Planning Pregnancy

From her work with women with diabetes in the Joslin Clinic more than 50 years ago, Priscilla White observed that: 'To many, if not all, of these women, life lacks meaning, and even may be unendurable without successful child-bearing'7. Fortunately, nowadays there are in principle no medical reasons for a woman with established diabetes not to become pregnant—provided she takes adequate care of her blood glucose control before conception and throughout the pregnancy. Only on rare occasions may doctors advise against pregnancy, for instance when the woman with diabetes has seriously advanced microvascular complications, and the pregnancy may accelerate these complications and cause severe physical disability or even death in the diabetic woman8.

As it has been convincingly demonstrated that poor glycaemic control during early pregnancy greatly increases the risk of birth defects in infants of mothers with established diabetes, health care professionals have taken the attitude that women with diabetes have it in their own hands to prevent birth defects by maintaining optimal blood glucose levels before conception and throughout pregnancy. For women with established diabetes who are in poor metabolic control, the requirements of more intensive self-care and medical management can complicate decision making and give way to worries and increased stress levels. While little is known yet about the heredity of type 1 diabetes, the issue of 'passing on' the disease to the unborn child appears of increasing concern for women with diabetes who are planning a family.

Large individual differences may be observed in how diabetic women and their partners cope with the need for 'preconception watchfulness' and pregnancy planning. While some women or couples may be 'unrealistically' optimistic regarding the health risks involved, others may react over-anxiously and develop a phobia of hyperglycaemia, leading to excessive blood glucose monitoring and very frequent consultations of the diabetes health care team.

In cases where a woman does achieve near-normal glucose levels, but with no pregnancy occurring, the woman and her partner may perceive this as 'unjust' and difficult to accept. The woman may find it hard to keep striving for tight control, and 'give up' on her treatment adherence. While from a psychological point of view we would be inclined to advise couples struggling with infertility to take a more laisser faire attitude towards pregnancy, this approach may be less useful in women with diabetes, as developing a more accepting attitude may be incompatible with staying adherent to the diabetes regimen.

In contrast to what one might expect in view of the health risks involved, research suggests that most women with diabetes tend to seek medical care after they are pregnant, when damage to the fetus may already have occurred. In the often-cited Maine study, in which providers in a statewide network were trained in pre-conception care and attempts were made to reach all diabetic women before pregnancy, only 34% of the diabetic pregnancies occurred in women who had received pre-conception counselling9. In a recent study performed by Holing et al.10, it was found, in a sample of 85 women with diabetes diagnosed before the index pregnancy, that fewer than half of the pregnancies were planned. The authors conclude that most unplanned pregnancies are not contraceptive failures, but may have been consciously or subconsciously intended. Interestingly, the authors found that women who felt that their doctor discouraged pregnancy were more likely to have an unplanned pregnancy than women who had been reassured they could have a healthy baby. This finding may be biased but does seem to underscore the importance of the doctor-patient relationship11. Social support appears to play a significant role, as women with unplanned pregnancies are reported to be less satisfied with their partner relationship than those who have planned their pregnancies, and only eight out of 50 felt that their partners were informed about diabetes and pregnancy. Most of the women in this study with unplanned pregnancies felt that their partners did not understand the risks or the enormity of effort required to achieve good diabetes control. Unplanned pregnancies are likely to occur more often in women with low education and low income. As Janz and colleagues12 have reported, lower income, unemployment, less education and unmarried status are all factors having a major impact on whether or not women seek preconception care. In a prospective, longitudinal study, St James et al.13 made an analysis of psychosocial factors related to unplanned pregnancies, comparing women with diabetes to women with phenylketonuria (PKU). While use and type of birth control were comparable for both groups, diabetic women used condoms more often. Consistent birth control in diabetic women was associated with social support and positive attitudes towards birth control, accounting for 21% of the variance in frequency of birth control use. Having an 'internal locus of control' and higher knowledge of maternal diabetes each accounted for 6% of the variance, while sociodemographic variables were not significant factors in regression analyses. The authors conclude that the two most important factors influencing contraceptive use among diabetic women would be (a) attitudes towards contraception and (b) perception of the extent to which significant others want the woman to use contraception. Interviewing younger diabetic women revealed that fear of future complications is a major concern to them, and seems to outweigh concerns about future children. Many wondered if they would live long enough to raise their child.

In the study by Holing et al.10 it was observed that most women who said their pregnancies were unplanned were using contraception less than half of the time and were happy to learn they were pregnant. The authors then conclude: 'For some women, the difficulties in fully planning and preparing for pregnancy may be outweighed by the desire to have a child; these women may subconsciously ''let it happen"'.

Pregnancy Guide

Pregnancy Guide

A Beginner's Guide to Healthy Pregnancy. If you suspect, or know, that you are pregnant, we ho pe you have already visited your doctor. Presuming that you have confirmed your suspicions and that this is your first child, or that you wish to take better care of yourself d uring pregnancy than you did during your other pregnancies; you have come to the right place.

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