post-DVD cohort (n = 135), including a viewed-DVD subgroup (n = 58), were compared with an historical cohort (pre-DVD, n = 114). Primary outcome was HbA1c at first diabetes-antenatal visit. Secondary outcomes included preconception folic acid consumption, planned pregnancy and HbA1c recorded in the 6 months preconception.
Mean first visit HbA1c was lower post-DVD vs. pre-DVD: 7.5% vs. 7.8% [58.4 vs. 61.8 mmol/mol]; p = 0.12), although not statistically significant. 53% and 20% of women with type 1 and 2 diabetes, respectively, viewed the DVD. The viewed-DVD subgroup were significantly more likely to have lower first visit HbA1c: 6.9% vs. 7.8% [52.1 vs. 61.8 mmol/mol], P < 0.001; planned pregnancy (88% vs. 59%, P < 0.001); taken folic acid preconception (81% vs. 43%, P = 0.001); and had HbA1c recorded preconception (88% vs. 53%, P < 0.001) than the pre-DVD cohort.
Implementation of a preconception counselling resource was associated with improved pregnancy planning indicators. Women with type 2 diabetes are difficult to reach. Greater awareness within primary care of the importance of preconception counselling among this population is needed.
The preconceptional period as an opportunity for prediction and prevention of noncommunicable disease
2015, Best Practice and Research: Clinical Obstetrics and Gynaecology
Citation Excerpt :
Key organizations have published extensive guidelines and recommendations for preconceptional care, including the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), and the Centers for Disease Control and Prevention (CDC) [3–5]. It is estimated that 30–90% of women have at least one indication that may benefit by an appropriate preconceptional intervention [6,7]. However, only 30–50% of pregnancies are planned with a proper preconceptional care plan [7–14].
Preconceptional care is a set of interventions, aimed to identify and modify medical, behavioral, and social risks to a woman's health and her pregnancy outcome, prior to conception. Diagnosing and treating some of the common noncommunicable diseases (NCDs) may have an impact on pregnancy outcome. Ample time should be allowed to properly intervene in some of the following situations: hypertension, diabetes, obesity, systemic lupus erythematosus, thyroid disease, anemia, epilepsy, asthma, and cardiac disease. Diabetes mellitus and obesity are common NCDs, with proven efficacy for preconceptional care, for both maternal and perinatal outcome. These primary components of the metabolic syndrome, if properly treated prior to pregnancy, will prevent long-term hazards for the mother, her children, and the next generations, by providing in utero primary prevention of NCDs.
Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States
2015, American Journal of Obstetrics and Gynecology
Preconception care for women with diabetes can reduce the occurrence of adverse birth outcomes. We aimed to estimate the preconception care (PCC)–preventable health and cost burden of adverse birth outcomes associated with diagnosed and undiagnosed pregestational diabetes mellitus (PGDM) in the United States.
Among women of reproductive age (15-44 years), we estimated age- and race/ethnicity-specific prevalence of diagnosed and undiagnosed diabetes. We applied age and race/ethnicity-specific pregnancy rates, estimates of the risk reduction from PCC for 3 adverse birth outcomes (preterm birth, major birth defects, and perinatal mortality), and lifetime medical and lost productivity costs for children with those outcomes. Using a probabilistic model, we estimated the reduction in adverse birth outcomes and costs associated with universal PCC compared with no PCC among women with PGDM. We did not assess maternal outcomes and associated costs.
We estimated 2.2% of US births are to women with PGDM. Among women with diagnosed diabetes, universal PCC might avert 8397 (90% prediction interval [PI], 5252-11,449) preterm deliveries, 3725 (90% PI, 3259-4126) birth defects, and 1872 (90% PI, 1239-2415) perinatal deaths annually. Associated discounted lifetime costs averted for the affected cohort of children could be as high as $4.3 billion (90% PI, 3.4-5.1 billion) (2012 US dollars). PCC among women with undiagnosed diabetes could yield an additional $1.2 billion (90% PI, 951 million-1.4 billion) in averted cost.
Results suggest a substantial health and cost burden associated with PGDM that could be prevented by universal PCC, which might offset the cost of providing such care.
Rate of preconception care in women with type 2 diabetes still lags behind that of women with type 1 diabetes
2012, Canadian Journal of Diabetes
To examine the rate of preconception care, associated factors and impact on glycemic control among pregnant women with pre-existing diabetes.
A descriptive study of pregnant women with type 1 or 2 diabetes mellitus who attended specialized clinics from 2006 to 2010. Referring physician, medications, obstetrical history and history of diabetes and glycemic control were determined.
The rate of preconception care in type 1 diabetes, at 43.1% (85/197), was significantly greater than type 2 diabetes, at 18.4% (49/267; p<0.001). For women with type 1 diabetes, those with 2 or more pregnancies were more likely to have received preconception care than women with only one pregnancy (odds ratio 7.0, 95% confidence interval 2.0–24.6). The first trimester glycated hemoglobin was significantly lower in women with preconception care compared to women without preconception care for type 1 diabetes (6.9 ± 0.7% vs. 7.7 ± 1.5%, p<0.001) and type 2 diabetes (6.4 ± 1.1% vs. 7.6 ± 1.8%, p=0.007).
The rate of preconception care in women with known diabetes remains suboptimal, especially among woman with type 2 diabetes. We confirmed that preconception care is associated with better glycemic control in early pregnancy.
Examiner le taux de recours aux soins avant la conception, les facteurs associés et l’incidence sur la régulation glycémique chez les femmes enceintes ayant un diabète préexistant.
Une étude descriptive de femmes enceintes ayant le diabète sucré de type 1 ou 2 qui ont fréquenté des cliniques spécialisées de 2006 à 2010. Le médecin traitant, les médicaments, les antécédents obstétricaux, et les antécédents de diabète et de régulation glycémique ont été déterminés.
Le taux de recours aux soins avant la conception lors du diabète de type 1, à 43,1 % (85/197), a été significativement plus grand que lors du diabète de type 2, à 18,4 % (49/267; p < 0,001). Chez les femmes ayant le diabète de type 1, celles ayant eu 2 grossesses ou plus étaient plus susceptibles d’avoir reçu des soins avant la conception que les femmes n’ayant eu qu’une (1) seule grossesse (ratio d’incidence approché 7,0, intervalle de confiance à 95 %, 2,0-24,6). Au premier trimestre, l’hémoglobine glyquée était significativement plus basse chez les femmes ayant reçu des soins avant la conception que celle des femmes n’ayant pas reçu de soins avant la conception lors du diabète de type 1 (6,9 ± 0,7 % vs 7,7 ± 1,5 %, p < 0,001) et lors du diabète de type 2 (6,4 ± 1,1 % vs 7,6 ± 1,8 %, p = 0,007).
Le taux de recours aux soins avant la conception chez les femmes ayant un diabète connu semble sous-optimal, particulièrement chez les femmes ayant le diabète de type 2. Nous avons démontré que les soins avant la conception sont associés à une meilleure régulation glycémique en début de grossesse.
Preconception care for women with type 1 and type 2 diabetesdthe same but different
2012, Canadian Journal of Diabetes
Citation Excerpt :
The key maternal characteristics that tend to predict the likelihood of not receiving prepregnancy counselling including smoking, being unmarried, lower family income and poor relationship with provider (31). Kim et al. (32) asked women with type 1 and type 2 diabetes receiving care in a managed care setting to recall discussions about glycemic control before conception and use of family planning. Younger maternal age (OR 0.91, CI 0.86–0.96) and lower BMI (OR 0.96, CI 0.93–0.99) predicted glucose control counselling.
Women with type 1 and type 2 diabetes are at increased risk for spontaneous pregnancy loss and other adverse obstetrical outcomes including congenital anomalies. Most of these risks can be reduced through preconception planning and optimization. Although many of the components of preconception care are essential for both groups of women, there are some important differences between type 1 and type 2 diabetes. Specialized clinics improve outcomes, however, most women do not attend them. A poor relationship with the healthcare provider continues to be a major risk for not receiving prepregnancy care. All healthcare providers need to use effective communication strategies to enhance open dialogue and increase the likelihood of prepregnancy optimization for women with pregestational diabetes.
Les femmes ayant le diabète de type 1 et celles ayant le diabète de type 2 sont exposées à un risque élevé d'avortement spontané et à d'autres issues obstétricales indésirables, dont les anomalies congénitales. La plupart de ces risques peuvent être réduits par la planification et l'optimisation avant la conception. Même si plusieurs des composantes des soins avant la conception sont essentielles pour les femmes des deux groupes, il y a d'importantes différences entre le diabète de type 1 et le diabète de type 2. Les cliniques spécialisées améliorent l'issue de la maladie. Cependant, la plupart des femmes ne les fréquentent pas. Une mauvaise relation avec le fournisseur de soins de santé demeure un risque majeur pour ne pas recevoir de soins avant la grossesse. Tous les fournisseurs de soins de santé ont besoin d'utiliser des stratégies de communication efficaces pour favoriser l'ouverture du dialogue et augmenter la probabilité de l'optimisation avant la grossesse chez les femmes ayant un diabète prégestationnel.
Preconception care: a clinical case of "think globally, act locally"
2008, American Journal of Obstetrics and Gynecology

