Type 2 diabetes mellitus has become a common condition afflicting individuals worldwide. There are an increasing number of women in the reproductive age group presenting with type 2 diabetes, which necessitates appropriate risk management in order to reduce the likelihood of any negative effects for mothers and fetuses (Mahmud & Mazza, 2010). Prevention of any complications among this high risk group is best achieved through preconception care including counseling that effectively provides women with type 2 diabetes with information and guidance in order to achieve the most successful pregnancy outcomes. How is this preconception care most effectively delivered and how are pregnancy outcomes impacted?
Guidelines for preconception care should consist of counseling surrounding risks that uncontrolled preconceptional blood sugar poses regarding congenital malformation, and how appropriate blood sugar control should be achieved prior to conception, thus placing emphasis on the importance of effective contraception (Mahmud & Mazza, 2010). However, there seems to be a general deficit in knowledge regarding what is the most effective and suitable form of contraception for women with type 2 diabetes, as well as at what point folate supplementation should be commenced prior to conception (Mahmud & Mazza, 2010). Counseling measures for preconception care should also include screening for depression, risk assessments based on genetic and family history, information surrounding immunization, as well as important health information involving alcohol intake, smoking cessation, exercise, and management of healthy weight (Mahmud & Mazza, 2010).
Nurses play an important part in the provision of effective preconception care to women with type 2 diabetes. Nurses can serve as primary educators in preconceptual counseling, providing needed information to women regarding risks and strategies for achieving positive outcomes. The specific role of nurses with regard to preconception counseling and training in the practice was investigated by Michel & Charron-Prowchownik (2006). Results of this study indicated that nurse educators were generally aware of the concept of preconception counseling although the majority had not received specific training in the practice. Furthermore, survey results from the study determined that 30% of nurses in the study did not regularly provide preconception counseling to adult clients with type 2 diabetes, and 40% of nurses did not provide this counseling to adolescent clients (Michel & Charron-Prowchownik, 2006). Furthermore, nurses in general could benefit from education and training in preconception counseling methods (Michel & Charron-Prowchownik, 2006).
Without appropriate counseling and preconception care, women with diabetes may lack pertinent information in order to ensure healthy pregnancy outcomes for themselves and their babies. Without knowledge of risk factors involved in pregnancy, women with diabetes, especially adolescents, may unknowingly put their health at risk. A study by Charron-Prochownik et al. (2006) sought to investigate preconception counseling awareness among adolescents with diabetes. Results from this study indicated that 65% of adolescents in the sample surveyed were completely unaware of the existence of preconception counseling, and the majority of women sampled were not aware of possible complications associated with pregnancy and diabetes (Charron-Prochownik et al., 2006). Approximately 25% of adolescent women in the study had awareness regarding the importance of planning a pregnancy and how important it is to maintain appropriate metabolic control prior to conception (Charron-Prochownik et al., 2006).
Nurses can have an important impact on the well-being of women with diabetes prior to conception through education and counseling. This focused care aimed at promoting the most positive outcomes for mothers and babies must continue beyond conception throughout the pregnancy and into the post-partum period. A study by Brooten et al. (2001) examined the pregnancy outcomes for women with high risk pregnancies, including diabetes, after receiving prenatal care from a nurse specialist in their homes in the form of counseling and unlimited telephone availability. Results of the study indicated that women in the intervention group that received care from nurses demonstrated lower fetal and infant mortality, fewer preterm births, fewer hospitalizations during pregnancy, as well as fewer rehospitalizations for infants in comparison to women who did not receive the intervention (Brooten et al., 2001). Studies such as this point to the crucial role nurses play in ensuring positive outcomes for pregnancies among women with diabetes.
Another area of focus for counseling and nursing care is in the prevention problems with diabetes among women with histories of past gestational diabetes. Preconception counseling with this population is focused on preventing any future occurrences of gestational diabetes during pregnancy. The counseling provided by nurses in the provision of preconception care may need to be more involving or active than simply providing education about risks. A study by Kim et al. (2007) determined that simple counseling alone may not be effective enough in the promotion of healthy post-partum behaviors in women with gestational diabetes. In particular, recall of discussions with health care providers regarding risks associated with diabetes and pregnancy as well as lifestyle modifications did not prove to be significantly effective in achieving improvements in diet or exercise among women with gestational diabetes (Kim et al., 2007). Furthermore, counseling may be the first crucial step toward substantially increasing awareness among diabetes patients with regard to the important role that lifestyle and behavior change plays in healthy outcomes for mothers and babies in the context of diabetes (Kim et al., 2007). Of particular value are components to counseling such as motivational interviewing as well as stage of change assessments (Kim et al., 2007).
