Prepregnancy Care: A Shared Responsibility

The effective management of pregnancies complicated by diabetes is a shared responsibility—an equal partnership between health care professionals and a responsible woman. Over the last 30 years, major advances in our understanding of the pathophysiology and care of diabetes has led to the hope that pregnancy outcomes for women with diabetes would be similar to the outcomes for women without diabetes as stated in the goal of the Saint Vincent's Declaration in 1989 (1). Unfortunately this has not been realized with the risk of congenital malformations, stillbirths, and neonatal death remaining as high as 3–10 times that of the background population (2,,–5).

For over a decade, major evidence-based guidelines have called for the counseling of women of child-bearing age with diabetes about the need for family planning and excellent control prior to conception (6,,–9). Also, preconception care provides the opportunity for the woman and her health caregivers to evaluate nutritional needs, the presence and extent of any micro-/macrovascular complications, and to adjust medications or diabetes management plans before pregnancy occurs.

Ideally, every woman with known diabetes would not only have prepregnancy counseling but actually receive effective prepregnancy care. This has been an elusive goal that is underlined in the article by Murphy et al. (10) in this issue of Diabetes Care. These investigators developed a remarkable “marketing” plan, which included a website, lively and encouraging pamphlets mailed directly to potential patients, as well as local and community educational activities for health professionals. Disappointingly, only 27% of the eligible women with pregestational diabetes actually presented for prepregnancy care. This mirrors similar attempts in Maine (34%) using a statewide community–based educational program for health providers and Ohio (37% in the third 5-year phase of a 15-year program) to optimize access and use of prepregnancy counseling and care (11,12). In the Ohio study, as in the study by Murphy et al., improvement in prepregnancy care equated with improvement in adverse pregnancy outcomes.

Thus, a care gap exists between “desired” and “real” prepregnancy care. The suggested reasons for this gap include socioeconomic deprivation, ethnic differences in the risks and use of the health care system, or difficulties with health literacy (3,13,–15). Murphy et al. observed that some women became pregnant faster than expected after discontinuing contraception or instituting lifestyle changes and thus had not yet achieved optimal control or changed medications. Logistical and financial concerns also played roles as well as previous negative relationships with health professionals. There was also a fear of disappointment or a desire for minimal medical input to maximize positive pregnancy experiences (15,16).

Only about half of women with type 1 diabetes receive prepregnancy care with little evidence of improved outcomes over the last 10 years (4,10). The normal glucose values in pregnancy (mean A1C 5.3% and upper limit of normal under 5.7%) are achieved by few women, and the goal A1C of under 6% remains elusive (4,17). Achievement of this level of glucose control without hypoglycemia requires a truly expert and experienced health care team and a highly motivated and knowledgeable woman with type 1 diabetes. The significant knowledge and attention to detail needed concerning nutrition, insulin self-adjustment, and use of frequent glucose monitoring information with frequent injections and/or pump therapy can prove to be beyond the woman's capabilities; others lack the needed motivation to intensify their management adequately. Indeed, such demands of knowledge and motivational methods may prove to be even beyond the abilities of their team of health professionals. Not all women will have access to adequately experienced teams in specialized centers who can work with them to achieve such control or family support integral to effective self-care. Additionally, advanced technologies such as continuous glucose monitoring and pump therapy may be required in order to safely achieve such normal glucose levels, and these technologies may be unavailable for economic or pragmatic reasons to many women with type 1 diabetes (18,19).

The prevalence of type 2 diabetes is rising worldwide in women of childbearing age, and their care is generally in the hands of primary-care physicians (20). Thus, fewer women with type 2 diabetes relative to type 1 diabetes are seen in multidisciplinary prepregnancy clinics and, although most guidelines—including the International Diabetes Federation's Global Diabetes in Pregnancy Guideline—recommend insulin as optimal therapy ideally initiated prior to pregnancy, the reality is that this is often not done (3,7,10,13). A recent review of maternal and fetal outcomes in type 1 and type 2 diabetic women suggests that, although women with type 2 diabetes generally have had the disease for a shorter period of time, have and can achieve better glucose control in the pregnancy, and have lower rates of diabetes complications, they have equally poor outcomes (21). Yet women with type 2 diabetes who access prepregnancy care can safely achieve normal glycemia in pregnancy with much less effort, as discussed in a recent review (22).

Interestingly, it was the outcomes of the women with type 2 diabetes in the study of Murphy et al. that experienced statistically significant improvements that helped to reduce overall adverse outcomes (10). For women with type 2 diabetes, the congenital malformation rate fell from 12.3 to 4.4%, perinatal mortality fell from 6.2 to 0.9%, and any serious adverse outcome fell from 16.4 to 5.3%, whereas in all these subcategories, there was very little change for women with type 1 diabetes. The importance of the reported study is that it shows that access to prepregnancy counseling and care does reduce adverse pregnancy outcomes by about 80% (odds ratio 0.2 [95% CI 0.05−0.89]; P = 0.03) (10).

For women with type 1 diabetes, not only do we need to improve their use of and access to prepregnancy care, but we need to continue to improve management techniques to safely achieve levels of glucose control in our efforts to improve outcomes. We must never cease to sensitize the women with diabetes as to how important their efforts are in learning and applying self-management techniques in order to achieve excellent outcomes. As Dr. Donald R. Coustan suggested in his editorial in Diabetes Care over 10 years ago, “the relationship's the thing.” The role of the interpersonal relationship between the woman and her health care provider as well as the strength of her relationship with her partner and his involvement and understanding play roles in the successful outcome of pregnancy in women with diabetes that are difficult to measure (23).

For women with type 2 diabetes, this is a growing problem, particularly in areas of the world where the ethnic risk of type 2 diabetes is higher and access to adequate medical care may be an issue, such as in India and China (24). Many women with type 2 diabetes are treated with oral agents prior to conception, which are usually prescribed by their family physician or obstetric-care provider. Any physician prescribing oral agents, statins, and/or ACE inhibitors to a woman of childbearing age must automatically review any potential plans she may have for pregnancy and remind the woman of the necessity of planning and adjustments to her medications should she become pregnant. It is crucial that prepregnancy counseling becomes an essential part of overall diabetes management, and primary-care providers are well aware of the improvement in outcome it provides. It is equally crucial that women are well acquainted with their responsibilities in undertaking a pregnancy in the face of diabetes.

Integration of preconception care within a larger maternal and child health continuum of care is consistent with the Kathmandu Declaration made in 2009, which encompasses the concept of the life circle (25). Periconception care of women with diabetes becomes an essential component of preventive efforts to avoid more diabetes in future generations (7,25). Programs like the one reported by Murphy et al. can make a difference. Based on the Ohio experience, efforts become more effective when they occur consistently over longer periods of time. Successful efforts to eliminate the risks in pregnancy and for the offspring in women with known diabetes will require improvements in and maintenance of clinical expertise. However the best health care system available is of no use unless the customers, in this case women with diabetes of reproductive age, are responsive and responsible. Clearly, individual women must become more involved and sensitized to the necessity and usefulness of preparing adequately for a pregnancy and learning self-management. This is an ongoing challenge in the care of diabetes.