Use of contraception by women with type 1 or type 2 diabetes mellitus: ‘It's funny that nobody really spoke to me about it’

ABSTRACT

Objectives To understand factors which promote or discourage use of contraception in women with diabetes mellitus (DM). To identify contraceptive knowledge, skills and attitudes of health professionals involved in diabetes care.

Methods The research formed part of a larger mixed methods study and included a questionnaire survey (107 women with DM) and semi-structured qualitative interviews with women with DM (n = 16) and diabetes specialists (n = 16). Analysis was by SPSS and NVivo 7.

Results Two main themes emerged: Contraceptive provision and advice and Choice of contraceptive methods. There was incongruence in views between the diabetes specialists and women with DM in relation to advice and use of contraception. Many diabetes specialists felt unqualified to give advice and saw general practitioners as contraception providers. There was low use of long-acting reversible contraceptives, and women used ‘natural’ methods in their wish to ‘avoid taking hormones or chemicals’.

Conclusions Despite awareness of the need to plan pregnancies to avoid poor outcomes, women with DM are likely to receive little advice about their contraceptive options. Contraception should evidently be a legitimate part of diabetes care and diabetes specialists require training to enable them to assist women in making their own informed choices.     

Cost-effectiveness analysis of cardiovascular risk factor screening in women who experienced hypertensive pregnancy disorders at term

ObjectivesTo assess the cost-effectiveness of post-partum screening on cardiovascular risk factors and subsequent treatment in women with a history of gestational hypertension or pre-eclampsia at term.Study designTwo separate Markov models evaluated the cost-effectiveness analysis of hypertension (HT) screening and screening on metabolic syndrome (MetS), respectively, as compared to current practice in women with a history of term hypertensive pregnancy disorders. Analyses were performed from the Dutch health care perspective, using a lifetime horizon. One-way sensitivity analyses and Monte Carlo simulation evaluated the robustness of the results.ResultsBoth screening on HT and MetS in women with a history of gestational hypertension or pre-eclampsia resulted in increase in life expectancy (HT screening 0.23 year (95% CI −0.06 to 0.54); MetS screening 0.14 years (95% CI −0.16 to 0.45)). The gain in QALYs was limited, with HT screening and MetS screening generating 0.04 QALYs (95% CI −0.12 to 0.20) and 0.03 QALYs (95% CI −0.14 to 0.19), resulting in costs to gain one QALY of €4228 and €28,148, respectively. Analyses for uncertainty showed a chance of 74% and 75%, respectively, that post-partum screening is cost-effective at a threshold of €60,000/QALY.ConclusionsAccording to the available knowledge post-partum screening on cardiovascular risk factors and subsequent treatment in women with a history of gestational hypertension or pre-eclampsia at term is likely to be cost-effective.     

Ácido úrico herramienta de tamización para preeclampsia. Una revisión sistemática de la literatura

IntroductionUric acid has been described as a possible risk marker for the appearance of pre-eclampsia. However, so far there is no solid evidence to support it. The objective of this study is to synthesize the available literature to determine the usefulness of uric acid as a screening tool for pre-eclampsia.MethodologySystematic review of the literature of primary studies that analyse serum uric acid levels in the first and second trimesters of gestation with the development of pre-eclampsia. Search in PubMed (n: 639).ResultsTwo studies (2 cohort studies) were included with a total of 9,746 pregnant women and 398 cases of pre-eclampsia. In the studies, higher serum uric acid levels were found in pregnant women who developed preeclampsia (OR 1.8 to 2.0).ConclusionsUric acid is related to the presence of preeclampsia and its pathophysiology. The scientific community is invited to continue investigating the applicability of uric acid for its implementation as a screening tool in the first and second trimester of pregnancy.     

Changing screening strategies for genital chlamydia in family planning clinics: a good public health strategy?

Objective To estimate the prevalence and factors associated with genital chlamydia in 1996 and to evaluate the introduction of restricted screening criteria based on diagnostic testing and prevention of iatrogenic pelvic inflammatory disease in 1997.