View all citing articles on Scopus

TRIAD was funded through the Centers for Disease Control and Prevention (U48/CCU516410-02).

Reprints not available from the authors.

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General Obstetrics and Gynecology: ObstetricsPreconception care in managed care: The translating research into action for diabetes study

Objectives

Study design

Results

Conclusions

Section snippets

Study setting and population

Results

Comment

Acknowledgments

Womens Health Issues

Obstet Gynecol

Diabetes prevalence among American Indians and Alaska Natives and the overall population—United States, 1994-2002

MMWR Morb Mortal Wkly Rep

Use of services by diabetes patients in managed care organizations

Diabetes Care

The impact of preconception counseling on pregnancy outcomes

Diabetes Care

Pre-conception management of insulin-dependent diabetes: improvement of pregnancy outcome

Obstet Gynecol

Cost-benefit analysis of preconception care for women with established diabetes mellitus

Diabetes Care

Preconceptional care. Number 205-May 1995. American College of Obstetricians and Gynecologists

Int J Gynaecol Obstet

Preconception care of women with diabetes

Diabetes Care

Diabetes and pregnancy: factors associated with seeking pre-conception care

Diabetes Care

Why don't women with diabetes plan their pregnancies?

Diabetes Care

General Obstetrics and Gynecology: Obstetrics
Preconception care in managed care: The translating research into action for diabetes study