Cost-benefit analysis of preconception care for women with established diabetes mellitus

Investigating the pathways from preconception care to preventing maternal, perinatal and child mortality: A scoping review and causal loop diagram

In recent years, there has been a growing recognition that developing preconception care provides an opportunity to significantly reduce maternal and child mortality and morbidity. This involves targeting multiple risk factors through a large array of medical, behavioural and social interventions. In this study, we created a Causal Loop Diagram (CLD) to describe several pathways by which a set of preconception interventions may lead to women's improved health and better pregnancy outcomes. The CLD was informed by a scoping review of meta-analyses. It summarises evidence on the outcomes and interventions related to eight preconception risk factors. The authors reviewed literature from two databases (PubMed and Embase) and used the framework developed by Arksey and O'Malley. The CLD includes 29 constructs categorised into five different levels (mortality, causes of death, preconception risk factors, intermediate factors, interventions or policies). The model indicates interconnections between five sub-systems and highlights the role of preventing early and rapidly repeated pregnancies, as well as optimising women's nutritional status in the preconception period. It also shows the prevention of preterm birth as a privileged route for lowering child mortality and morbidity. The CLD demonstrates the potential benefits of strategies that address multiple preconception risk factors simultaneously and can be used as a tool to promote the integration of preconception care into efforts to prevent maternal and child mortality. With further improvements, this model could serve as a basis for future research on the costs and benefits of preconception care.

15. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Swedish guidelines for type 1 diabetes and pregnancy outcomes: A nationwide descriptive study of consensus and adherence

AIMS

Type 1 diabetes (DM1) during pregnancy and labor is associated with an increased risk of maternal and fetal complications. Evidence-based care is therefore provided in accordance with guidelines. In this study, we aimed to compare all the Swedish guidelines for DM1 during pregnancy and labor in terms of the variables emphasized in the national guidelines from the US and from England and Wales. The second aim was to measure adherence to local guidelines at the four hospitals in Stockholm that cared for pregnant women with DM1 during 2016 and to describe the pregnancy and labor outcomes.

METHODS

All the Swedish guidelines for DM1 during pregnancy and labor were reviewed on 31 variables. The medical records of 114 women were reviewed according to whether ≥70% of 22 variables in the guidelines were followed.

RESULTS

No consensus was found in the Swedish guidelines for any of the 31 variables. Some guidelines were contradictory. The pregnancy guidelines were followed in 17.5% of the medical records, 18.4% followed the labor guidelines, and 5.3% followed both guidelines. The onset of labor, mode of delivery and HbA1c in the third trimester varied significantly, depending on the adherence to guidelines.

CONCLUSIONS

The Swedish guidelines for DM1 during pregnancy and labor lack both consensus and adherence. A national guideline on DM1 during pregnancy and childbirth with high adherence could improve care for pregnant Swedish women with DM1 and their fetuses.

14. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Systematic review of economic evaluation studies on preconception care interventions

Implementation of preconception care interventions have been encouraged for improving maternal and child health outcomes; therefore, evidence on their cost-effectiveness is needed. We conducted the systematic review to examine the efficiency of those interventions by collecting evidence from published economic evaluation studies. Out of 14 included studies, almost all (12/14) were in high-income countries. All studies were not cost-utility analysis with genetic disease screening and diabetes management were the common interventions for evaluating their efficiency during preconception period. Preconception care interventions are likely to be cost-effective, especially in low-income countries which incremental benefits had a greater return than developed nations.

14. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

14. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

A Prepregnancy Care Program for Women With Diabetes: Effective and Cost Saving

CONTEXT

Only a minority of women with diabetes attend prepregnancy care service and the economic effects of providing this service are unclear.

OBJECTIVE

The objective of the study was to design, put into practice, and evaluate a regional prepregnancy care program for women with types 1 and 2 diabetes.

DESIGN

This was a prospective cohort and cost-analysis study.

SETTING

The study was conducted at antenatal centers along the Irish Atlantic Seaboard.

PARTICIPANTS

Four hundred fourteen women with type 1 or 2 diabetes participated in the study.

INTERVENTIONS

The intervention for the study was a newly developed prepregnancy care program.

MAIN OUTCOME MEASURES

The program was assessed for its effect on the risk of adverse pregnancy outcomes. The difference between program delivery cost and the excess cost of treating adverse outcomes in nonattendees was evaluated.

RESULTS

In total, 149 (36%) attended: this increased from 19% to 50% after increased recruitment measures in 2010. Attendees were more likely to take preconception folic acid (97.3% vs 57.7%, P < .001) and less likely to smoke (8.7% vs 16.6%, P = .03) or take potentially teratogenic medications at conception (0.7 vs 6.0, P = .008). Attendees had lower glycated hemoglobin levels throughout pregnancy (first trimester glycated hemoglobin 6.8% vs 7.7%, P < .001; third trimester glycated hemoglobin 6.1% vs 6.5%, P = .001), and their offspring had lower rates of serious adverse outcomes (2.4% vs 10.5%, P = .007). The adjusted difference in complication costs between those who received prepregnancy care vs usual antenatal care only is €2578.00. The average cost of prepregnancy care delivery is €449.00 per pregnancy.