Patients Women attending Liverpool family planning clinics.

Method Clinical and demographic data were recorded at routine clinic consultations. Data were analyzed using logistic regression.

Results In 1996, a 5.7% (123/2165) chlamydial prevalence was detected. A significantly lower prevalence was observed in the over-25-year-old age group compared to those aged 16–19 years old (p < 0.0001), and in those with an interval of over 11 months since the last new sexual partner compared to those with a new partner in the past 1–3 months (p < 0.05). A significantly higher prevalence was detected in those only presenting with signs of infection alone compared to those presenting with either symptoms or both signs and symptoms of infection (p < 0.05). Those requesting a termination of pregnancy were at higher risk of genital chlamydia than those attending for contraceptive advice (odds ratio 1.97; 95% confidence interval 1.14–3.39).

Using the restricted screening criteria, prevalences of 5.4% (78/1438) and 3.7% (60/1641) were found for 1996 and 1997, respectively. Prevalences were significantly higher in 1996 than 1997 when adjusted for the other factors (p < 0.05).

Conclusion The study raised awareness of genital chlamydia among women attending family planning clinics and showed that primary care could make a significant contribution to the prevention of chlamydial infection. It is only by initiating intervention strategies in such settings that genital chlamydia will be controlled effectively in the UK.     

Effect of an Educational Intervention on Cardiovascular Disease Risk Perception among Women with Preeclampsia

ObjectiveTo promote knowledge and awareness about cardiovascular disease (CVD) among women with recent preeclampsia so that this population may develop more accurate perceptions of their personal CVD risk.DesignAn exploratory single group, pretest/posttest educational intervention study.SettingTelephone‐based interviews.ParticipantsSixty‐four women with preeclampsia in the most recent pregnancy completed the study. The sample was predominately African American.MethodsKnowledge about CVD and the study covariates (age, race, parity, income, marital status, education, and history of previous preeclampsia) were measured prior to CVD education. Levels of CVD risk perception were measured both before and after the CVD educational intervention.InterventionStructured CVD education by telephone.ResultsAfter CVD education, levels of CVD risk perception were significantly higher than at baseline.ConclusionAs an intervention, CVD education provided by telephone served as a practical and effective approach to contact postpartum women with recent preeclampsia and demonstrated effectiveness in increasing perception of CVD risk     

Women's awareness of long-acting,reversible contraceptive methods (LARCs) in community family planning clinics and general practice

Objectives To investigate whether awareness and choice of long-acting reversible contraceptives (LARCs) of women attending a community family planning clinic differ from those of women seeing general practitioners (GPs).

Methods Information was collected from women in their reproductive years about their current contraceptive method, their awareness of LARCs and whether they felt well informed about their options. After additional information was provided the respondents were asked whether they would consider changing their method and if their GP offered this option.

Results Questionnaires were completed by 177 women attending a city-centre contraception and sexual health (CASH) clinic (n = 96) and a GP's surgery in a neighbouring city (n = 81). Forty percent of women in the CASH cohort and 6% in the primary care group were using LARCs. Women attending the CASH service were more aware of their contraceptive options and felt better informed but less than 50% in either group had heard of the levonorgestrel-releasing intrauterine system. At least 50% of women would consider using a LARC yet few knew if their GP fitted/provided these methods.

Conclusion LARC usage was considerably higher in CASH services compared to primary care. Those providing contraceptive care should give up-to-date information covering all methods and referral to local specialist services, as appropriate.     

