Effectiveness of a Regional Prepregnancy Care Program in Women With Type 1 and Type 2 Diabetes: Benefits Beyond Glycemic Control

A large number of studies have demonstrated that prepregnancy care for women with preconceptional diabetes improves glycemic control and reduces adverse pregnancy outcomes. However, only 2 regional centers, both nearly 20 years ago, have described the benefits of implementing prepregnancy care programs. A large study in the United Kingdom reported that relatively few maternity units provided prepregnancy care clinics for women with diabetes and that only 10% of diabetic women attended such clinics. In the absence of prepregnancy care, a majority of women with type 1 and 2 diabetes are at increased risk of potentially preventable poor pregnancy outcomes.This prospective cohort study investigated the implementation and effectiveness of a regional prepregnancy care program on pregnancy preparation, glycemic control, and pregnancy outcomes in women with type 1 and type 2 diabetes at 10 regional maternity units. The study population comprised 680 pregnancies of women with type 1 and type 2 diabetes. Primary outcomes examined included adverse pregnancy outcome (miscarriage, congenital fetal malformation, stillbirth, neonatal death) and indicators of pregnancy preparation (folic acid supplementation, and glycemic control [HgbA1c]). A historical cohort of 613 pregnancies from the same units during 1999-2004 served as the control.Overall, 27% (181/680) of the women with diabetes attended prepregnancy care and 73% did not. On comparison with the controls, women who attended prepregnancy care presented earlier (6.7 vs. 7.7 weeks; P < 0.0001), were more likely to use 5 mg preconception folic acid (88.2% vs. 26.7%; P < 0.0001), achieved lower HgbA1c levels (6.9% vs. 7.6%; P < 0.0001), and were less likely to conceive while on potentially harmful ACE inhibitors (1.1% vs. 4.6%; P < 0.05) and/or statins (0% vs. 7.6%; P < 0.0003). Overall, attendees had fewer adverse pregnancy outcomes (1.3% vs. 7.8%; P = 0.009). Multivariate logistic regression analysis showed that independent predictors of adverse outcome were glycemic control at booking (odds ratio, 1.46; 95% confidence interval, 1.16-1.85; P = 0.001 per 1% HgbA1c increase) and lack of prepregnancy care (odds ratio, 0.2; 95% confidence interval, 0.05-0.89; P = 0.03). Neither maternal age, parity, obesity, ethnicity nor socioeconomic deprivation was independent predictors of adverse outcome. Notable differences in pregnancy outcomes during 2006-2009 compared with 1999-2004 included an increase in folic acid supplementation (40.7% vs. 32.5%; P = 0.006) and fewer congenital malformations (4.3% vs. 7.3%; P = 0.04).These findings show that implementation in routine care of a regional prepregnancy care program is associated with improved glycemic control and reduced risk of adverse pregnancy outcome in pregnancies of women with type 1 and type 2 diabetes.