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

7.5 Conclusions
One of the key fi ndings of the previous CEMACH report 4 was that women with diabetes in England, Wales
and Northern Ireland are poorly prepared for pregnancy, and many enter pregnancy with poor glycaemic
control. Further exploration of the underlying issues for the 442 women in the enquiry has confi rmed that
two thirds of women had suboptimal glycaemic control before and in early pregnancy, as assessed by
enquiry panels. It is of concern that the main underlying factors appeared to be social issues and women’s
approach to managing their diabetes.
Suboptimal glycaemic control and a suboptimal approach by women to diabetes management is
associated with poor pregnancy outcome (see Chapter 6), and the above issues need to be considered
as a matter of urgency if education programmes and preconception services are to reach those women
who need support to improve their pregnancy outcomes. Further research is needed into the possible
social, cultural and emotional factors affecting women’s preconception behaviour and how these can
be addressed. Primary and secondary care providers are likely to need to work together with local
communities in order to engage with women with diabetes before they enter pregnancy.
Some quotes from the panel discussions
Social and lifestyle issues:
• 'HbA1c 8.8. Communication problems (husband acted as interpreter). Cultural problems: woman
fasting during festivals. Suspected educational problems.'
• 'HbA1c 9.3 at 4 weeks. Patient not monitoring. Overseas refugee, language diffi culties' .
• ‘Lifestyle – hours of work - busy life.’
• 'Her obesity, social factors 'domestic turmoil'. No evidence of regular diabetes review - seems to
have lost contact with professionals.'
• 'Unplanned pregnancy' .
• Non-adherence to medical advice:
• 'patient did not take dietary recommendations and did not take insulin regularly' .
• 'HbA1c pre-pregnancy range 11.5 - 7.4%, but non-compliant with diet, forgets injection, regular
hypo's, lack of carbohydrates.'
• 'patient did not test her levels for optimal care (average three per week)' .
Non-attendance at planned appointments:
• 'No pre-pregnancy care. 5 appointments sent by midwife and DSN. Not checking blood sugars' .
• 'Inconsistent attendances at clinic. ? Lifestyle problems - single mother with 2 small children' .
• HBA1c 10.4 at booking, brittle diabetic disease process. Woman was poor attender. Diabetic
coma three months prior to pregnancy' .
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