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

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Commentary
Kirsty Samuel
CEMACH lay panel assessor, Legal assessor, woman with type 1 diabetes and mother of two children.
As a lay panel assessor in the CEMACH diabetes enquiry, a woman with diabetes and a mother of two
children, I feel this chapter highlights a number of important areas in explaining the unacceptably high
number of adverse pregnancy outcomes for women with diabetes. However it is the reasons behind the
fi gures that are of relevance in going forward. Why is suboptimal glycaemic control before and during
pregnancy so common and why is the woman’s approach to managing her diabetes less than ideal?
These two questions are, in my opinion, inextricably linked. The answer lies in the lack of accessible
diabetes education and pre-pregnancy counselling. Women do not realise the importance of good control,
and therefore do not ‘follow the advice given’, as it does not seem either signifi cant or achievable to them.
Women with diabetes of childbearing age need to be made more aware of the potential impact of poor
glycaemic control on pregnancy outcomes. This information should be made available before pregnancy
is seriously contemplated so that HbA1c levels can be reduced in preparation for pregnancy and
unplanned pregnancies can be avoided. Women with type 2 diabetes particularly need to be targeted
as many wrongly believe that their condition is less serious than type 1 diabetes and therefore will have
less of an impact on pregnancy.
In conjunction with this counselling, women need to be told of the tangible benefi ts of good control and
the greatly increased likelihood of having a healthy baby, as fear of complications and congenital
anomalies also has a part to play in non-attendance at clinics.
As optimal glycaemic control is central to diabetes management in pregnancy, the means to achieve it has
to be provided more effectively. The practicalities of attaining near perfect control for such a long period of
time are frightening and off-putting to many women, who fi nd good control hard enough to achieve without
the additional burden of pregnancy. Realistic targets must be set, and ongoing support and reassurance
provided. Women need to know that their blood sugar levels will fl uctuate, and should be taught how
to deal with these fl uctuations in practical terms - how to adjust their insulin, when and how to test their
urine for ketones, and when to seek medical help. This will require a great deal of additional support and
resources but by teaching women how to manage their glycaemic control more effectively, they will feel
more involved, more secure and more able to deal with the realities of pregnancy.
Non-attendance at appointments will hopefully decrease in the future with increased public knowledge and
awareness of the importance of adhering to medical advice. However this, along with a fear of being ‘told
off’ for failing to meet targets, is only one element of non-attendance at clinics. Practical problems such as
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