Summary

Funded by Diabetes UK the aim of the “Women with Diabetes” resource is to increase women’s awareness about the importance of planning for pregnancy and to positively influence attitudes, self-efficacy and intentions towards seeking pre-pregnancy care and preventing unplanned pregnancies. Originally produced as a DVD and later converted to a website, the resource was designed and developed in collaboration with women with diabetes under the direction of healthcare professionals in accordance with NICE pre-pregnancy care guidance. This resource has been embedded in routine care in Northern Ireland since 2010.  An evaluation of the DVD among 97 women with diabetes demonstrated that it was effective in increasing knowledge and enhancing attitudes of women with diabetes to pre-pregnancy care.

Results

After viewing the DVD there was positive change in women’s perceived benefits of, and their attitudes to, receiving pre-pregnancy care and contraception. Knowledge of pregnancy planning and pregnancy-related risks increased significantly. Since integration into routine care an evaluation of the pre-conception counselling resource is nearing completion. Women with diabetes attending any one of the antenatal-metabolic clinics in the period spanning eight to twenty months post DVD distribution have been included in this evaluation. 

Of all women who attended for joint antenatal care between June 2011 and June 2012, 63% had received the DVD prior to pregnancy with 73% viewing it. Of these viewers, 38% contacted their diabetes care team for specialised pre-pregnancy care, 31% made lifestyle changes, while a further 20% were already attending for pre-pregnancy care. Only 11% did not seek advice or make lifestyle changes.

Furthermore, and most importantly, this innovative resource has received positive feedback from the target audience with many women saying they wish something like this had been available to them in previous pregnancies.

Challenge

Rates of stillbirth, perinatal mortality and congenital anomaly are higher in women with diabetes compared with the general maternity population. Pre-pregnancy care is cost-effective and reduces adverse outcomes, yet not all women with diabetes are informed about the need or rationale for pre-pregnancy care, ultimately leading to poor uptake.

Although there is an increasing realisation that pre-pregnancy care is advantageous, most women only seek medical advice once they are pregnant. The National Institute for Health and Clinical Excellence (NICE) stressed the importance of effective pre-conception counselling and recommends that: ‘Women of childbearing age with diabetes are regularly informed of the benefits of pre-conception glycaemic control and of any risks, including medication that may harm an unborn child. Women with diabetes planning a pregnancy are offered pre-conception care and those not planning a pregnancy are offered advice on contraception.’

Despite these guidelines, rates of pre-conception counselling remain low and innovative strategies are urgently needed to increase the proportion of women seeking it.

Objectives

The aim of this initiative was to design, develop, pilot and evaluate an interactive DVD as an effective educational tool emphasising the importance of planning for pregnancy and to prevent unplanned pregnancies. The long term goal of the DVD, recently converted for website delivery, is to improve pregnancy management and outcome by increasing the proportion of women who plan their pregnancies and seek pre-pregnancy care. The ambition was to produce an effective tool which can be used by healthcare professionals to counsel women in what can be a very sensitive area.

Solution

DVD design and development centred on two key stakeholders, the user group and professional advisory group, working with a multimedia company. Design focus groups revealed that while women were well informed about the need to plan pregnancy, awareness of the rationale for this was only evident in those with children or those who had sought pre-pregnancy advice. 

The combined user and multi-professional group approach produced a DVD that features eight women sharing their views and experiences, alongside an evidence-based commentary. Evaluation of its acceptability and usefulness was assessed with 97 women via a postal questionnaire, followed by a concentrated distribution process. The DVD was adopted by all diabetes care teams at 15 hospitals in the five health and social care trusts throughout Northern Ireland. All GP practices were given a copy and invited to request copies for their patients who were not routinely reviewed in secondary care.

In total, 1,319 DVDs have been distributed among GPs; 3,391 went to health and social care trusts and a further 1,500 were distributed to five cross-border pre-pregnancy clinics.

Evaluation

Central to this initiative is the input from women with diabetes. The professional team had some initial ideas of what the resource might eventually contain but the final product is quite different from what was envisaged. This is a resource for women with diabetes, designed with input from women with diabetes. Also, the combination of an enquiry led design and development with a quantitative evaluation, allowed us to create an effective resource that is acceptable to the healthcare professionals charged with delivering pre-conception counselling. Challenges remain around the dissemination of this knowledge, particularly to primary care teams and professionals. The project team is seeking funding to enable this valuable resource to be propagated as widely as possible, for the benefit of as many women with diabetes as can be reached.

Impact

Results of a re-audit of pregnancy planning indicators and pregnancy management will be compared with audits performed before the DVD was introduced. If we are to achieve an ‘every woman, every time’ approach to pre-conception counselling and raise awareness of pregnancy planning, we need effective resources and this initiative could easily be adopted by clinics and healthcare professionals, both in primary and secondary care, throughout the UK and beyond. 

Converting the DVD to a website has enabled wider access with minimal expense. A link to the website is hosted by Diabetes UK and by the ‘Innovations Hub’ webpage within NHS Diabetes. An article describing the development of the resource has been published in the European Diabetes Nursing Journal, another has been written for Primary Care Diabetes and a press release was issued when the resource was launched. A link has been established with the HSC in Northern Ireland to make the resource available via the Primary Care Intranet to all GPs in the province and the website also hosts an e-learning package for student midwives. Converting the resource from DVD to a website also ensures sustainability and offers great potential for the material to be viewed well beyond Northern Ireland’s borders.