Development of an integrated, district-wide approach to pre-pregnancy management for women with pre-existing diabetes in a multi-ethnic population

Background: Poor diabetes management prior to conception, results in increased rates of fetal malformations and other adverse pregnancy outcomes. We describe the development of an integrated, pre-pregnancy management strategy to improve pregnancy outcomes among women of reproductive age with diabetes in a multi-ethnic district.Methods: The strategy included (i) a narrative literature review of contraception and pre-pregnancy interventions for women with diabetes and development of a draft plan; (ii) a chart review of pregnancy outcomes (e.g. congenital malformations, neonatal hypoglycaemia and caesarean sections) among women with type 1 diabetes (T1D) (n = 53) and type 2 diabetes (T2D) (n = 46) between 2010 and 2015 (iii) interview surveys of women with T1D and T2D (n = 15), and local health care professionals (n = 13); (iv) two focus groups (n = 4) and one-to-one interviews with women with T1D and T2D from an Australian background (n = 5), women with T2D from cultural and linguistically diverse (CALD) (n = 7) and indigenous backgrounds (n = 1) and partners of CALD women (n = 3); and (v) two group meetings, one comprising predominantly primary care, and another comprising district-wide multidisciplinary inter-sectoral professionals, where components of the intervention strategy were finalised using a Delphi approach for development of the final plan.Results: Our literature review showed that a range of interventions, particularly multifaceted educational programs for women and healthcare professionals, significantly increased contraception uptake, and reduced adverse outcomes of pregnancy (e.g. malformations and stillbirth). Our chart-review showed that local rates of adverse pregnancy outcomes were similarly poor among women with both T1D and T2D (e.g. major congenital malformations [9.1% vs 8.9%] and macrosomia [34.7% vs 24.4%]). Challenges included lack of knowledge among women and healthcare professionals relating to diabetes management and limited access to specialist pre-pregnancy care. Group meetings led to a consensus to develop a district-wide approach including healthcare professional and patient education and a structured approach to identification and optimisation of self-management, including contraception, in women of reproductive age with diabetes. Conclusions: Sufficient evidence exists for consensus on a district-wide strategy to improve pre-pregnancy management among women with pre-existing diabetes.