A Review of the Health Beliefs and Lifestyle Behaviors of Women with Previous Gestational Diabetes

ObjectiveTo critically review and synthesize original research designed to examine the health beliefs, including risk perceptions and health behaviors related to diet and physical activity of women with previous gestational diabetes mellitus.Data SourcesPubMed and CINAHL databases were searched for studies published in the last decade (1998-2008) that examined variables related to the health beliefs and behaviors of women with previous gestational diabetes mellitus. Keyword searches included health beliefs, health behaviors, perceived risk, gestational diabetes, type 2 diabetes, diet, physical activity, and postpartum.Study SelectionEight articles, representing 6 studies, were selected that met the inclusion criteria of original research, dependent variable of health beliefs and behaviors of women with previous gestational diabetes mellitus, and measurement after pregnancy.Data ExtractionArticles were reviewed and discussed according to the concepts of risk perception and health beliefs, health behaviors related to diet and physical activity, and psychosocial factors related to women's health beliefs and behaviors.Data SynthesisData revealed common health beliefs and behaviors of women with previous gestational diabetes mellitus, including low risk perceptions for future type 2 diabetes mellitus and suboptimal levels of physical activity and fruit and vegetable intake. The majority of studies revealed a distinct knowledge-behavior gap among women with previous gestational diabetes mellitus, whereas others revealed a lack of knowledge regarding necessary lifestyle modifications.ConclusionsFindings from this review may assist women's health researchers and clinicians in developing appropriate interventions for increasing risk awareness, promoting self-efficacy for weight loss and physical activity behaviors, and decreasing rates of diabetes and cardiovascular disease among women with previous gestational diabetes mellitus. Further research is necessary to identify factors that influence the health beliefs and behaviors of women with previous gestational diabetes mellitus. Future research should focus on populations of greater racial, ethnic, and socioeconomic diversity, as the majority of studies have been conducted with non-Hispanic White, socioeconomically advantaged women.     

The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared With Those Continuing Pregnancy

ObjectiveTo determine the prevalence of intimate partner violence (IPV) among women and teenagers seeking termination of pregnancy compared with those continuing with pregnancy.MethodsAll women who presented for elective termination of pregnancy at a family planning clinic between June 2001 and January 2003 were invited to participate. This study was conducted by means of face-to-face interviews with clinic nurses. The control group was composed of women who were continuing with pregnancy.ResultsIn total, 1003 women were interviewed, including 350 at the family planning clinic (elective abortion [EA] group) and 653 women at the perinatal clinic (continuing pregnancy [CP] group). For women in the EA group, the probability of being a victim of IPV in the past year (including psychological, physical, and/or sexual abuse) was almost three times higher than for women in the CP group (25.7% vs. 9.3%, P < 0.0001), and the risk of being a victim of physical and/or sexual IPV in the past year was almost four times higher (7.1% vs. 1.8%, P < 0.0001). Women in the EA group had also more often been victims of violence in their lifetime (41.1% vs. 29.1%, P = 0.0001). The principal factors predictive of having been a victim of physical and/or sexual IPV in the past year were being single, separated, divorced, or widowed, and being in a relationship that was in difficulty or breaking down. In the multivariate analysis adjusted for confounding factors, age was rarely a significant factor.ConclusionThe high prevalence rates of IPV among women seeking elective abortion justifies routine assessment for IPV during pre-abortion visits. Physicians have access to tools that will help them to identify IPV and to be proactive regarding this important issue.     

Soluble Endoglin as a new marker for prediction of pre-eclampsia in early pregnancy

ObjectiveTo evaluate the use of a new marker in the prediction of pre-eclampsia few months before the onset of manifestations.Materials and methodsSixty-six women during early pregnancy were enrolled in the present study and were divided as follows: Thirty-three pregnant women: 15 developed gestational hypertension and 18 pregnant women who later developed pre-eclampsia and 33 normotensive pregnant women taken as controls. Exclusion was done to twin pregnancies, cases with fetal abnormalities, maternal renal disease and connective tissue diseases. Serum concentration of angiogenic markers (VEGF, PIGF) and anti-angiogenic marker: soluble Endoglin (sEng) was measured during 14–18weeks gestation using ELISA technique. All women were followed up till delivery.ResultsA statistically significant difference was found in comparing the median level of VEGF and PIGF in cases of gestational hypertension and pre-eclampsia with controls (P<0.0005 and P<0.0005). A statistically significant difference was found in comparing the median level of VEGF in gestational hypertension group with pre-eclampsia (P=0.19). The median level of soluble Endoglin had a statistically significant difference in comparing gestational hypertension and pre-eclampsia group with controls (P<0.0005). A cut-off value of 31pg/ml VEGF yielded a sensitivity of 94.4%, specificity of 72.9% with accuracy 78.8%. PIGF at cut-off level of 49pg/ml had a sensitivity of 77.8, specificity of 89.6% with accuracy 86.6%. In case of sEng the sensitivity was 94.4%, specificity was 87.5% and accuracy was 89.5%.ConclusionPregnant women who are at risk of developing pre-eclampsia can be offered measuring these markers as a screening method to point out those who are more likely to develop pre-eclampsia and warrant close observation and intervention.     

