Diabetes mellitus continues to be one of the most common pre-existing medical conditions to complicate pregnancy and carries considerable risks for both the woman and the fetus (McCance, 2011; Knight et al, 2014). Women with pre-existing type 1 and type 2 diabetes have significant mortality and morbidity rates during pregnancy (Knight et al, 2014). Diabetes is known to carry a tenfold increase in the risk of congenital malformations such as cardiac anomalies, a fivefold increase in the risk of stillbirth and a threefold increase in the risk of neonatal death (Jensen et al, 2004; McCance, 2011). Poor glycaemic control in the early stages of organogenesis is thought to be a key aetiological contributor to these anomalies and to fetal loss (Inkster et al, 2006; Nelson-Piercy, 2010).
The National Institute for Health and Care Excellence (NICE, 2015) recommends that women with diabetes should not exceed 40 weeks' gestation because of the increased risk of stillbirth and the risks associated with macrosomia. Consequently, women with diabetes carry increased labour and birth complications associated with induction of labour, such as caesarean section and postpartum haemorrhage. The most recent MBRRACE-UK report (Knight et al, 2014) highlighted that four women with pre-existing type 1 or type 2 diabetes had died as a result of poor blood glucose control prior to conception and during pregnancy. These preventable deaths reiterate the need for health professionals to consider the importance of educating this group of women in relation to both preparing for pregnancy and early pregnancy management, to optimise outcomes.
This article explores the reasons why pre-conception care is important from a public health perspective and the challenges regarding its implementation, not only on a national scale but from a global standpoint. Some of the recent innovative approaches to pre-conception care will be highlighted, and discussion with regard to midwives being an effective conduit for pre-conception care provision will be debated.
Why is pre-conception care important?
Pre-conception care is recognised as a core strategy for reducing risk in pregnancy, particularly among women with chronic medical conditions such as diabetes, and is key to improving health outcomes (Temple, 2011; Knight et al, 2014). There is a lack of consensus regarding the most effective approaches for promoting pre-conception health and how best to encourage women to take up available services (World Health Organization (WHO), 2013; Glinianaia et al, 2014; Shannon et al, 2014). Directions for pre-conception care services are suggested to be lacking, for example in ad hoc service provision and a lack of written hospital policies (Shannon et al, 2014). These have potential to be detrimental for women and provide a significant public health issue (Shannon et al, 2014).
The lack of focused, well-designed studies continues to hamper effective measurement of the quality of pre-conception services available to women (Shannon et al, 2014). While there is readily available information on clinical guidance with regard to pre-conception care provision, there is a dearth of information on how to practically implement services and reach women successfully. Posner et al (2006) recognised a lack of comprehensive evidence-based literature to support the most effective pathway for policy development and argued that this has had an impact on effective approaches to pre-conception care. Johnson et al (2008) concurred, suggesting that the diversity of policies relating to pre-conception care are fragmented and that health professionals should adopt a more individualised, holistic approach for women, focusing primarily on improving birth outcomes.
Pre-conception care as a global public health issue
From a global perspective, pre-conception care is recognised as an effective mechanism not only to help reduce maternal and childhood morbidity and mortality, but also as an operational tool for addressing many health behaviours and health issues (WHO, 2013; NICE, 2015). This can be achieved through a process of screening interventions, preventive health-care messages and the targeting of health behavioural risks such as poor diet, smoking or alcohol misuse, which are recognised to cause higher risks of pregnancy and birth complications, including preterm birth or stillbirth (WHO, 2013). The provision of pre-conception care programmes is important for ensuring that women optimise opportunities for a healthy onset to pregnancy (Mathai, 2008). Targeting maternal behaviours prior to pregnancy may minimise the risk of harmful exposures to the fetus at the optimum time of organ development, between 4–10 weeks' gestation (Shannon et al, 2014).
One of the main challenges in relation to pre-conception care is identifying operational strategies for implementation, as there is limited evidence regarding the most effective methods for delivery of services (Mason et al, 2014). Dean et al (2013) have highlighted the challenges created by strategic research investment in relation to health-care funding and high-level decision-making. This has curbed investment in relation to issues such as pre-conception care. To make a comparison with an alternative health-care system, much of the USA's public policy literature relating to pre-conception care has recognised the need for action on investment in pre-conceptual health due to increasing adverse birth outcomes, in particular preterm birth (King, 2009). However, the USA faces different challenges than the UK, from the perspective of escalating private health-care costs and increasing marginalisation where individuals opt out of, or lose access to, health insurance (Porter and Teisberg, 2006). Kaestner and Lee (2005) studied low-income pregnant women without health insurance and found they were more likely to have poorer obstetric outcomes. In the UK, similar links to low socioeconomic status and birth weight have been detected (Smith et al, 2007). The NHS endures continual challenges with underfunding and the allocation of finite resources (Doetter and Götze, 2011). This has often created a fragmentation of services; Shannon et al (2014) reflected that the UK has struggled to determine the most effective strategies for implementing pre-conception care, mainly due to the generalised nature of health-system delivery and the diversity of strategies used in local populations, which then have an impact on overall service delivery. This article considers a number of possible strategies for encouraging women to take up pre-conception services.
