Summary
An intensive support package was introduced for pregnant women with type 1 diabetes (T1D). The package consists of a band 7 diabetes speicalist nurse (DSN) dedicated to antenatal care, intensive band 7 dietetic input, weekly appointments, telephone support, longer appointment times, MDT meetings, mental health support, alongside provision of continuous glucose monitoring (CGM). An audit was completed to establish whether the package had increased the number of women achieving a third trimester HbA1c of <48mmol/mol and if it improved neonatal outcomes. Results showed an increase in women achieving this, as well as fewer babies with macrosomia or admitted to NNU at birth.
Innovation
The National Pregnancy in Diabetes (NPID) audit found marked variation between units across the country regarding diabetes control and pre-conception care. NPID demonstrated that women with T1D who used insulin pumps early in pregnancy were more likely to achieve their HbA1c target. In addition, achieving a HbA1c <48mmol/ mol in late pregnancy, even if glycaemic control was suboptimal in early pregnancy, reduced the pre-term delivery rate by >15%. This suggested that more aggressive management would achieve better outcomes. Prior to 2021, despite rising numbers of new and follow-up patients, staffing for the Joint Diabetes Antenatal clinic (JANC) remained unchanged. The service consisted of two diabetes consultants and one part-time DSN. The consultants saw all new patients (pregnant or planning pregnancy) in the same clinic. The DSN worked part time (one session per week). Problems included minimal dietetic input, delayed access to carbohydrate counting and pump therapy, different documentation systems for the diabetes and maternity teams, little communication between diabetes, midwifery and obstetrics teams, no structured antenatal MDTs and minimal psychological support. The team made a case for a fulltime band 7 antenatal DSN and increased service provision across the wider antenatal team. Launched in 2021, the intensive support package comprised: increased JANC appointments for insulin adjustment, regular monitoring and optimisation of glycaemia; regular band 7 antenatal DSN input 1-2 weekly, support between appointments and a 4-weekly pre-conception clinic; all women began flash/CGM within seven days of referral; insulin pump therapy was provided quickly; dedicated, weekly band 7 diabetes dietitian-specific antenatal clinics supported overall diet quality for pregnancy and blood glucose management; a dedicated diabetes midwife coordinated appointments and arranged input from the mental health midwife; a monthly diabetes antenatal MDT discussed cases and other issues; one shared documentation system was used. Patient data was audited and shared at the pregnancy quality assurance meeting.
Equality, Diversity and Variation
St Helens and Knowsley (STHK) are among the top 10 most deprived boroughs in the UK Index of Multiple Deprivation. The prevalence of diabetes and obesity is slightly above the national average. Deprivation and multiple health conditions are common. The cost-of-living crisis affected the most vulnerable individuals particularly, potentially exacerbating existing health inequalities. Nearly a third of people with T1D experienced diabetes-related distress or mental health conditions. Financial burdens, stress and burnout related to managing blood glucose targets during pregnancy placed women with T1D at risk of further mental health deterioration. Inadequate nutrient intake during pregnancy could increase the risk of low birthweight, pre-term birth and developmental issues. Women with T1D were already at a higher risk of complications if their blood glucose levels were not managed. Pregnant women from BAME communities were supported through face-to-face interpreters, leaflets in different languages and personalised support. All patient clinic letters were sent in the woman’s first language.
Results
2021 results showed an improvement to HbA1c, 10% more women taking Folic Acid 5mg daily prior to conception, compared to 2018, plus 22% more patients referred to the team at <8 weeks pregnant. STHK results from the NPID audit in 2022 showed many improvements in 12 months, compared with 2018 (prior to the care package). Although numbers remained low, efforts were being made to increase them, particularly in the pre-conception clinic, which had around 80% of patients with T1D. Awareness of the clinic was low, so the team worked with St Helens primary care to ensure women with established diabetes were referred. Initiatives included posters for GP waiting rooms and pharmacies, an outreach team to discuss pre-conception and pregnancy with GPs and practice nurses, plus patients commenced on CGM in a timely manner. Compared to patients in 2018, women who used CGM showed a 17% reduction in third trimester HbA1c, 15% fewer babies were admitted to NNU, fetal weight at birth reduced by 6% and macrosomia reduced by 35%. The antenatal service now offers weekly DSN input with longer appointments, intensive dietetic support and education and increased dietetic slots, quick access to consultant clinics with an emergency T1D slot, access to a pre-conception clinic with DSN four-weekly, quick access to CGM and pumps, a monthly diabetes/antenatal MDT dedicated to complex cases, a diabetes specialist midwife arranging timely appointments, plus access to a mental health midwife.
User Feedback
Prior to the intensive support package, patient experience and satisfaction were poor. Since the launch of the package, feedback from healthcare professionals (HCPs) and service users has been positive, shown by anonymous patient experience and satisfaction surveys. There is a feedback box in the antenatal waiting area and non-clinical staff can assist with the forms. A member of the antenatal team has worked with Diabetes UK on educating HCPs on the importance of patient and public involvement (PPI) in diabetes research. It is hoped that informal PPI meetings with those who have experienced the support package will give them the opportunity to share their views. The antenatal DSN had been nominated for the Trust’s ‘Maternity Star’ award.
Dissemination and Sustainability
This project was produced locally and carried out by the diabetes antenatal MDT across the joint diabetes antenatal clinics. The positive results have been shared at meetings locally and nationally, including with the local Diabetes UK service user group and maternity voice partnership. The plan is to disseminate findings via social media and publications. This service represents a good benchmark to support future business cases in T1D and pregnancy.