CONCLUSIONS

This regional prepregnancy care program is clinically effective. The cost of program delivery is less than the excess cost of managing adverse pregnancy outcomes.

Evaluating Cost-effectiveness of Interventions That Affect Fertility and Childbearing: How Health Effects Are Measured Matters

BACKGROUND

Current guidelines for economic evaluations of health interventions define relevant outcomes as those accruing to individuals receiving interventions. Little consensus exists on counting health impacts on current and future fertility and childbearing. Our objective was to characterize current practices for counting such health outcomes.

METHODS

We developed a framework characterizing health interventions with direct and/or indirect effects on fertility and childbearing and how such outcomes are reported. We identified interventions spanning the framework and performed a targeted literature review for economic evaluations of these interventions. For each article, we characterized how the potential health outcomes from each intervention were considered, focusing on quality-adjusted life-years (QALYs) associated with fertility and childbearing.

RESULTS

We reviewed 108 studies, identifying 7 themes: 1) Studies were heterogeneous in reporting outcomes. 2) Studies often selected outcomes for inclusion that tend to bias toward finding the intervention to be cost-effective. 3) Studies often avoided the challenges of assigning QALYs for pregnancy and fertility by instead considering cost per intermediate outcome. 4) Even for the same intervention, studies took heterogeneous approaches to outcome evaluation. 5) Studies used multiple, competing rationales for whether and how to include fertility-related QALYs and whose QALYs to include. 6) Studies examining interventions with indirect effects on fertility typically ignored such QALYs. 7) Even recent studies had these shortcomings. Limitations include that the review was targeted rather than systematic.

CONCLUSIONS

Economic evaluations inconsistently consider QALYs from current and future fertility and childbearing in ways that frequently appear biased toward the interventions considered. As the Panel on Cost-Effectiveness in Health and Medicine updates its guidelines, making the practice of cost-effectiveness analysis more consistent is a priority. Our study contributes to harmonizing methods in this respect.

Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States

OBJECTIVE

Preconception care for women with diabetes can reduce the occurrence of adverse birth outcomes. We aimed to estimate the preconception care (PCC)-preventable health and cost burden of adverse birth outcomes associated with diagnosed and undiagnosed pregestational diabetes mellitus (PGDM) in the United States.

STUDY DESIGN

Among women of reproductive age (15-44 years), we estimated age- and race/ethnicity-specific prevalence of diagnosed and undiagnosed diabetes. We applied age and race/ethnicity-specific pregnancy rates, estimates of the risk reduction from PCC for 3 adverse birth outcomes (preterm birth, major birth defects, and perinatal mortality), and lifetime medical and lost productivity costs for children with those outcomes. Using a probabilistic model, we estimated the reduction in adverse birth outcomes and costs associated with universal PCC compared with no PCC among women with PGDM. We did not assess maternal outcomes and associated costs.

RESULTS

We estimated 2.2% of US births are to women with PGDM. Among women with diagnosed diabetes, universal PCC might avert 8397 (90% prediction interval [PI], 5252-11,449) preterm deliveries, 3725 (90% PI, 3259-4126) birth defects, and 1872 (90% PI, 1239-2415) perinatal deaths annually. Associated discounted lifetime costs averted for the affected cohort of children could be as high as $4.3 billion (90% PI, 3.4-5.1 billion) (2012 US dollars). PCC among women with undiagnosed diabetes could yield an additional $1.2 billion (90% PI, 951 million-1.4 billion) in averted cost.

CONCLUSION

Results suggest a substantial health and cost burden associated with PGDM that could be prevented by universal PCC, which might offset the cost of providing such care.

Preconception care: advancing from 'important to do and can be done' to 'is being done and is making a difference'

