Prepregnancy Diabetes Care Program Is Cost Effective and Improves Glycemic Control and Infant Outcomes

Commentary by lead author Aoife M. Egan, MD and Sara J Meltzer, MD, FRCPC, FACP

Women with diabetes who attend a preconception program have better outcomes.

A prepregnancy care program for women with type 1 and type 2 diabetes is effective and cost-effective, according to a prospective cohort and cost-analysis study published in the Journal of Clinical Endocrinology and Metabolism.

“Women who attended a prepregnancy care program are better prepared for pregnancy with a significantly lower hemoglobin A1C and higher rates of folic acid use than nonattenders,” said lead author Aoife M. Egan, MD, with the Galway Diabetes Research Centre at National University of Ireland Galway, Ireland.

“They are also less likely to be smoking or taking a potentially harmful medication at conception. Leading on from this, infants of attendees experience lower rates of congenital malformations (1% versus 5%) and are 30% less likely to need admission to the neonatal intensive care unit after birth.”

“Clinically, this is a current, prospective study that looks at actual direct cost assessments of the care of the mother and of the offspring in women with or without pre-pregnancy clinic attendance,” commented Sara J Meltzer, MD, FRCPC, FACP, Associate Professor of Medicine and Obstetrics and Gynecology, McGill University Montreal, Quebec, Canada.

“Previous studies are based on care data, much of which is 20 years old, other than the data from Cambridge and The Netherlands," Dr. Meltzer said. “Since the benefits shown are both clinical and economic, hopefully this article will provide a push for health care providers to at least increase the local uptake of any available prepregnancy clinics in the area (by preparation and distribution of leaflets or similar communications) and support their maintenance (by economically supporting the local endocrinologist, nurse educator, and dietitian who form the core of the service).”

Study Rationale
“Although the clinical value of prepregnancy care for women with diabetes is well established, only a minority of women received this care and the economic benefits are unclear,” Dr. Egan said. “Prior to 2006, there were no dedicated prepregnancy care clinics in our region, which covers a mixed urban-rural population of 500,000 along the Irish Atlantic Seaboard. This gap in service delivery was recognized by the Atlantic Diabetes in Pregnancy Initiative, a multidisciplinary group of healthcare professionals working together to improve outcomes for women with diabetes. 

“A prospective cohort study was therefore designed with the aim of designing, implementing and clinically and economically evaluating a regional prepregnancy care program,” Dr. Egan explained.

Prospective Study Design
The findings are based on data from 414 pregnancies among women with type 1 and type 2 diabetes, who attended antenatal centers along the Irish Atlantic Seaboard between January 2006 and December 2014. Of this group, 149 women (36%) attended prepregnancy care. Women entered the program through a referral from specialists or primary care clinicians, or by self-referral.

The prepregnancy care program included patient education, medication review, assessment and treatment of diabetes complications and thyroid status, prescription of folic acid 5 mg per day, and a focus on intensive glucose monitoring with a target hemoglobin A1C of <6.1% preconception if possible. The program was delivered at each site by a local endocrinologist, diabetes nurse specialist, and dietician with backup visits monthly from a consultant and a project coordinator at the study hub.

Women who received prepregnancy care were significantly older (33.8 vs 31.9 years; P<0.001), had a longer duration of diabetes (11.7 vs 9.5 years), had a lower hemoglobin A1C (7.4% vs 8.1%; P=0.002), and were more likely to be nulliparous (45.0% vs 38.9%; P=0.001).

Beneficial Effects Found for A1C levels and Infant Outcomes

Women who participated in the pregnancy care program were significantly more likely to take folic acid (97.3% vs 57.7%; P<0.001), less likely to smoke (8.7 vs 16.6%; P=0.03) or take potentially teratogenic medications at conception (0.7 vs 6.0; P=0.008). Median A1C levels were significantly lower throughout pregnancy in the pregnancy care program group (first-trimester trimester A1C: 6.8% vs 7.7%, P<0.001, third trimester A1C: 6.1% vs 6.5%, P=0.001). In addition, infants born to mothers who participated in the program had lower rates of serious adverse outcome (2.4% vs 10.5%; P=0.001).

“The benefits were itemized more for those women with type 1 diabetes,” Dr. Meltzer said. However, that the overall risk for serious adverse outcome was significantly reduced in the prepregnancy care group (odds ratio, 0.26; P=0.04), with participation in the program as the only significant predictor of risk for the combined type 1 and 2 group, Dr. Meltzer noted.

Of note, for women with type 1 diabetes, attendance in the prepregnancy program was linked to a higher rate of excessive maternal gestational weight gain (37.7 vs 24.7%, P=0.03), Dr. Meltzer said, adding that clinicians should be aware of this potential outcome when counseling women in prepregnancy care programs.

Prepregnancy Care Linked to Reduced Health Care Costs
According to multivariate regression analysis, attendance at the prepregnancy care program was the only factor significantly associated with a reduction in costs. The adjusted difference in complication costs between prepregnancy care vs usual care was €2,577.70), which offsets the per pregnancy cost of delivering prepregnancy care (€449.02), the study authors noted.

“We believe that all the clinical findings are broadly applicable to other geographic regions,” Dr. Egan said. “Limitations of the cost-savings analysis include generalizability to alternative health-care delivery systems. However, overall patterns of service use are likely similar between populations and we are confident that if applied to an alternate healthcare program, the cost-savings would remain evident.”  

How to Encourage Women With Diabetes to Attend Prepregnancy Care Programs
We improved our attendance rates in the latter part of the study through a number of initiatives.  This included providing flexible appointments and ensuring a supportive clinical environment with a focus on the positive aspects of childbearing.  We also encouraged women to bring along their young children to appointments to overcome childcare barriers.  Finally, we mailed information leaflets to all general practitioners, diabetes specialists and women in the region of childbearing age on an annual basis to inform them of the service.  We advise clinicians to take this approach when encouraging women to attend.  However, certain groups of women, including those with type 2 diabetes and very poor glycemic control are less likely to attend.  Future research should examine strategies to encourage these women to engage.  

“At our institution, we have a prepregnancy clinic associated with our pregnancy clinic for women with diabetes, so they are able to meet and interact with the team who eventually will manage their diabetes with them during the pregnancy,” Dr. Meltzer noted. “We have found that this lessens the transition difficulties once a pregnancy occurs. We have not had specific educational material prepared to enhance the uptake of the service, but the results of this study and that of Murphy et al would suggest it is something we should be doing.”

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