Improving maternal health care in the US requires addressing the longitudinal continuum of women’s health care across the life course, from pre-pregnancy to maternity to postpartum care. Care in the pre-pregnancy, or preconception, space is critical as it allows for early intervention for health conditions and behaviors that can ultimately improve patient health before pregnancy. For women with chronic medical conditions, pre-pregnancy care strategies may include provision of family planning services to prevent or delay pregnancy, optimizing disease status in preparation for pregnancy, and changing medications that may be teratogenic to something that is safer for pregnancy. For brevity, we refer to “women” throughout the post but note that transmen and gender non-confirming individuals may also be able to become pregnant while managing chronic conditions.
Diabetes is one such condition where pre-pregnancy care is especially important, but is inadequately delivered. Diabetes is increasingly prevalent among women during their reproductive years and during pregnancy in the United States, disproportionately affecting racial/ethnic minorities. When diabetes is established before conception, elevated blood sugar is associated with severe maternal and infant complications, including perinatal loss, fetal anomalies, preeclampsia, and macrosomia. Guidelines recommend diabetes-specific preconception care, which is the care individuals receive prior to pregnancy to improve their health and foster healthy birth outcomes. However, only about half of postpartum women with preexisting diabetes report receiving preconception care. Studies have identified barriers and challenges to preconception care delivery to women with diabetes. These include unplanned pregnancy, competing priorities, and limited time in the clinical setting.
In our recent paper published in Healthcare: The Journal of Delivery Science and Innovation, we offered suggestions for the clinical encounter and for health systems that may help address barriers and better deliver diabetes-specific preconception care for this growing demographic. We highlight a few suggestions below.
Strategies for Delivering Family Planning and Preconception Counseling for Women with Diabetes
At the clinical encounter, delivering preconception counseling to women with diabetes in a patient-centered manner is critical. Preconception counseling can be patient-centered by tailoring content to women's current goals, such as using the framework of the “awareness” phase for women who are not planning a pregnancy, “overview” phase for women who are thinking about planning a pregnancy, and “in-depth” phase for women who are actively planning. For women not actively planning pregnancy, it is important to decrease barriers to contraception use and provide high-quality contraceptive counseling. Some have suggested routine queries about pregnancy intentions to guide provision of contraceptive care and/or preconception care, using approaches such as the One Key Question. To support patient education, evidence-based preconception health materials have been developed for adolescents with diabetes. There is need for materials for adults with diabetes, particularly those which are culturally relevant.
Health System Interventions to Support Care Delivery
There are health systems interventions that can support and enable providers in delivering family planning and preconception care to women with diabetes. Electronic Health Records (EHRs) integrated across settings of care can promote care coordination, addressing the fragmentation of care that can occur when specialties intersect. Clinical decision support and best practice alerts may be useful in helping clinicians assess patients’ reproductive goals as described above and/or delivering contraceptive care using the US Medical Eligibility Criteria for Contraceptive Use (US MEC), which provides guidance for providers on the safe use of contraceptive methods for patients with medical conditions. The delivery of preconception counseling can begin outside of the clinical encounter may help address the barriers of limited time and competing priorities during health care visits. Patient-facing educational materials delivered through electronic patient portals should be considered.
The strategies described above point to a new framing to help achieve high quality diabetes care for patients with reproductive potential: family planning should be conceptualized as concurrently supporting each patient's diabetes management as well personal childbearing goals, rather than siloing these concerns. Making these improvements will likely have a great return: one study estimated that successfully delivering preconception care to every woman with diabetes would save $5.5 billion in healthcare costs and lost productivity due to preterm deliveries, birth defects, and perinatal mortality.