There is a growing evidence base for preconception care--the provision of biomedical, behavioral and social interventions to women and couples before conception occurs. Firstly, there is evidence that health problems, problem behaviours and individual and environmental risks contribute to poor maternal and child health outcomes. Secondly, there are biomedical, behavioural and social interventions that when delivered beforeconception occurs, effectively address many of these health problems, problem behaviours and risk factors.And thirdly, there is emerging experience of how to deliver these interventions in low and middle income countries (LMIC).The preconception care interventions delivered and whom they are delivered to, will need to be tailored to local realities. The package of preconception care interventions delivered in a particular setting will depend on the local epidemiology, the interventions already being delivered, and the resources in place to deliver additionalinterventions. Although a range of population groups could benefit from preconception care, prioritization based on need and feasibility will be needed.There are both potential benefits and risks associated with preconception care. Preconception care could result in large health and social benefits in LMIC. It could also be misused to limit the autonomy of women and reinforce the notion that the focus of all efforts to improve the health of girls and women should be at improving maternal and child health outcomes rather than at improving the health of girls and women as individuals in their own right.There are challenges in delivering preconception care. While the potential benefits of preconception care programmes could be substantial, extending the traditional Maternal and Child Health package will be both a logistic and financial challenge.We need to help countries set and achieve pragmatic and meaningful short term goals. While our longterm goal for preconception care should be for a full package of health and social interventions to be delivered to all women and couples of reproductive age everywhere, our short-term goals must be pragmatic. This is because countries that need preconception care most are the ones least likely to be able to afford them and deliver them.If we want these countries to take on the additional challenge of providing preconception care while they struggle to increase the coverage of prenatal care, skilled care at birth etc., we must help them identify and deliver a small number of effective interventions based on epidemiology and feasibility.

Gestational diabetes mellitus: a positive predictor of type 2 diabetes?

The aim of this paper is to consider the relative benefits of screening for type two diabetes mellitus in women with a previous pregnancy complicated by gestational diabetes mellitus. Recent studies suggest that women who experience GDM are at a greater risk of developing type 2 diabetes within 10-20 years of their index pregnancy. If considered as a stand-alone indicator of the risk of developing type 2 diabetes, GDM is a poor diagnostic test. Most women do not develop GDM during pregnancy and of those that do most do not develop type 2 diabetes. There is, however, a clear need for better early detection of predisposition to disease and/or disease onset to significantly impact on this global pandemic. The putative benefits of multivariate approaches and first trimester and preconception screening to increase the sensitivity of risk assignment modalities for type 2 diabetes are proposed.

Care of the infant of the diabetic mother

Gestational diabetes mellitus (GDM) from all causes of diabetes is the most common medical complication of pregnancy and is increasing in incidence, particularly as type 2 diabetes continues to increase worldwide. Despite advances in perinatal care, infants of diabetic mothers (IDMs) remain at risk for a multitude of physiologic, metabolic, and congenital complications such as preterm birth, macrosomia, asphyxia, respiratory distress, hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia and hyperviscosity, hypertrophic cardiomyopathy, and congenital anomalies, particularly of the central nervous system. Overt type 1 diabetes around conception produces marked risk of embryopathy (neural tube defects, cardiac defects, caudal regression syndrome), whereas later in gestation, severe and unstable type 1 maternal diabetes carries a higher risk of intrauterine growth restriction, asphyxia, and fetal death. IDMs born to mothers with type 2 diabetes are more commonly obese (macrosomic) with milder conditions of the common problems found in IDMs. IDMs from all causes of GDM also are predisposed to later-life risk of obesity, diabetes, and cardiovascular disease. Care of the IDM neonate needs to focus on ensuring adequate cardiorespiratory adaptation at birth, possible birth injuries, maintenance of normal glucose metabolism, and close observation for polycythemia, hyperbilirubinemia, and feeding intolerance.

Preconception care for women with diabetes: is it effective and who should provide it?

The association between hyperglycaemia and congenital malformations was first recognised over 40 years ago and was followed by the development of preconception clinics for women with diabetes. A fresh look at preconception care is needed as many studies were conducted during the late 1970s and early 1980s, before the introduction of regular home blood glucose monitoring and glycosylated haemoglobin assays, and when many patients with diabetes had microvascular complications. Recent observational studies and a meta-analysis suggest preconception care is effective with an approximately threefold reduction in the risk of malformations. There is now a worldwide epidemic of type 2 diabetes, but only few studies of preconception care have included women with type 2 diabetes. Furthermore, few studies have addressed the relationship between preconception care and perinatal morbidity. This article will review the evidence for preconception care in women with diabetes, evaluate different models of preconception care and discuss future strategies.

Implications of type 2 diabetes on adolescent reproductive health risk: an expert model

PURPOSE

The purpose of this article was to summarize scientific knowledge from an expert panel on reproductive health among adolescents with type 2 diabetes (T2D).

METHODS

Using a mental model approach, a panel of experts--representing perspectives on diabetes, adolescents, preconception counseling, and reproductive health--was convened to discuss reproductive health issues for female adolescents with T2D.

RESULTS

Several critical issues emerged. Compared with adolescents with type 1 diabetes, (1) adolescents with T2D may perceive their disease as less severe and have less experience managing it, putting them at risk for complications; (2) T2D is more prevalent among African Americans, who may be less trusting of the medical establishment; (3) T2D is associated with obesity, and it is often difficult to change one's lifestyle within family environments practicing sedentary and dietary behaviors leading to obesity; (4) teens with T2D could be more fertile, because obesity is related to earlier puberty; (5) although obese teens with T2D have a higher risk of polycystic ovary syndrome, which is associated with infertility, treatment with metformin can increase fertility; and (6) women with type 2 diabetes are routinely transferred to insulin before or during pregnancy to allow more intensive management.