Impact of the creation of a specialized clinic for prenatal blood sampling and follow-up care in pregnant women

ObjectiveTo evaluate (1) the effect on gestational diabetes mellitus (GDM) screening rates of having a specialized clinic for pregnant women offering blood sampling and screening for GDM, and (2) the impact on perinatal outcomes of having early GDM screening and follow-up provided by the specialized clinic.MethodsWe performed a retrospective cohort study, based on electronic health records. We compared data from women who delivered during a period when the Blood Sampling in Pregnancy (BSP) clinic was operating (2008–2009; n = 2780) to a time period before the clinic was established (2006–2007; n = 2591). During the 2008–2009 period, we compared data from women who had GDM screening in the first trimester with women who had screening during the second trimester and with women who were not screened.ResultsFollowing the creation of the BSP clinic, overall GDM screening rates reached 72.4% in 2008–2009, compared with 48.9% in 2006-2007 (P < 0.001) and GDM screening was more likely to be performed in the first trimester (36.7% vs. 0.4%; P < 0.001). During the period when the BSP clinic was operating (2008-2009), women who had GDM screening in the first trimester had lower rates of Caesarean section (15.7% vs. 22.1 %; P < 0.001) and neonatal complications (bradycardia: 3.6% vs. 6.8%; P = 0.003; respiratory distress: 9 6% vs 13 2%; P = 0 02; and admission to NICU: 15.4% vs. 26.8%; P < 0.001) than women who did not perform GDM screening.ConclusionIn our population, creation of a clinic offering specialized care to pregnant women improved GDM screening rates. With the support of the BSP clinic, women who had early GDM screening were less likely to undergo Caesarean section and their offspring had fewer perinatal complications.     

Pre-eclampsia Educational Tool Impact on Knowledge,Anxiety, and Satisfaction in Pregnant Women: A Randomized Trial

ObjectiveThis study aimed to evaluate the impact of educational tools concerning pre-eclampsia on knowledge, anxiety, and women's satisfaction.MethodsThe investigators conducted a randomized controlled trial from March to July 2014 at the Centre Hospitalier Universitaire de Sherbrooke (Sherbrooke, QC) by comparing ambulatory pregnant women (20–32 weeks of gestation) who were receiving educational tools on pre-eclampsia with control patients who received routine care. Tools consisted of an informative pamphlet, a video, and a pictographic magnet, all validated by a multidisciplinary team. The primary outcome was global knowledge (number of correct answers on 35 items) about the disease after 1 month, as assessed by questionnaire. Secondary outcomes included anxiety regarding pre-eclampsia and satisfaction concerning the different tools (a 1–6 Likert scale was used).ResultsAmong 362 pregnant women approached for the research, 269 were randomized. After 1 month, 247 questionnaires (92%) were filled and analyzed: 122 from the control group and 125 from the intervention group. Baseline characteristics were similar between the groups. Patients who received the tools scored significantly higher on global knowledge (70.1% ± 19.2% compared with 51.1% ± 23.4%; mean difference of 19.0%; P < 0.001). Anxiety scores regarding pre-eclampsia were similar between the groups, with a mean of 2.40 out of 6 for the control group and 2.53 out of 6 for the intervention group (equivalence test, P < 0.001). High score levels of satisfaction for the pamphlet and video were found: 5.1 out of 6 and 5.2 out of 6, respectively.ConclusionThese well-received educational tools for pregnant women increased their knowledge about pre-eclampsia without increasing their anxiety about it. Women reported the highest satisfaction for the tools.     

