Quality standard
Quality statement 1: Preconception planning
Quality statement 1: Preconception planning
Quality statement
Women with diabetes who are of childbearing potential are offered preconception planning advice at diabetes care reviews. [new 2023]
Rationale
Preconception planning advice for women with diabetes is important because it helps to ensure that they are prepared for pregnancy, which can reduce the risk of adverse outcomes. This advice includes discussing optimal HbA1c levels for pregnancy, taking high-dose folic acid, and advice on medication safety and smoking cessation. Having an HbA1c level below 48 mmol/mol can reduce the risk of miscarriage, stillbirth and neonatal death. Taking high-dose (5 mg per day) folic acid can reduce the risk of women with diabetes having a baby with a neural tube defect, such as spina bifida (when the spine and the spinal cord do not develop completely). If women with diabetes are planning a pregnancy, they can inform their healthcare professional and folic acid can be prescribed.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Process
Proportion of women with diabetes who are of childbearing potential and attend a diabetes care review who are offered advice about preconception planning.
Numerator – the number in the denominator who are offered advice about preconception planning.
Denominator – the number of women with diabetes who are of childbearing potential and attend a diabetes care review.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records. While childbearing potential depends on the individual, for measurement purposes, an age range of 15 to 50 years could be used.
Outcome
a) Percentage of pregnancies in women with diabetes where 5 mg folic acid was taken at the time of the last menstrual period.
Data source: The National Pregnancy in Diabetes Audit measures this. Data can also be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.
b) Percentage of pregnancies in women with diabetes who had early pregnancy HbA1c less than 48 mmol/mol.
Data source: The National Pregnancy in Diabetes Audit measures this as under 20 weeks' gestation. Data can also be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.
c) Percentage of women with diabetes who were well-prepared for pregnancy.
Data source: The National Pregnancy in Diabetes Audit measures this. Data can also be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.
What the quality statement means for different audiences
Service providers (such as GP practices and community and secondary care diabetes services) ensure that during diabetes care reviews, women of childbearing potential are informed of the importance of preconception planning and the steps they should take before becoming pregnant and when their pregnancy is confirmed.
Healthcare professionals (such as GPs, practice nurses and diabetes nurse specialists) inform women of childbearing potential during diabetes care reviews of the importance of preconception planning. This includes the importance of smoking cessation, medication safety, trying to ensure their HbA1c levels are below 48 mmol/mol before pregnancy and taking high-dose folic acid before and for the first 12 weeks of pregnancy.
Commissioners (integrated care systems) ensure that they commission services in which diabetes care reviews include the importance of preconception planning for women of childbearing potential.
Women with diabetes who could become pregnant are offered advice about planning a pregnancy at their diabetes care reviews. This advice includes stopping smoking, having a review of their medication to ensure it is safe during pregnancy, trying to reduce their HbA1c to below 48 mmol/mol and taking a high dose of folic acid before they become pregnant. High-dose folic acid can be prescribed for them by their healthcare professional.
Source guidance
Diabetes in pregnancy: management from preconception to the postnatal period. NICE guideline NG3 (2015, updated 2020), recommendations 1.1.2, 1.1.4, 1.1.11, 1.1.18, and expert opinion
Definitions of terms used in this quality statement
Women of childbearing potential
Childbearing potential should be determined on an individual basis. It should not be determined solely by age because childbearing potential can be dependent on factors other than age. However, for measurement purposes, the age range of 15 to 50 years could be used. [Adapted from NICE's guideline on antenatal and postnatal mental health, definition section, National Pregnancy in Diabetes Audit and expert opinion]
Equality and diversity considerations
Self-reported levels of preparation for pregnancy among women with diabetes are lowest in the most deprived communities. Healthcare professionals should actively encourage these women to attend regular diabetes care reviews, where the importance of pregnancy planning can be emphasised.
Women with diabetes should be given information about preconception planning that they can easily read and understand themselves, or with support, so they can communicate effectively with health services. Information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally and age appropriate. People should have access to an interpreter or advocate if needed.
For women with diabetes with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard or the equivalent standards for the devolved nations.