CONCLUSIONS

Findings from the expert panel provide compelling reasons to provide early, developmentally appropriate, culturally sensitive preconception counseling for teens with T2D.

Cost-effectiveness of insulin aspart compared to human insulin in pregnant women with type 1 diabetes in the UK

OBJECTIVES

In women with type 1 diabetes, poor glycaemic control during pregnancy is associated with high risk of pre-term delivery, perinatal mortality and morbidity. This economic analysis utilises clinical effectiveness data from the Insulin Aspart Pregnancy Study Group Trial to assess costs and outcomes associated with insulin aspart (IAsp) and human insulin (HI) as part of a basal-bolus insulin regimen in pregnant women with type 1 diabetes in the UK.

RESEARCH DESIGN AND METHODS

Women with type 1 diabetes were enrolled if <or= 10 weeks pregnant or planning to become pregnant, and had HbA(1c) <or= 8% at confirmation of pregnancy. Subjects were randomised to treatment with IAsp or HI in a basal-bolus regimen with NPH insulin, with doses titrated according to American Diabetes Association guidelines. An effectiveness endpoint, retrospectively defined for this analysis, was the percentage of women with a live birth at term (>or=37 weeks' gestation). We considered costs of insulin, adverse events, delivery, and neonatal care for pre-term infants. Expected need for neonatal care was estimated from gestational age, using data from the literature and a large UK hospital. Costs were calculated from the perspective of the UK National Health Service.

RESULTS

A total of 322 pregnant women were enrolled in the study and the outcome of pregnancy was known for 302, 151 in each arm. More women experienced a live birth at term with IAsp (72.8%) than with HI (60.9%), difference 11.9% (95% CI 2.0%, 22.5%, p = 0.028). Mean cost per woman was 3222 pounds for IAsp and 3539 pounds for HI, difference--318 pounds (95% CI--1353 pounds, 576 pounds; p = 0.49).

CONCLUSIONS

Compared with HI, the use of IAsp in pregnant women with type 1 diabetes resulted in more live births at term, without increasing total costs of treatment. A prospectively defined study is required to confirm these conclusions.

The clinical content of preconception care: women with chronic medical conditions

This article reviews the medical conditions that are associated with adverse pregnancy outcomes for women and their offspring. We also present the degree to which specific preconception interventions and treatments can impact the effects of the condition on birth outcomes. Because avoiding, delaying, or achieving optimal timing of a pregnancy is often an important component of the preconception care of women with medical conditions, contraceptive considerations particular to the medical conditions are also presented.

The business case for preconception care: methods and issues

Only a limited number of economic evaluations have addressed the costs and benefits of preconception care. In order to persuade health care providers, payers, or purchasers to become actively involved in promoting preconception care, it is important to demonstrate the value of doing so through development of a “business case”. Perceived benefits in terms of organizational reputation and market share can be influential in forming a business case. In addition, it is standard to include an economic analysis of financial costs and benefits from the perspective of the provider practice, payer, or purchaser in a business case. The methods, data needs, and other issues involved with preparing an economic analysis of the likely financial return on investment in preconception care are presented here. This is accompanied by a review or case study of economic evaluations of preconception care for women with recognized diabetes. Although the data are not sufficient to draw firm conclusions, there are indications that such care may yield positive financial benefits to health care organizations through reduction in maternal and infant hospitalizations. More work is needed to establish how costs and economic benefits are distributed among different types of organizations. Also, the optimum methods of delivering preconception care for women with diabetes need to be evaluated. Similar assessments should also be conducted for other forms of preconception care, including comprehensive care.

Outcome of fetuses in women with pregestational diabetes mellitus

OBJECTIVE

To investigate the effects of pregestational diabetes on pregnancy outcome.

METHODS

Data of 126 women with pregestational diabetes prospectively collected and controlled in a single tertiary center. HbA(1C) levels at early pregnancy were registered. Adverse pregnancy outcome was defined as spontaneous abortion, congenital defect, stillbirth, or neonatal death.