Using innovative approaches to pre-conception care
A 3-year prospective study of women with diabetes emphasised that pre-conception services are not moving at a similar pace to other NHS services from an organisational and technological perspective (Murphy et al, 2010). The study suggested this had created a fragmentation of services and a deficiency of structured education processes for women, highlighting that there needed to be a more innovative approach to service delivery. This was supported by O'Higgins et al (2014), who interviewed women with diabetes in Ireland to seek ways of improving uptake of pre-conception services. The women emphasised the importance of education, highlighting that increased use of social media as a source of information could be developed by health professionals and may promote uptake of services.
Smartphone technology is increasingly recognised as a vehicle for information provision and support (Tripp et al, 2014). The increasing interactivity of this technology allows women to personalise information to the extent that it can almost feel like a consultation (Tripp et al, 2014). Challenges to the use of technology can be related to both the quality of information available and the interpretation of literature. Ready accessibility to information may be counteracted by practical issues such as poor phone signal in rural areas or limited storage capacity on a phone (Robinson and Jones, 2014; Hussain et al, 2015). However, the use of this form of technology, particularly for adolescents, is recognised as an effective means of communication, particularly in the health-care field.
Adolescent women with diabetes continue to show limited awareness of the risks associated with unplanned pregnancy; this reiterates that the adolescent period should be considered a key point in encouraging young women to consider pre-conception health outcomes (Dean et al, 2013; Xaverius et al, 2013). Utilisation of smartphone technology could help to achieve this.
Women have cited a number of barriers to accessing services, including distance to travel, issues around childcare requirements and lack of time (Infanti et al, 2014). Younger women have also reported embarrassment at discussing pre-conception issues with health professionals (Schwarz et al, 2010). An example that could address this issue, which has been implemented in the UK, is a DVD on pre-conception advice aimed at women with diabetes, which is circulated by health professionals such as diabetes physicians, GPs or diabetes nurses at routine appointments (Spence et al, 2013). Primary evaluation of the DVD demonstrated significant increases in knowledge and understanding of the importance of pregnancy planning, and increased verbal willingness to access pre-conception services (Holmes et al, 2012). Similarly, the use of educational websites could enhance knowledge acquisition and prompt women to access pre-conception services. An example of this can be found at www.womenwithdiabetes.net.
Multidisciplinary support
Many elements of the NICE (2015) diabetes guideline have been incorporated as standard into maternity clinic settings across the UK, with one of the key elements being the provision of multidisciplinary team input. One challenge is that the quality of multidisciplinary input can vary across the UK, with some units unable to offer specialist obstetricians or midwives; this could have an impact on the quality of pregnancy-focused information being provided to women (Temple, 2011). In the USA, Jack et al (2008) found that a common barrier to pre-conception advice-giving is that health professionals often give inconsistent messages regarding risk and appropriate pregnancy-related health promotion advice.
The Diabetes and Pregnancy Group (2005) identified that women of childbearing age with diabetes have a poor understanding of associated pregnancy risks, despite being reviewed approximately three times per year by their routine diabetes team; this emphasises the lack of focused information being provided on this subject. A qualitative study by McCorry et al (2012) suggested that women with diabetes were unaware of the consequences of not planning a pregnancy. Murphy et al (2010) suggested women were not motivated to attend for pre-conception care despite being aware of the risks of pregnancy, and found that women with a previous poor personal obstetric history were reluctant to attend for pre-conception care. Reasons cited by women included a lack of acceptance with regard to their diabetes condition; however, there was also a strong adverse perception of health professionals as a result of previous negative encounters in the practice setting (Murphy et al, 2010). Perceived social stereotyping by health professionals has been cited as a barrier to women with diabetes receiving any pre-conception advice at all; for example, where women were only given pre-conception advice if they were in a marital relationship or appeared to be in an appropriate age bracket (Spence et al, 2010). These challenges reiterate the importance of multidisciplinary communication and educational support to reduce negative or inappropriate consultations.
