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Perspectives in Disease Prevention and Health Promotion Public Health Guidelines for Enhancing Diabetes Control Through Maternal- and Child-Health Programs
Publication date: 04/04/1986
Table of Contents
ArticleThese guidelines were developed by the Division of Diabetes Control, Center for Prevention Services, CDC, in collaboration with the Division of Maternal and Child Health, Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, and have been endorsed by the Association for Maternal and Child Health and Crippled Children's Programs.
INTRODUCTIONThis document provides guidelines for maternal- and child-health programs for an appropriate public health approach to diabetes control during pregnancy. Particular concerns for the public health-care sector include: (1) screening of women to detect gestational diabetes; (2) identification of women with established diabetes who may become pregnant; (3) ensurance of appropriate care for women with diagnosed diabetes (either established or gestational) on-site or through referral; (4) postpartum follow-up and continuing care of women with established diabetes to maintain good blood-glucose control before pregnancy and throughout subsequent pregnancies; and (5) postpartum follow-up of women with gestational diabetes to detect previously undiagnosed established diabetes, to monitor the maintenance of ideal body weight to reduce the chance of developing diabetes later in life, and to ensure prompt diagnosis of diabetes if and when it develops. Key elements are: the identification and establishment of linkages with existing programs and resources and development of the necessary referral and follow-up mechanisms.
STATEMENT OF THE PROBLEMThe presentation of a pregnant woman with established diabetes mellitus* or gestational diabetes mellitus** (GDM) to a public health clinic is relatively rare (about 3%-4% of all pregnancies). However, the morbidity associated with pregnancies affected by diabetes may be substantial, since diabetes may result in a disproportionate number of adverse pregnancy outcomes (1). Therefore, the combination of diabetes and pregnancy presents a special challenge in the public health-care setting.
Incorporating several basic guidelines and principles into the public health sector's management of pregnancy may markedly improve pregnancy outcomes for women with either established or gestational diabetes. With appropriate care, the level of risk associated with diabetes and pregnancy can be reduced to that of the nondiabetic population.
Problems Related to Established Diabetes. While only approximately 0.3% of all U.S. pregnancies occurs among women with established diabetes, many serious clinical problems are associated with diabetes during pregnancy. The estimated 10,000-14,000 infants born annually to women with established diabetes are at high risk for mortality; prematurity; congenital defects; macrosomia; neonatal hypoglycemia; respiratory distress syndrome; and hyperbilirubinemia, particularly when maternal glucose levels are not tightly controlled during pregnancy (1).
Risks of maternal complications are also associated with diabetes during pregnancy and include: ketoacidosis; exacerbated microvascular, renal, ocular, and neural complications; urinary-tract infections; toxemia; and hydramnios (2).
Problems Related to Gestational Diabetes. GDM occurs in about 2%-3% of pregnancies in the United States (3) and usually develops during the second or third trimester, when levels of insulin-antagonist hormones increase and insulin resistance usually occurs. Approximately 90,000 women with GDM give birth each year. GDM may go undetected in up to 50% of cases.
The effects of GDM on offspring include: macrosomia; birth trauma due to difficult delivery; shoulder dystocia; hypoglycemia; increased incidence of fetal/neonatal mortality (particularly from women with previously unidentified adult-onset, Type II, diabetes); hypocalcemia; and hyperbilirubinemia (4).
Women with GDM are at increased risk for developing diabetes after parturition (5). In addition, many women diagnosed as glucose-intolerant during pregnancy may be previously unidentified Type II diabetics. This risk of developing diabetes and the opportunity to identify as yet undiagnosed women with Type II diabetes are also compelling reasons for screening.
Opportunities to Improve Outcomes. The public health sector can improve pregnancy outcomes among women with established diabetes and women in whom GDM is detected by several methods, including: (1) identification (including outreach, screening, and diagnosis); (2) care/referral (including appropriate patient education and nutrition counseling, referrals to high-risk centers or to private care); (3) maternal/neonatal follow-up; and (4) professional education.
Purpose of the Guidelines. The guidelines should be adapted to the needs of each state, its health-care delivery system, and the levels of professional and fiscal resources available. The guidelines are designed to: (1) increase public and provider awareness of the problem and identify special needs related to diabetes before conception and during pregnancy; (2) propose concrete suggestions for enhancing diabetes control through maternal- and child-health programs in the public health system by improving coordination of the health-care system components, use of resources, and patient involvement in the care regimen; and (3) provide a framework for states/localities to use in adapting these guidelines to meet their specific planning, care, and training needs.
IDENTIFICATION OF WOMEN WITH DIABETESOutreach. Prepregnancy counseling and early prenatal care by professionals knowledgeable about diabetes during pregnancy are particularly important for women with established diabetes (6). Normalization of maternal glucose levels before pregnancy and during the first 8 weeks of gestation has been effective in reducing the occurrence of congenital malformations (1). Strict control of glucose throughout pregnancy can reduce the risk of perinatal mortality among infants of mothers with diabetes to a level seen in nondiabetic pregnant women. Therefore, prepregnancy counseling--with the goal of attaining euglycemia before conception and maintaining it throughout gestation--is important for women with diabetes. Prepregnancy evaluation is also important to assess maternal complications of diabetes, such as detecting the presence of retinopathy, nephropathy, hypertension, and coronary atherosclerosis.
Ideally, a woman with established diabetes is aware of the risks associated with diabetes and pregnancy and will consult a physician when contemplating pregnancy. In reality, however, most women come to public health-care settings already several weeks pregnant. Outreach efforts for women with established diabetes include:
To maximize resources, localities should develop an outreach plan to target their efforts and to optimally use scarce public health resources.
- Identifying women with established diabetes who come to family planning clinics and encouraging referral for prepregnancy counseling;
- Asking women with diabetes already under care to disseminate messages to their friends and acquaintances (e.g., through support groups) about the importance of preconception counseling and prenatal care;
- Discussing with women who have established diabetes the importance of glycemic control before pregnancy when they bring children into public health clinics for care;
- Increasing provider awareness through professional education;
- Enlisting the aid of local American Diabetes Association or Juvenile Diabetes Foundation chapters in arranging for public service announcements regarding the importance of planned pregnancy and early care for women with diabetes;
- Developing media campaigns that encourage preconception and early prenatal care (e.g., placing posters in highly visible areas);
- Providing patient-education materials to local physicians;
- Recruiting and training persons indigenous to the target population, such as volunteers or community-health workers, to stress the importance of preconception and early prenatal care and proper nutrition during pregnancy;
- Identifying home-health nurses and enlisting their aid in referral for specialized and follow-up care during pregnancy;
- Maintaining communications with directors of nursing and education coordinators of outlying hospitals to ensure the availability of patient-education opportunities;
- Working with primary-care centers;
- Developing and identifying specialized-care referral centers for women with established diabetes or GDM who cannot be adequately treated in a public health-care setting.
Unlike women with established diabetes, women who develop GDM need to be identified by health-care providers. Therefore, outreach efforts related to identifying GDM should be targeted at those health-care professionals who have contact with pregnant women (e.g., nurse-midwives, nurse-practitioners, family practitioners, obstetricians, and nutritionists).
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