RESULTS

There were 10 spontaneous abortions (7.9%) and 17 fetuses with congenital anomalies (13.4%), including 8 major malformations (6.3%). Compared with pregnancies with a favorable outcome, a higher HbA(1C) concentration in early pregnancy was observed in pregnancies with adverse perinatal outcome [mean (SD): 6.3 (1.6) vs. 7.2 (1.7), P=0.001]. A positive correlation between increased maternal HbA(1C) levels and the rate of fetal malformations was observed, and the group of women with poor metabolic control (early maternal HbA(1c) concentration >7%) showed a 3 to 5-fold increase in the major malformation rate. Cardiovascular and genitourinary defects accounted for 58.8% of the anomalies, and the ultrasound examinations detected seven of them (41.2%). For major malformations, the detection rate was 50% (4/8). Perinatal mortality rate was 26 per thousand (3/116). There was almost 5-fold increase in the total pregnancy loss rate in the poor control group compared with the group with fair control [22.2% vs. 5.3%, OR (95% CI): 5.1 (1.4-17.1)]. Only 11.9% of mothers used a preconception care program.

CONCLUSIONS

Pregestational diabetes mellitus is a significant risk factor for the developing fetus. Spontaneous abortions and congenital defects are more common when a poor metabolic control is present in early pregnancy. It is most important to improve access to preconception care programs for achieving a good metabolic control in early pregnancy. Ultrasound examinations have a low performance for detecting congenital defects in diabetic pregnancies.

Knowledge, attitudes and behaviors related to sexuality and family planning in adolescent women with and without diabetes

BACKGROUND

Sexually active adolescents with diabetes are at high risk for unplanned pregnancies and reproductive complications.

OBJECTIVE

Knowledge, attitudes, intentions, and behaviors regarding diabetes and reproductive issues, sexuality, and contraception were examined in teens with diabetes in relation to a non-diabetic group.

METHODS

A multisite, case-control, theory-based structured telephone interview was conducted on adolescent women: 80 with diabetes mellitus (DM) and 37 matched controls without diabetes (non-DM).

RESULTS

Teens with diabetes appeared to lack an understanding of critical information that could prevent unplanned pregnancies and pregnancy-related complications. Although they scored significantly higher than the non-DM group on diabetes-related information, the DM group had their lowest mean average of 59% for the diabetes and pregnancy score. They did not appear to have greater protective attitudes regarding reproductive health issues than the non-DM group. The DM group felt that they were only moderately susceptible to becoming pregnant and that severe complications would not happen to them. The DM group perceived greater severity to sex-related outcomes (p = 0.001). The DM group did not report safer and more effective family planning behaviors (mean age coitus = 15.7 yr), which for them could be more detrimental. Similar trends were noted between groups regarding contraceptive methods; only a single method (e.g., pill only) rather than a dual method (e.g., pill and condom) was most frequently used.

CONCLUSION

Having diabetes did not appear to significantly decrease the risk-taking behavior of the teens. Early and some unsafe sexual practices may increase their risk for an unplanned pregnancy that could result in pregnancy-related complications. Enhancing awareness, knowledge, and attitudes through preconception counseling and reproductive health education may reduce these risks by empowering young women to plan healthy future pregnancies.

Preconception care in managed care: the translating research into action for diabetes study

OBJECTIVES

This study was undertaken to examine the rates of preconception counseling in managed care for women with diabetes and associated patient and physician characteristics.

STUDY DESIGN

Participants included women aged 18 to 45 years enrolled in a study of diabetes care in managed care. Women were asked if they recalled discussions regarding glucose control before conception (n = 236) and use of family planning until glucose control was achieved (n = 227). Hierarchical logistic regression models accounted for patient and physician characteristics.

RESULTS

Fifty-two percent of women recalled being counseled about glucose control and 37% recalled family planning advice. In adjusted models, patient age (years) (odds ratio [OR] 0.91, 95% CI 0.86-0.96) and body mass index (BMI) (kg/m2) (OR 0.96, 95% CI 0.93-0.99) remained significant predictors of glucose control counseling. Similarly, patient age (years) (OR 0.94, 95% CI 0.89-0.99) and BMI (kg/m2) (0.96, 95% CI 0.93-0.99) remained significant predictors of family planning counseling.

CONCLUSIONS

Preconception counseling rates for diabetic women are low and associated with younger age and lower BMI.

Health literacy and pregnancy preparedness in pregestational diabetes

OBJECTIVE

We investigated the association between functional health literacy and markers of pregnancy preparedness in women with pregestational diabetes.

RESEARCH DESIGN AND METHODS

English- and Spanish-speaking pregnant women with pregestational diabetes were recruited. Women completed the Test of Functional Health Literacy in Adults (TOFHLA) short form and a questionnaire. A TOFHLA score of < or =30 was defined as low functional health literacy.

RESULTS

Of 74 women participating in the study, 16 (22%) were classified as having low functional health literacy. Compared with women with adequate health literacy, those with low health literacy were significantly more likely to have an unplanned pregnancy (P = 0.02) and significantly less likely to have either discussed pregnancy ahead of time with an endocrinologist or obstetrician (P = 0.01) or taken folic acid (P = 0.001).

