Introduction

This quality standard covers managing diabetes and its complications in women (all females of childbearing potential) who are planning a pregnancy and women who are already pregnant. It also covers areas in which additional or different care should be offered to women with diabetes and their newborn babies. For more information see the diabetes in pregnancy topic overview.

This quality standard should be considered alongside quality statement 7 in the NICE quality standard on diabetes in adults (QS6).

Why this quality standard is needed

Approximately 700,000 women give birth in England and Wales each year, and up to 5% of these women have either pre‑existing diabetes or gestational diabetes. Of women who have diabetes during pregnancy, it is estimated that approximately 87.5% have gestational diabetes (which may or may not resolve after pregnancy), 7.5% have type 1 diabetes and the remaining 5% have type 2 diabetes. The incidence of gestational diabetes is also increasing as a result of higher rates of obesity in the general population and more pregnancies in older women.

Diabetes in pregnancy is associated with risks to the woman and to the developing fetus. Miscarriage, pre‑eclampsia and preterm labour are more common in women with pre‑existing diabetes. In addition, diabetic retinopathy can worsen rapidly during pregnancy. Stillbirth, congenital malformations, macrosomia, birth injury, perinatal mortality and postnatal adaptation problems (such as hypoglycaemia) are more common in babies born to women with pre‑existing diabetes.

Diabetes in pregnant women is managed primarily in secondary care by joint diabetes and antenatal services. Most costs associated with treating diabetes in pregnancy are likely to be incurred in secondary care, in services commissioned by clinical commissioning groups (CCGs). Some aspects of care, such as referring for preconception care, prescribing blood glucose testing strips and organising postnatal care, take place within primary care, and there are points along the pathway when community care services are also involved.

In women diagnosed with gestational diabetes, hyperglycaemia usually resolves after pregnancy, but a proportion of these women will have type 2 diabetes after the birth.

Pre‑existing diabetes in women will be managed in general adult diabetes services after the birth.

The quality standard is expected to contribute to improvements in the following outcomes:

  • miscarriage rates

  • fetal anomalies

  • rates of preterm births

  • perinatal mortality

  • babies who are large for gestational age

  • rates of instrumental births and caesarean sections

  • retinopathy

  • maternal diabetic complications

  • early detection of type 2 diabetes

  • maternal satisfaction.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicators

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

i Adults ii Children and young people

1c Neonatal mortality and stillbirths

Improvement areas

Reducing mortality in children

1.6 i Infant mortality*

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Reducing time spent in hospital by people with longterm conditions

2.3 ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

i GP services

ii GP Out‑of‑hours services

4b Patient experience of hospital care

4c Friends and family test

4d Patient experience characterised as poor or worse

I Primary care

ii Hospital care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving access to primary care services

4.4 Access to i GP services

Improving women and their families' experience of maternity services

4.5 Women's experience of maternity services

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Improving the safety of maternity services

5.5 Admission of full‑term babies to neonatal care

Improving the culture of safety reporting

5.6 Patient safety incidents reported

Alignment with Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Table 2 Public health outcomes framework for England, 2013–16

Domain

Objectives and indicators

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

Indicators

2.1 Low birth weight of term babies

2.2 Breastfeeding

2.3 Smoking status at time of delivery

2.11 Diet

2.12 Excess weight in adults

2.17 Recorded diabetes

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities

Indicators

4.1 Infant mortality*

Alignment with NHS Outcomes Framework

* Indicator is shared

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to diabetes in pregnancy.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that affect patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for diabetes in pregnancy specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole diabetes in pregnancy care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to pregnant women with diabetes and their newborn babies.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality diabetes in pregnancy service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating pregnant women with diabetes and their newborn babies should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development source(s) on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting pregnant women with diabetes. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.