There are dramatic differences associated with the provision of preconception care among women with diabetes with regard to outcome measures. Overall, diabetic women that receive preconception care demonstrated more positive outcomes. A study by Herman et al. (1999) investigated the difference in pregnancy outcomes between women receiving preconception care and women receiving only prenatal care. Results of the studies indicated that women receiving preconception care were better able to be monitored in the early gestational period, which led to glycosylated hemoglobin levels that were significantly lower than women in the prenatal care group (Herman et al., 1999). Length of hospitalization was also shorter for women that received preconception care and this group was hospitalized less than the women that received prenatal care (Herman et al., 1999). Furthermore, infants of mothers receiving preconception care had shorter hospital stays and received less intense care (Herman et al., 1999).
In order for preconception counseling for diabetic women to have widespread effectiveness, its application must be widespread. Therefore, there may be great benefit in providing this type of counseling to teens prior to childbearing. Fischl et al. (2010) investigated this concept by studying the effects of a preconception counseling program designed for delivery to teens with diabetes based on psychosocial, cognitive, and behavioral outcome measures. The name of the program was READY-Girls, an acronym for Reproductive-health Education and Awareness of Diabetes in Youth for Girls, and the program consisted of 3 visits to a diabetes clinic in which the girls received educational information surrounding diabetes and pregnancy and also received counseling from a nurse. The effectiveness of the program was assessed by measuring the knowledge and attitudes of the girls with regard to diabetes, pregnancy, and the preconception counseling itself immediately after the program and nine months later. Results of this study indicated that the knowledge and positive behaviors associated with preconception were significantly sustained after nine months, and that the girls receiving the counseling were more likely to initiate reproductive health discussions (Fischl et al., 2010). The next step in this type of study would be to follow-up with these girls in the future at conception in order to longitudinally assess the effectiveness of this early preconception counseling intervention on actual pregnancy outcomes with this population.
Diabetes in pregnancy is related to several complications including a greater likelihood of miscarriage, preterm labour, pre-eclampsia, greater risk of fetal malformation, neural tube defects, birth injury, macrosomia, urinary tract problems, as well as increased risk of perinatal mortality (Mahmud & Mazza, 2010). These issues place tremendous stress physically and psychologically on mothers and babies and also are very costly in regards to strains on the healthcare system, which can be prevented through behavioral and lifestyle modifications. The importance lies in bringing education and awareness to women with diabetes before conception, so healthy choices and changes can take place early. Overall, preconception care provided by nurses in the form of counseling results in positive pregnancy outcomes for moms and babies.
Brooten, D., Youngblut, J.M., Brown, L., Finkler, S.A., Madigan, E. (2001). A randomized trial of nurse specialist home care for women with high-risk pregnancies: outcomes and costs. American Journal of Managed Care, 7(8), 793-803.
Charron-Prowchownik, D., Sereika, S.M., Wang, S.L., Hannan, M.F., Fischl, A.R., Stewart, S.H., Dean McElhinny, T. (2006). Reproductive health and preconception counseling awareness in adolescents with diabetes: what they don’t know can hurt them. Diabetes Education, 32(2), 235-42.
Fischl, A.F., Herman, W.H., Sereika, S.M., Hannan, M., Becker, D., Mansfield, M.J., Freytag, L.L., Milaszewski, K., Botscheller, A.N., Charron-Prochownik, D. (2010). Impact of a preconception counseling program for teens with type 1 diabetes (READY-Girls) on patient provider interaction, resource utilization, and cost. Diabetes Care, 33(4), 701-5.
Herman, W.H., Janz, N.K., Becker, M.P., Charron-Prochownik, D. (1999). Diabetes and pregnancy: preconception care, pregnancy outcomes, resource utilization and costs. Journal of Reproductive Medicine, 44(1), 33-8.
Kim, C., McEwen, L.N., Kerr, E.A., Pette, J.D., Chames, M.C., Ferrara, A., Herman, W.H. (2007). Preventive counseling among women with histories of gestational diabetes mellitus. Diabetes Care, 30(10), 2489-95.
Mahmud, M., Massa, D. (2010). Preconception care of women with diabetes: a review of current guideline recommendations. BMC Women’s Health, 10(5), retrieved 30 October, 2011 from http://www.biomedcentral.com/1472-6874/10/5.
Michel, B., Charron=Prochownik, D. (2006). Diabetes nurse educators and preconception counseling. Diabetes Education, 32(1), 108-16.
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