Beliefs about health and illness postpartum in women born in Sweden and the Middle East

Objective

to explore beliefs about health and illness three months postpartum in women born in Sweden and the Middle East, and to study whether they perceive gestational diabetes mellitus (GDM) as a prediabetic condition.

Design

an explorative study using semi-structured interviews 3 months postpartum.

Setting

in-hospital diabetes specialist clinic in Sweden.

Participants

interviews three months after birth. Consecutive sample of women with GDM; 13 born in Sweden and 14 born in the Middle East.

Measurement and findings

irrespective of origin, health was focused on well-being and being able to care for the baby. Many Middle Eastern women did not know how long GDM would last or said that they had been informed by staff about its transience. They worried about still having diabetes mellitus (DM), which directed them to self-monitoring of blood glucose and the desire for health-care staff to verify the disease. They showed tendencies to dietary changes. Swedish-born women feared development of type 2 DM and had undertaken active health-related behaviour.

Key conclusions

beliefs about health and illness differ, change and affect awareness of risk and self-care practice postpartum. Swedish women showed high risk awareness with changes in life style and the desire for more information to avoid developing DM. Middle Eastern women showed increased risk awareness and sought help from staff in checking whether GDM was present in the postpartum period.

Implications for practice

it is important to recognise that Middle Eastern women, in contrast to Swedish-born women, have not incorporated the message that GDM is a risk marker for future development of DM. Health professionals have a significant role in supporting women and their families undergoing the transition to motherhood, particularly migrants in a new country. Identifying individual beliefs is of crucial importance. Pre-existing baby health clinics can be developed to address mothers’ needs as well as the health of the baby.     

Accuracy of angiogenic biomarkers at ⩽20 weeks’ gestation in predicting the risk of pre-eclampsia: A WHO multicentre study

ObjectiveTo assess the accuracy of angiogenic biomarkers to predict pre-eclampsia.DesignProspective multicentre study. From 2006 to 2009, 5121 pregnant women with risk factors for pre-eclampsia (nulliparity, diabetes, previous pre-eclampsia, chronic hypertension) from Argentina, Colombia, Peru, India, Italy, Kenya, Switzerland and Thailand had their serum tested for sFlt-1, PlGF and sEng levels and their urine for PlGF levels at ⩽20, 23–27 and 32–35 weeks’ gestation (index tests, results blinded from carers). Women were monitored for signs of pre-eclampsia, diagnosed by systolic blood pressure ⩾140 mmHg and/or diastolic blood pressure ⩾90 mmHg, and proteinuria (protein/creatinine ratio ⩾0.3, protein ⩾1 g/l, or one dipstick measurement ⩾2+) appearing after 20 weeks’ gestation. Early pre-eclampsia was defined when these signs appeared ⩽34 weeks’ gestation.Main outcome measurePre-eclampsia.ResultsPre-eclampsia was diagnosed in 198 of 5121 women tested (3.9%) of whom 47 (0.9%) developed it early. The median maternal serum concentrations of index tests were significantly altered in women who subsequently developed pre-eclampsia than in those who did not. However, the area under receiver operating characteristics curve at ⩽20 weeks’ gestation were closer to 0.5 than to 1.0 for all biomarkers both for predicting any pre-eclampsia or at ⩽34 weeks’ gestation. The corresponding sensitivity, specificity and likelihood ratios were poor. Multivariable models combining sEng with clinical features slightly improved the prediction capability.ConclusionsAngiogenic biomarkers in first half of pregnancy do not perform well enough in predicting the later development of pre-eclampsia.     

Changing models of public antenatal care in Australia: Is current practice meeting the needs of vulnerable populations?