Appropriate setting for the provision of pre-conception care
Difficulties remain with regard to the most effective setting for delivering pre-conception care. Ideally, pre-conception care for women with diabetes should take place in diabetes multidisciplinary team settings at the woman's annual diabetes review; however, there is a lack of evidence in this area to encapsulate the quality of advice being provided. Shannon et al (2014) revealed that the most common approach to pre-conception care delivery in primary care settings remains opportunistic. This is challenging as it is reliant on the motivations and knowledge of the health professional and also on the number of women attending the setting, therefore it will not capture the entire childbearing population. A report commissioned by the King's Fund in 2010 highlighted the changing face of maternity service provision in relation to GPs, underlining a decline in their input in this area (Smith et al, 2010). This was despite a Royal College of Obstetricians and Gynaecologists (2008) report emphasising the importance of the GP role in delivering pre-conception advice for women with complex medical conditions.
Posner et al (2006: s199) developed a framework demonstrating the importance of interrelationships for developing successful pre-conception interventions using an ‘ecological’ model with the woman as the central core, but the role of the community, health-care providers and health-care institutions having an interactive influence on her health outcomes. The authors argued that all levels are integrated and reliant on one another, suggesting that if one level is not engaged, the woman's health is more likely to suffer. This is reflective of Dahlgren and Whitehead's (1991) Determinants of Health model, which recognised the multi-layered responsibility for health encompassing not only the individual, but his or her social and community network and other influential cultural and economic conditions.
The Ottawa Charter for Health Promotion reiterated the responsibility of communities to become empowered to improve health outcomes for their inhabitants (WHO, 1986). Irvine (2010) argued that adopting a more community-focused approach to health promotion activities is more likely to encourage sociopolitical change on a larger scale, which will ultimately enhance positive community health. Placing pre-conception services within community settings that are locally accessible to women could help enhance women's ability to negotiate and improve their health. The use of peer support groups in the community, where women can share their experiences, may be another option to promote and empower women with diabetes.
Are midwives the most appropriate health professional to support women with pre-conception care?
In the UK, midwives are increasingly being viewed as the first point of contact for pregnant women, and women with diabetes could benefit from the support midwives offer in relation to preparing for pregnancy (Hughes et al, 2010; Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). However, a study in the Netherlands highlighted that midwives still do not view themselves as having a pre-conception role, and have cited a lack of knowledge and time as barriers to providing this type of care (van Heesch et al, 2006). One way for midwives to incorporate delivery of pre-conception advice into their practice could be to use the postnatal period as an optimum time to target women with regard to subsequent pregnancies; however, this does not account for women planning a first pregnancy. The use of a specialist midwifery practice role could be another avenue for targeting pre-conception care; however, there is currently a recognised lack of specialist midwife roles in relation to diabetes, despite recommendations from NICE about the benefits of such a role (Irwin, 2010).
Service development
There are initiatives under development which aim to support and integrate diabetes services to create a more seamless service in the NHS. Diabetes UK, in conjunction with the NHS, has encouraged the development of local diabetes networks to improve integrated care for people with diabetes and to minimise duplication of services (Diabetes UK, 2013). Similarly, the Year of Care Initiative has been developed to encourage self-management for people with diabetes through proactive partnership working (Doherty et al, 2012). It is argued that these approaches are cost-effective and offer improved client experience (Diabetes UK, 2013). Diabetes UK suggests local diabetes networks have the ability to help translate policy into action through lobbying for commissioning of services. The use of peer support groups may provide support for women with diabetes who are contemplating pregnancy. The use of alternative technologies for educating women about pregnancy planning could be another option where access to local services is challenging.
Conclusion
The introduction and development of services in the NHS system is always based on cost/benefit analysis, so there is a definitive need for quality research studies to explore pre-conception services and uncover the most effective strategies for targeting women successfully. Ad hoc service provision is not enough. Women, particularly those with chronic medical disorders and long-term conditions, need early and effective triggers to seek support and advice with regard to pregnancy planning.
Midwifery 2020 (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010), while not clearly elucidating a midwifery role in pre-conception care, reiterates the importance of embedding midwives in the heart of the community as the first point of contact for pregnancy. The document emphasises the importance of seamless working with other health professionals to ensure a high-quality maternity service. Working closely with diabetes services could be an avenue for midwives to develop more effective relationships with this particular group of childbearing women, and could ultimately lead to better health outcomes in this challenging area of public health.