Women with pre-gestational diabetes have significantly increased risk of adverse pregnancy outcome, with a two- and five-fold increased risk of fetal congenital anomaly and stillbirth, respectively, compared with the general maternity population (Confidential Enquiry into Maternal and Child Health [CEMACH], 2005).
It is now well recognised that major congenital malformations and miscarriage are related to glycaemic control before and during early pregnancy (Ray et al, 2001). Pregnancy planning and markers of pre-pregnancy care are associated with reduced risks of adverse pregnancy outcome, with lower rates of adverse outcome in women who discontinue contraception after achieving optimal HbA1c (Pearson et al, 2007). However, the CEMACH (2007) enquiry highlighted that women with diabetes were poorly prepared for pregnancy, with two thirds receiving suboptimal pre-conception care, and only a minority using any form of contraception in the 12 months before pregnancy. These findings suggest that women are not aware of the importance of continuing to use contraception until near-normal glycaemic control is achieved.
It is important to define what is meant by pre-conception counselling and pre-conception care, although the terms are often used interchangeably. Pre-conception counselling should be an ongoing process, starting in adolescence, with the healthcare professional counselling their patient about the importance of avoiding an unplanned pregnancy, the risks associated with unplanned pregnancy and, importantly, providing women with advice on contraception and on how to access pre-pregnancy care. Pre-pregnancy or pre-conception care is the additional support and care required to help a woman with diabetes to prepare for pregnancy. Women should seek pre-pregnancy care at least 6 months before pregnancy, with one of the main aims to optimise glycaemic control before conception (Temple, 2010).
NICE guidance highlights the need to remove barriers to the uptake of pre-conception care (National Collaborating Centre for Women’s and Children’s Health [NCCWCH], 2008). Inadequate pre-conception counselling may be one of the main barriers to accessing pre-conception care. To address this, our research team, together with healthcare professionals from the South Eastern and Belfast Health and Social Care Trusts has recently produced an educational DVD: “Women with Diabetes – Things You Need to Know (But Maybe Don’t)”. Funded by a research grant from Diabetes UK, this DVD covers both pre-conception counselling for those not planning a pregnancy and pre-conception care for women thinking about having a baby.
The DVD was developed under the direction of a multidisciplinary team adhering to NICE guidance (NCCWCH, 2008) and with input from women with diabetes. Initial exploration of the needs and knowledge of women with diabetes using focus groups directed the tone, key messages and format of the DVD (Spence et al, 2010). Eight women with diabetes were filmed as “the cast” of the DVD, sharing their stories, views and experiences alongside an evidence-based commentary.
The DVD is currently being distributed to all women with diabetes of child-bearing age in Northern Ireland (NI) via their diabetes care team. GP surgeries throughout NI have been invited to request copies for any women who do not attend a diabetes clinic for annual review (this DVD is not currently available to people outside of NI). The effect of the DVD on pregnancy planning, management and outcome within NI will subsequently be evaluated using a pre/post DVD intervention study design using historical controls.
This DVD is a timely, novel and useful product, developed with the input of women with diabetes to complement and reinforce pre-conception counselling. Our aim is to empower women with diabetes to access pre-conception care. Long-term evaluation of this DVD is ongoing, and the impact of this tool on pregnancy outcomes is currently not known. In the meantime, healthcare professionals can individually and collectively work towards removing barriers to the uptake of pre-conception care, by engaging in pre-pregnancy counselling at every contact with women with diabetes of child-bearing potential (NCCWCH, 2008).