Objectiveto investigate women's views and experiences of public antenatal care.Designpopulation-based survey in two states.SettingSouth Australia and Victoria, Australia.Participants4366 women surveyed at 5–6 months post partum.Findingsof 8468 eligible women mailed the survey, 52% returned completed questionnaires. Fifty-seven per cent of women (2496/4339) received public antenatal care. Of these, half attended a GP for some/all antenatal visits, 38% attended a public hospital clinic or midwives clinic, and 12% had primary midwife care, mostly in a midwifery group practice. Women with complex needs – young women, those experiencing multiple social health problems, women of non-English speaking background, and women at higher risk of complications in pregnancy – were the least likely to say that care met their needs. Women attending a GP or midwife as a primary caregiver were the most positive about their antenatal care: 69% and 74% respectively describing their antenatal care as ‘very good’. Women attending a standard public hospital clinic were the least positive about their antenatal care with only 48% rating their care as ‘very good’. Women enroling in GP shared care or attending a midwives clinic at a public hospital gave intermediate ratings.Conclusion and implications for practiceModels of public antenatal care involving a designated lead primary caregiver (GP or midwife) came closest to meeting women's need for information, individualised care and support.     

Knowledge of the Female Athlete Triad,and Prevalence of Triad Risk Factors among Female High School Athletes and their Coaches

Study ObjectiveThis study aimed to determine awareness/knowledge of the Triad and its health implications among female high school athletes and their coaches, and to evaluate coaches' Triad screening/intervention practices.DesignCross-sectional survey.SettingTwo high schools in the western United States.ParticipantsFemale athletes from a variety of sports (N = 240) ages 14-18 years and their coaches (N = 10).InterventionParticipants completed surveys that assessed Triad knowledge and athlete Triad risk factors.Main Outcome MeasuresFrequency of responses to Triad knowledge, Triad risk factor, and Triad education/screening procedures questions; athlete summative knowledge score.ResultsHalf (N = 120) of participants reported menstrual irregularity, and 42% (N = 101) had 2 or more Triad risk factors: past amenorrhea (N = 39), past stress fracture (N = 41), self-reported not eating enough (N = 53), underweight (BMI-for-age < 5^th percentile) (N = 10), pressure to be a certain weight (N = 143), and wanting to lose >10 pounds when self-reported weight was in a healthy range (N = 34). Average athlete Triad knowledge score was 2.97 ± 1.61 out of 8. Coach Triad knowledge was limited; however, most (9/10) were comfortable discussing menstruation with their athletes. Barriers to Triad screening/education were coaches' insufficient time, knowledge, and educational resources.ConclusionTriad risk factors were prevalent among athletes and coach and athlete Triad knowledge was low. Providing coaches with Triad screening/education training may increase Triad knowledge and decrease Triad risk among high school athletes.     

Early diabetes screening in obese women

Objective: To describe maternal characteristics related to early screening for diabetes in obese women and evaluate the benefits of early diabetes screening and diagnosis.

Study design: Retrospective cohort of obese women (BMI?≥30?kg/m²) without pregestational diabetes who delivered a singleton gestation between 2011 and 2012. Maternal characteristics/demographics and maternal and neonatal outcomes were compared between women with early diabetes screening (<20 weeks) versus traditional screening. We additionally compared maternal and neonatal outcomes for women with an early versus traditional diabetes diagnosis.

Results: Of the 504 eligible women, 135 (26.8%) had early diabetes screening. Obese women with early screening were older, had a higher BMI, were more likely to have hypertension and neonates admitted to the NICU. Of women with early screening, 31 (23%) were diagnosed early. Women with an early diagnosis of diabetes were more likely to require treatment with insulin (36% vs. 23%, p?=?0.003). Women with an early diagnosis of diabetes were more likely to have neonates in the NICU (48% vs. 26%, p?=?0.03).

Conclusions: Early screening for diabetes was more common in older women with additional comorbidities. Obese women diagnosed via early screening were more likely to require medical treatment for diabetes, suggesting a value to early screening.