CONCLUSIONS

The results of this study suggest that low functional health literacy among women with pregestational diabetes is associated with several factors that may adversely impact birth outcomes.

Preconception care of women with diabetes

Preconception care in women with diabetes reduces the risk of spontaneous abortion and congenital malformations as a result of improved glycemic control before and during organogenesis. Prepregnancy planning encompasses optimizing glycemic control and also affording the opportunity for genetic counseling, contraceptive selection, management of diabetes complications, and evaluation of psychosocial aspects of pregnancy, childbearing, and diabetes care. The purpose of this article is to provide nurses with current clinical assessment and management strategies of women with diabetes in order to implement a comprehensive individualized preconception plan of care.

Preconception health counseling for women exposed to teratogens: the role of the nurse

Women with unintended pregnancies who are exposed to teratogens constitute the highest risk group for fetal harm. Teratogen exposures come from substances, medications, chronic and acute diseases, and environmental factors. Nurses play a critical role in reducing unintended pregnancy and promoting preconception health. A greater understanding of the role of teratogens and strategies to improve history taking and help women prevent unintended pregnancy will improve nurses' ability to reduce teratogen exposure in women at risk.

Preconception care: a systematic review

OBJECTIVES

To perform a systematic review of published research trials of preconception care services to determine what evidence for effectiveness of care at improving the course of pregnancy or its outcomes has accumulated since the last major review in 1990.

METHODS

The review was conducted adapting the systematic methods developed by the Cochrane Collaboration to collect evidence from published clinical research literature with as little bias as possible. The review included literature published after January 1990, and posted on MEDLINE by July 1999.

RESULTS

Although more than 40 preconception risk conditions were searched and 470 articles were abstracted, only four problem areas and 19 research trials met the review criteria. New evidence of effectiveness was found for screening women who are seeking family planning for risk conditions; having sexually active women of reproductive age take dietary folate supplements; and providing women affected by certain metabolic conditions (diabetes and hyperphenylalanemia) with nutrition services.

CONCLUSIONS

To help improve pregnancy outcomes MCH professionals need to promote the concept of readiness for pregnancy and help see that women are as healthy and appropriately nourished as possible before they become pregnant.

Maternal hypoglycemia during pregnancy in type 1 diabetes: maternal and fetal consequences

There is strong evidence that the avoidance of hyperglycemia is essential inoptimizing pregnancy outcome in type 1 diabetes. The price to pay is a striking increase in severe hypoglycemia (SH), defined as episodes requiring help from another person. During type 1 diabetic pregnancy, occurrence rates of SH up to 15 times higher as in the intensively treated group of the Diabetes Control and Complications Trial (DCCT) are reported. Blood glucose (BG) treatment targets differ considerably between clinics; some authors advocate lower limits as low as 3.3 mmol/l. Improved glycemic control and/or recurrent hypoglycemia (i.e. BG <3.9 mmol/l) may result in impairment of glucose counterregulatory responses. Also, glucose counterregulation may be altered by pregnancy itself. Short-acting insulin analogs may help reduce hypoglycemia with preservation of good glycemic control, but their use during pregnancy has yet to be proven safe.Several clinical studies did not establish an association between maternal hypoglycemia and diabetic embryopathy. However, animal studies clearly indicate that hypoglycemia is potentially teratogenic during organogenesis. Increased rates of macrosomia continue to be observed despite near normal HbA(1c) levels. This may, at least in part, be the result of rebound hyperglycemia elicited by hypoglycemia. Exposure to hypoglycemia in utero may have long-term effects on offspring including neuropsychological defects. It is yet unclear to what extent the benefits of tight glycemic control balance with the increased risk of (severe) hypoglycemia during type 1 diabetic pregnancy. Efforts must be made to avoid low BG, i.e. <3.9 mmol/l, when tightening glycemic control.

Benefits, risks, costs, and patient satisfaction associated with insulin pump therapy for the pregnancy complicated by type 1 diabetes mellitus

OBJECTIVE

Glycemic control, perinatal outcome, and health care costs were evaluated among women with type 1 diabetes mellitus who began insulin pump therapy during pregnancy (group 1, n = 24), were treated with multiple insulin injections (group 2, n = 24), or were already using an insulin pump before pregnancy (group 3, n = 12). Patient satisfaction and continuation of pump therapy post partum were assessed.

STUDY DESIGN

A retrospective review of maternal and neonatal medical records was performed, and a questionnaire was sent to patients after delivery. Patients in groups 1 and 2 were matched for age, age at onset and duration of diabetes mellitus, White class, and date of delivery.

