Women with diabetes are at an increased risk of adverse antenatal outcomes and good pre-pregnancy care reduces the risk. The National Pregnancy in Diabetes (NPID) 2018 audit showed pre-pregnancy care for women with diabetes remains sub-optimal. In Sheffield, only 22-31% of women were prescribed high dose folic acid 5mg daily and 5-10% were taking harmful medication (renin angiotensin system blockers and statins) at the time of their antenatal booking appointment. These care variables have not improved since 2014.
From the NPID data, there was an urgent need to review the service model to improve the pre-pregnancy care for women with diabetes. The objective was to increase the uptake of high dose folic acid 5mg daily and reduce harmful medications at antenatal booking. These care variables were defined by the NICE Diabetes in Pregnancy Guideline (NG3) 2015.
There were a number of challenges to achieving these goals. Firstly, at least 50% of pregnant women with diabetes had type 2 diabetes and the majority of these women were managed in primary care where awareness of pre-pregnancy management may be limited. A significant proportion was from ethnic minority groups with poor healthcare engagement. Secondly, compared with type 1 diabetes, women with type 2 diabetes of child-bearing age (15–45 years) were more likely to be taking harmful medications and less likely to be on folic acid prior to pregnancy. Thirdly, in addition to minimal city-wide educational initiatives, there was no robust system in primary care to raise awareness of the importance of pre-pregnancy management for women of child-bearing age.
To overcome these challenges, engagement across the ACP/STP was essential. The strategy was threefold: (1) establish links with healthcare workers including general practitioners, practice nurses, community pharmacists and health trainers; through buy-in from key stakeholders; (Local Pharmaceutical Committee, and Sheffield City Council) (2) develop a robust foundation to educate and raise awareness on pre-pregnancy care in primary care and (3) work collaboratively with the consultant diabetologist; diabetes specialist nurses based at Sheffield Teaching Hospitals and the GP diabetes lead in primary care.
Multiple interventions were implemented. Meetings were arranged with community pharmacists, health trainers and practice nurses from all neighbourhood areas in the city to publicize and address concerns with this project. 'SAFER' posters and small business cards highlighting the importance of pre-pregnancy care were designed and distributed to all general practices and community pharmacists across the city. Regular 3-monthly reminders on pre-pregnancy care were sent to the primary care workforce (general practitioners, practice nurses and community pharmacists) via the CCG's weekly e-bulletin, with the principal aim of reinforcing this clinical message. Patient information leaflets and a safety checklist for healthcare professionals on pre-pregnancy care were developed; these information leaflets and clinical systems pop-up reminder messages for clinicians to discuss pre- pregnancy care with women of child-bearing age were embedded into the primary care IT system. These interventions were introduced between October 2018 and March 2019.
The impact of this project was reviewed by assessing the prescription of folic acid and harmful medications at booking during the pre-intervention (January - September 2018) and post-intervention (October 2018 and March 2020) phase. Prior to intervention, 29% of women were taking folic acid at booking. After the intervention, this proportion increased to 47%. For harmful medications, the proportion remained unchanged at 5.9% and 6.1% for the pre- and post-intervention cohorts, respectively. Data on referrals to the pre-pregnancy clinic between September 2019 and February 2020 were obtained. There were 36 referrals over a 5-month period, a significant increase from the annual rate of 12 referrals.
My experience indicated that collaboration between primary and secondary care was essential to improve pre- pregnancy care city-wide.
