Atlantic Dip: a regional approach to the delivery of care results in improved pregnancy outcomes in women with pre-gestational diabetes mellitus.

Abstract

Background and aims: The Atlantic Diabetes in Pregnancy (DIP) group established in 2005 represents 5 antenatal centres in a wide geographical location. The group provides care for women with diabetes before during and after pregnancy. We examined the outcomes of pregnancy in 2 periods (2005-2007) and (2008-2010) before and after the implementation of a region wide approach to delivery of care. The process of care changed from stand alone clinics with different personnel to integrated pre-pregnancy (PPC) and combined diabetes antenatal clinics in a hub and spoke fashion supported by an electronic data collection system, clinical care guidelines, professional education and patient education materials. Materials and Methods: Maternal (Glycated Haemoglobin (HbA1C), attendance at PPC, uptake of folic acid, Caesarean Section (CS) rates) and fetal/neonatal (miscarriage, stillbirth and perinatal mortality, admission to neonatal unit and birth weight >4kg) outcomes were recorded. Results: 104 and 152 pregnancies (23% and 30% Type 2) occurred in periods 1 and 2 respectively. Attendance for PPC increased from 28% to 53%, uptake of folic acid from 43% to 57%, and % of women with glycated haemoglobin at booking <7% increased from 51% to 60% between the 2 periods. In addition HbA1C decreased across all trimesters for women with both type 1 and type 2 diabetes over time. Elective CS rate increased from 18% to 41% with no change in the emergency CS rate. The take home baby rate increased from 76% to 89% and miscarriage/deaths<24 weeks decreased from 22% to 11%. The stillbirth and perinatal mortality rates both decreased from 25 to 15/1000, admission to neonatal unit decreased from 63% to 57% and % of babies >4kg decreased from 32% to 24%. Conclusion: A regional approach to the delivery of care has resulted in better pregnancy preparation for the mother and better neonatal outcomes as a consequence, resulting in a higher take home baby rate. The higher elective CS rate needs to be addressed.