RESULTS

No differences in glycosylated hemoglobin A levels were observed among groups 1, 2 or 3 in the first, second, or third trimester. Patients in group 1 started pump therapy at a mean of 16.8 weeks' gestation, and 17 (70.8%) began therapy as outpatients. No deterioration in glycemic control was noted during the 2- to 4-week period after the start of pump treatment. Among the women in group 1 eight had at least one episode of severe hypoglycemia before starting pump therapy, but only one had such an episode after this treatment was begun. Two episodes of ketoacidosis occurred in group 1, and no episodes occurred in groups 2 and 3. No significant differences in perinatal outcomes or health care costs were observed among groups 1, 2, and 3. After delivery 94. 7% of the women in group 1 continued to use the pump because it provided better glycemic control and a more flexible lifestyle. Postpartum glycosylated hemoglobin A values were 7.2% in group 1 and 9.1% in group 2, a significant difference.

CONCLUSIONS

Insulin pump therapy was initiated during pregnancy without a deterioration of glycemic control and was associated with maternal and perinatal outcomes and health care costs comparable to those among women who were already using the pump before pregnancy or who received multiple-dose insulin therapy. Women who began pump therapy in pregnancy were highly likely to continue pump use after delivery and preferred the flexible lifestyle that this treatment allowed.

Out-patient management does not impair outcome of pregnancy in women with type 1 diabetes

In recent years, out-patient protocols have mainly displaced historical obstetric management of diabetic pregnancy. The impact of the change from centralized in-patient to decentralized out-patient treatment on glycaemic control and its effects on the outcome of newborns in diabetic pregnancies was therefore studied using the population-based data on 296 pregnancies in 224 women with type 1 diabetes over 10 years (1986-1995) in the two northernmost provinces of Finland. The area comprises one tertiary level and four other central hospitals. The change of policy was effected in 1990 and to determine the impact of this change, the study period was divided in two (period 1, 1986-1990, n = 135; period 2, 1991-1995, n = 161). At the first antenatal contact (mean 9.9 weeks of gestation) 73% of women had unsatisfactory glycaemic control, but it improved rapidly with pregnancy and was significantly better (P < 0.05) in the second study period. The incidence of congenital malformations was somewhat greater (NS) in period 2 but perinatal mortality did not change. Out-patient management does not impair outcome in type 1 diabetic pregnancy.

Preconception care: challenge of the new millennium?

Couples who plan their pregnancies can elect anticipatory care with the aim of improved health for mother and child. While it has proved to be beneficial in such specific disorders as maternal diabetes mellitus, preconception care is not yet established as a part of primary care. Preconception care is a form of community genetics and consists of three main components: risk assessment, health promotion, and intervention. Intake of folic acid during the time surrounding conception is important in preventing neural tube defects and other congenital anomalies. Primary care health professionals may be involved in providing preconception care, as may be gynecologists, midwives, nurses, clinical geneticists, and genetic counselors. Several questions arose from a Dutch pilot study. Is there a need for preconception care? Do women want this care? Can positive effects (and cost-effectiveness) be documented? How best are the parents-to-be contacted? Last, but not least, who should provide the care?

Modeling economic evaluations of pharmaceuticals: manipulation or valuable tool?

Controversy surrounds the use of models in economic evaluations of pharmaceuticals. Many believe that modeling is a way of manipulating results and is not credible, whereas others consider modeling a valuable tool in economic evaluations. The purpose of this article is to provide a historical perspective on modeling, focus on the controversy and policy implications of using models, and review the suggested framework and guidelines for modeling practices. Models can be used to extrapolate beyond intermediate end points, predict costs and consequences of alternative therapies, generalize data to other settings, pose questions instead of providing answers when no data exist, design an evaluation to reduce uncertainty, and perform direct comparisons that are not currently available. We believe that a useful model should document the detailed inner workings, assumptions, and inherent bias during production (and at publication time), so that its reviewers and users can evaluate the appropriateness of the model's outcomes. The acceptability of models in the future rests with the researchers constructing them. If constructed appropriately, modeling economic evaluations is not a manipulation but rather a valuable tool.

Preconceptional health care model

During the last 10 years, there has been a movement to expand the definition of prenatal care to encompass preconceptional counseling. Major organizations throughout the world have endorsed preconceptional counseling as an integral component of care for all women contemplating pregnancy. This article will assist health care providers who interact with women of reproductive age to understand the potential benefits and limitations of preconceptional counseling and to develop an approach to that service relating to nutrition, infections, and metabolic diseases as they impact on reproductive outcome. Although there are many potential benefits of the preconception health care model, barriers to its implementation remain.

Cost-benefit analyses in the health-care literature: don't judge a study by its label

OBJECTIVES

To assess whether health-care related economic evaluations labeled as "cost benefit analyses" (CBA) meet a contemporary definition of CBA methodology and to assess the prevalence of methods used for assigning monetary units to health outcomes.

DATA SOURCES

Medline, Current Contents, and HSTAR databases and reference lists of review articles, 1991-1995.

