Improving maternity services for women with diabetes case study

Women with diabetes before pregnancy as well as gestational diabetes, have raised concerns over lack of access, awareness and unequal care depending on ethnic minorities and deprived communities in Birmingham. Thanks to a charitable grant of £24,000, researchers developed a simulation model which showed the path of a patient, and what would happen if some tweaks were made to improve care.  

Birmingham has the highest infant mortality rates in the country with diabetes being one of the biggest factors. Type 2 and gestational diabetes are more prevalent in women who are of global majority ethnicity, be living in deprived areas and experience health inequalities before and during pregnancy. These women now make up 2/3 of those with pre-existing diabetes entering pregnancy in Birmingham and Solihull. Currently, 11% of women with type 2 diabetes have evidence of adequate preparation for pregnancy, reducing to only 6% of those living in the most deprived areas of Birmingham. 

Talking to clinicians, service managers and patients, researchers created complex flowcharts with patients entering and exiting different appointment and monitoring schedules. The pathway is: 

1. pre-conception clinics which do not have a standardised criteria for referral 
2. antenatal diabetes clinics with diabetes monitored through an app or phone appointments
3. follow-up test after delivery.

Not all of these are offered to every patient, or the patient doesn’t attend every clinic. Then they asked the clinicians what changes they would make to improve their care and efficiency, and see if that made any changes to the flowcharts, such as improving waiting times, or staff efficiency when on shift. 

One major issue was not many women went to the pre-conception clinics, but GPs couldn’t refer every diabetic patient due to a lack of clinics, so a proposed solution was to only refer based on their blood sugar levels. They found that if 50% of patients in this pre-conception period said their intentions to become pregnant, there would only be enough pre-conception clinics for highest band of blood sugar levels; for the ‘middle’ band, the system could only cope with 36% of eligible patients. They found this was an opportunity for improvement as they found that if those with a ‘middle’ blood sugar level were referred, this would lead to a 15% decrease in babies being born early and with newborn health complications, as well as reducing the need for intensive care and monitoring for the mother during pregnancy by 50%.

These findings are being shared nationally with NHS leaders to change the pathway for these women.