Diabetes in pregnancy: are we providing the best care ... - HQIP

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13. Conclusions The St. Vincent declaration in 1989 1 that ‘in fi ve years, the outcome of diabetic pregnancy should approximate that of non-diabetic pregnancy’, has not yet been achieved. However, there have been a number of national and local initiatives focusing on improving the care and outcomes of pregnant women with type 1 and type 2 diabetes. The Diabetes National Service Framework 2 , fi rst published by the Department of Health in 2001, set out a series of national standards for the care of people with diabetes. This included a standard for pregnancy which emphasised the importance of tight blood glucose control before conception and during pregnancy in order to optimise the chance of a good pregnancy outcome. The NSF includes key interventions, targets and illustrative service models which are available for NHS organisations to draw upon during the development of their local services, and local NHS performance will be assessed against the three-year and ten-year targets in the NSF’s Delivery Strategy. 3 In addition, the Diabetes Commissioning Toolkit 4 published by the Department of Health in November 2006 includes best practice quality markers, evidence of improvement, and key outcomes that should be sought by commissioners of services. In particular, it specifi es that there should be evidence of defi ned leadership within specialist services and integration between primary and secondary care for pre-pregnancy care and support. The CEMACH Diabetes Programme has provided a comprehensive national overview of diabetes maternity services, standards of care for women with diabetes, and the possible reasons underlying suboptimal clinical care and lack of involvement of women in their own care. This should aid health care providers and commissioners in planning the most appropriate services for their local populations. The programme has highlighted a number of areas which need to be addressed. These include poor preparation for pregnancy and the need for effective education programmes for women of childbearing age with diabetes; fragmented preconception care services and variations in the standard of preconception care provided by health professionals; the increasing problem of women with type 2 diabetes and their different needs; and neonatal care policies. As a response to the fi nding that the majority of women with diabetes are poorly prepared for pregnancy, CEMACH, together with the Royal College of General Practitioners and Diabetes UK, has published a joint information leafl et for GPs and the primary care team. This sets out information about the appropriate care and advice to provide for women of childbearing age with diabetes. The leafl et has been distributed to GPs throughout the UK and is also available for downloading from the CEMACH website. Poor preparation for pregnancy appears to be the next barrier to overcome for women with diabetes. The CEMACH programme has found that pregnant women with type 2 diabetes, who are also more likely to be from a Black, Asian and Other ethnic minority group and live in a deprived area, appear to be less likely to access preconception care and annual diabetes reviews than women with type 1 diabetes. In order to better understand the reasons and possible solutions to this, CEMACH has commenced a research project with the University College London (UCL) Elizabeth Garrett Anderson Institute for Women’s Health which is funded by Novo Nordisk. This will investigate the issues affecting preconception care in women with type 1 and type 2 diabetes. It is clear that commissioners and providers of health care in both primary and secondary care settings need to work collaboratively. Their joint aim should be to ensure that women with diabetes are better 96
informed and motivated to manage their diabetes before they become pregnant and that accessible multidisciplinary services are provided for them before pregnancy, during pregnancy and after delivery. References 1. Workshop Report. Diabetes Care and Research in Europe: The Saint Vincent Declaration. Diabetic Med 1990:7;360. 2. Department of Health. National Service Framework for Diabetes (England) Standards. London: The Stationery Offi ce: 2001. 3. Department of Health. National Service Framework for Diabetes: Delivery Strategy. London: Department of Health: 2002 [http://www.dh.gov.uk/assetRoot/04/03/28/23/04032823.pdf] accessed 17 January 2007. 4. Department of Health. Diabetes Commissioning Toolkit. London: Department of Health: 2006 [http://www.dh.gov.uk/assetRoot/04/14/02/85/04140285.pdf] accessed 17 January 2007. 97
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Confidential Enquiry into Maternal
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Contents Acknowledgements .........
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• Members of the CEMACH Diabetes
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Erb’s palsy Injury to the nerve r
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Neonatal unit A unit which provides
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Foreword This third and fi nal repo
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1. Introduction This is the fi nal
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2. Key fi ndings of the CEMACH Diab
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Suboptimal fetal surveillance of ba
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3. Summary of recommendations This
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2. Patient pathways of care includi
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the pregnancies meeting this defi n
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in order to remove any identifi abl
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When deriving odds ratios for any p
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Associations are reported in Chapte
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Table 5.1 Characteristics of women
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Table 5.4 Characteristics of women
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was no information available to pan
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6. Factors associated with poor pre
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Table 6.2 Association of clinical c
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Table 6.5 Association of specifi c
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Table 6.8 Association of postnatal
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folic acid before pregnancy (19% of
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Table 7.2 Panel comments on social
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7.5 Conclusions One of the key fi n
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11.Dex S, Heather J (eds). Millenni
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8. Clinical care issues: preconcept
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chance of induction of labour was r
Page 57 and 58: 8.6.1 Enquiry fi ndings Just over h
Page 59 and 60: Some quotes from the panel discussi
Page 61 and 62: Apart from the explanation of pregn
Page 63 and 64: was associated with poor pregnancy
Page 65 and 66: of women after the fi rst trimester
Page 67 and 68: 9.5.1 Panel comments on suboptimal
Page 69 and 70: During labour and delivery, the maj
Page 71 and 72: Just 52% of 383 women (38% of 164 c
Page 73 and 74: • ‘No serial growth scans perfo
Page 75 and 76: The panel enquiries, which are in e
Page 77 and 78: 10.3.1 Enquiry fi ndings Seventy fi
Page 79 and 80: 10.6 Communication Effective commun
Page 81 and 82: Some quotes from the panel discussi
Page 83 and 84: working between primary and seconda
Page 85 and 86: we therefore selected 7.2% of pregn
Page 87 and 88: 11.4 Preconception behaviour The CE
Page 89 and 90: enquiry related to a 12 month prior
Page 91 and 92: Table 11.10 Differences in postnata
Page 93 and 94: Type 1 and type 2 diabetes have tra
Page 95 and 96: Panels were chaired by the panel ch
Page 97 and 98: In 57% (24/42) of cases, a junior d
Page 99 and 100: Infant formula given as fi rst feed
Page 101 and 102: 2.1 hours in babies remaining with
Page 103 and 104: 12.7.1 Panel comments on suboptimal
Page 105 and 106: The concerns described here probabl
Page 107: External commentary Patricia Hamilt
Page 112 and 113: 100 Appendix A: Pre-pregnancy care
Page 114 and 115: 102 Appendix B: Diabetes enquiry pr
Page 132 and 133: Appendix C Association between demo
Page 134 and 135: Appendix C Association of preconcep
Page 136 and 137: Appendix C Association of postnatal
Page 138 and 139: Appendix D Association of social an
Page 140 and 141: Appendix D Association of diabetes
Page 142 and 143: Appendix E Association between demo
Page 144 and 145: Appendix E Association between prec
Page 146 and 147: Appendix E Association between post
Page 148 and 149: Appendix F - CEMACH advisory groups
Page 150: Appendix F - CEMACH advisory groups
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