Aims/Objective: Prepregnancy care has been shown to be beneficial for women with type 1 diabetes when delivered in specialist centres. Critics suggest this focuses resources on selected women rather than those who need it most. Our aim was to implement and evaluate a regional prepregnancy care programme for unselected women with type 1 and type 2 diabetes.
Research Design and Methods: Prepregnancy care was promoted among patients and health professionals and delivered across 10 regional maternity units (annual birth rate 50,000). A prospective cohort study of 680 pregnancies in women with type 1 and type 2 diabetes was performed. Primary outcomes were adverse pregnancy outcome (congenital malformation, stillbirth or neonatal death), congenital malformation and indicators of pregnancy preparation (5mg folic acid, gestational age, HbA1c). Comparisons were made with a historical cohort (n= 613 pregnancies) from the same maternity units during 1999-2004.
Results: 181 (27%) women attended and 499 women (73%) did not attend prepregnancy care. Women with prepregnancy care presented earlier (6.7 versus 7.7 weeks; p<0.001), were more likely to take 5mg preconception folic acid (88.2% versus 26.7%; p<0.0001) and had lower HbA1c levels (HbA1c 6.9% versus 7.6%; p<0.0001). They had fewer adverse pregnancy outcomes (1.3% versus 7.8%; p=0.009). Multivariate logistic regression confirmed that in addition to glycaemic control, lack of prepregnancy care was independently associated with adverse outcome (Odds ratio 0.2, 95% Confidence Interval 0.05-0.89; p=0.03). Compared to previously, folic acid supplementation increased (40.7% versus 32.5%; p=0.006) and congenital malformations decreased (4.3% versus 7.3%; p=0.04).
Conclusions: Regional prepregnancy care was associated with improved pregnancy preparation and reduced risk of adverse pregnancy outcome in type 1 and type 2 diabetes. Prepregnancy care had benefits beyond improved glycaemic control and was a stronger predictor of pregnancy outcome than maternal obesity, ethnicity or social disadvantage. More work is needed to improve attendance, particularly in women with type 2 diabetes, and to optimise preconception glycaemic control, in type 1 diabetes.