New standards for the lead midwife in diabetes role

The new Lead Midwife in Diabetes: Standards, Role and Competencies guidance (NHS Diabetes, 2010) – jointly published by NHS Diabetes and the Royal College of Midwives (RCM) – is to be welcomed, as this document is a resource for improving maternity care of pregnant women with diabetes, including gestational diabetes.

The Confidential Enquiry into Maternal and Child Health (2005) survey of pregnant women with type 1 and 2 diabetes found that standards of pre-conception care for these women were poor. In addition, they had increased risks of stillbirth (five-fold), macrosomia (two-fold), neonatal death (three-fold) and congenital anomalies (two-fold) compared with women in the general population. Therefore, this new guidance aims to address the concerns of poor standards in diabetes maternity services and the increased risk of adverse pregnancy outcomes among women with diabetes.

Background
The number of midwives taking on the lead midwife in diabetes (LMD) role – either formally or informally – is increasing, thus giving credence to the need for new guidance for this group of healthcare professionals.

The initiative to develop the new standards stemmed from the Pregnancy and Diabetes open space event held by NHS Diabetes in December 2008, hosted by Dr Rowan Hillson, National Clinical Director for Diabetes. Stakeholders of the care pathway were invited to explore areas of concern in relation to different aspects of care in pregnant women with diabetes and identify how healthcare professionals could support the woman’s journey through pregnancy. This event, which followed the publication of the NICE (2008) Diabetes in Pregnancy: Management of Diabetes and its Complications from Preconception to the Postnatal Period guideline, was well represented by many different NHS healthcare professionals who are involved with providing care to women from the pre-conception to the postnatal period.

One of the concerns raised at the open space event was the scope, extent and diversity of practice of the role of the diabetes midwife. As a result, a multiprofessional advisory group was established to formulate new standards for the role of LMDs, bringing together expertise from NHS Diabetes, the RCM and other healthcare professionals involved in women’s care.

The long-awaited standards document provides direction and structure for LMDs where previously none existed. This group of professionals, with advanced specialist knowledge, skills and burgeoning caseloads, have been on the fringe of DSN teams for too long. The LMD has endured disparity in practice and, on occasions, has lacked support or understanding from peers. Pioneering centres with the foresight to develop this role have been disadvantaged by the lack of benchmarks to measure their success by, and individual LMDs have reported problems with integrating into embedded DSN teams and accessing appropriate postgraduate education and continuing professional development.

Across the country, the role of the LMD has varied enormously in its remit and, therefore, depth of practice; hence, many LMDs have found it difficult to measure their effectiveness as no two roles are the same. Although it is important that any role reflects the needs of the local population, the new standards document aims to ensure that all LMDs are working toward the same standards.

LMD standards
The NHS Diabetes and RCM document (NHS Diabetes, 2010) sets out new standards that LMDs must meet in providing care for pregnant women with diabetes. The rationale behind each standard is outlined and guidance on how to achieve them are included in the document. There are six standards:

• Access to specialist services – to ensure that all pregnant women with diabetes have access to specialist services, such as LMDs.
• Organisational issues – LMDs should be integrated into the multidisciplinary teams that provide care for this population of women.
• Clinical governance – clinical governance and risk-management procedures must be in place to ensure that LMDs deliver high-quality, safe care to this population.
• Communication – information needs to be accessible to aid decision-making and to assist communication with women, their families and other healthcare professionals.
• Education and training – to ensure that practitioners have necessary skills and support to deliver high-quality, safe care to this population.
• Diabetes-specific midwifery practice – the LMD, with enhanced skills and knowledge of diabetes, should be an advocate for pregnant women with diabetes and contribute to multidisciplinary teams to ensure the delivery of optimal care for this population.

This document provides recommendations for service commissioners and suggests the rationale for a needs assessment of local populations. It is essential that a robust assessment of current and future needs in the care of pregnant women with diabetes is undertaken. Healthcare professionals face many challenges in the future, one being the estimated increase in prevalence of diabetes, including gestational diabetes. Geographical variations will exist depending on this needs assessment and will ultimately determine the potential caseload of the LMD.

There needs to be assurance that GP consortia will have the breadth of vision and sufficient unity to undertake the needs assessment and be able to commission services for women with pre-gestational diabetes and gestational diabetes, otherwise care will become fragmented and the care pathway indistinct. In a recent press release by NHS Diabetes (2011), Anna Morton, Director of NHS Diabetes, added that “maternity services need to be proactive in addressing the needs of these women locally”.

Conclusion
Although the Lead Midwife in Diabetes: Standards, Role and Competencies document does not specifically address issues relating to education, its very existence will hopefully enable greater emphasis to be placed on supporting LMDs in developing their diabetes knowledge and skills. Modules on diabetes in pregnancy have always been aside mainstream diabetes educational courses either at degree or masters level – this should now change. It is imperative that educational establishments develop specific courses to address the needs of pregnant women with diabetes.