STUDY SELECTION

Economic analyses labeled as CBAs were included. Agreement on study selection was assessed. STUDY EVALUATION: CBA studies were classified according to standard definitions of economic analytical techniques. For those valuing health outcomes in monetary units (bona fide CBAs), the method of valuation was classified.

RESULTS

53% of 95 studies were reclassified as cost comparisons because health outcomes were not appraised. Among the 32% considered bona fide CBAs, the human capital approach was employed to value health states in monetary units in 70%. Contingent valuation methods were employed infrequently (13%).

CONCLUSIONS

Studies labeled as CBAs in the health-care literature often offer only partial program evaluation. Decisions based only on resource costs are unlikely to improve efficiency in resource allocation. Among bona fide CBAs, the human capital approach was most commonly used to valuing health, despite its limitations. The results of health-care related CBAs should be interpreted with extreme caution.

Preconception counseling for the primary care physician

All health care providers that interact with women of childbearing age should understand the potential benefits of preconception counseling and to approach the evaluation in a thorough manner during routine health maintenance visits. With the increased number of patients enrolled in managed care programs, health maintenance visits provide the unique opportunity to educate women contemplating pregnancy regarding the potential influences of their lifestyle and health status on the future pregnancy. It is becoming increasingly apparent that interventions made during the preconception period are just as crucial as the subsequent 9 months of prenatal care to achieve an optimal maternal-fetal outcome. Some guidelines for the preconception evaluation have been provided, and the implications of chronic medical illness on pregnancy have been discussed.

Women with diabetes during pregnancy: sociodemographics, outcomes, and costs of care

This study provides sociodemographic, outcome, and cost data on a population (N = 55) of predominately low-income, diabetic women who were hospitalized during pregnancy. Study findings indicated that 43 percent received no prenatal care in the first trimester, 20 percent delivered a low-birthweight infant, 47 percent had a cesarean delivery, and 63 percent reported an annual income under $12,500. Following the women's initial admission for glucose control, 19 acute care visits and 32 rehospitalizations were recorded for them. The mean hospital charges for antepartum initial hospitalization for glucose control were $4,665 (4.3 days). The mean charges for postpartum hospitalization were $7,793 (4.3 days). The mean hospital charges per infant were $12,991. Given the data presented in this study, it is imperative that monies be targeted to provide a broad spectrum of health care services that will meet the unique needs of this population. These services should address not only the needs related to superimposed disease state but also identify mechanisms to assist women to receive care prior to conception, or at the very least to begin prenatal care in the first trimester of pregnancy.

A practical guide to intensive insulin therapy

In a landmark study, the Diabetes Control and Complications Trial proved that intensive insulin therapy (IIT) reduced the incidence and severity of the microvascular complications of insulin-dependent diabetes mellitus. Retinopathy, nephropathy, and neuropathy were all improved by IIT. The trial was conducted by endocrinologists experienced in the management of IIT. However, only a small minority of patients with diabetes are cared for by endocrinologists; the vast majority receive their care from primary care physicians. In this article, the authors describe the practical aspects of IIT for those physicians unfamiliar with IIT but who want to offer the benefits of this therapy to patients with diabetes. The authors define suitable candidates for IIT, describe the initiation and management of IIT, and emphasize the potential complications of this therapy. Severe hypoglycemia is the major risk of ITT, and caution must be used to reduce the incidence of this dangerous complication.

Pregnant women with diabetes: antepartum and postpartum morbidity

Despite advances in obstetrical management, the problems that women with diabetes experience most frequently during their pregnancies and postpartum have not been clearly defined. The purpose of this study was to provide morbidity data on this patient population to assist in determining appropriate interventions.

In vitro study of the carry-over effect associated with early diabetic embryopathy in the rat

Embryos were recovered from diabetic rats on day 5 of pregnancy and incubated in vitro for up to 72 h. Compared to control embryos, blastocysts from diabetic rats showed a marked impairment in growth that resulted at 48 h in a higher rate of degeneration and a lower morphological score in the developing population. After 72 h in vitro, fewer developing blastocysts from diabetic rats formed trophoblastic outgrowths and fewer of those implanted developed an inner cell mass when compared with the control group. When assessed for their cell content, blastocysts from diabetic rats contained fewer cells than control embryos at the start of the culture. This difference persisted, and even worsened, during the ensuing incubation period. The increasing cellular deficiency in blastocysts from diabetic rats was primarily located to their inner cell mass lineage but trophoblast growth was also affected. When trophoblast outgrowths were compared for their surface area and number of nuclei, those collected from diabetic rats were smaller, contained fewer nuclei and had a higher proportion of giant nuclei than control outgrowths. Our data thus demonstrate that despite their removal from the abnormal intra-uterine environment, blastocysts from diabetic rats remain functionally affected by their early exposure and fare less well than control embryos cultured under the same standard conditions.