Enhancing care for women with diabetes in pregnancy living in fly-in communities, a quality improvement initiative.
Innovative Approaches to Care Delivery, Public Health, and Equity, Diversity & Inclusion
In fly-in communities in Northwestern Ontario, the risk of developing diabetes in pregnancy is particularly high due to poverty and food insecurity. In addition to impacting the health of pregnant women it increases the risk of newborns to develop early onset diabetes. We were able to estimate screening rates and the prevalence of diabetes in pregnancy. We assessed the impact of diabetes of pregnancy on birth outcomes. Using this information, we were able to devise an early screening approach, harmonized treatment and monitoring interventions and improved methods for post-partum follow-up. We will continue to track the prevalence of diabetes in pregnancy in the region and the screening rates. We are looking forward seeing the results of this quality improvement initiative materialize in improved screening rates, reduced morbidity associated with diabetes in pregnancy and assist in ensuring a new generation has the best chance of growing up without early onset diabetes.
The goal of the project was to document the burden of gestational diabetes (GDM) in the region, improve care, facilitate improved early detection and follow up, and empower community-based services. The project is innovative in several ways. We have documented for the first time the prevalence of GDM in this First Nations population and the prevalence of progression to T2DM:
- The work has been undertaken in collaboration with the Sioux Lookout First Nations Health Authority (SLFNHA). This has been a valuable innovation, linking researchers with medical, nursing, administrative and community care providers.
- The rates of gestational diabetes (GDM) are double (12% vs 6%) Ontario rates. Also, Type 2 diabetes mellitus in pregnancy is far more prevalent in First Nations mothers (4% vs 0.2%).
- First Nations women who experience GDM commonly progress to T2DM: 18% at 2 years, 39% at 6 years, compared to a provincial rate of 19% at 9 years.
- We have identified the need for adopting screening for diabetes in the 1st trimester in this high-risk population; data has been presented to Indigenous Services Canada to include screening with an A1C at first prenatal visit at remote community nursing stations, where most initial bloodwork is performed.
- We performed a systematic review of the utility of a 1st trimester A1C in predicting maternal and neonatal complications.
- Knowledge translation: results of the systematic reviews and retrospective cohort studies and clinical treatment protocols have been published in peer reviewed journal and presented at a national conference. We have made practical steps forward in improving care. Work is ongoing with the First Nations Health Authority for developing robust community-based support for pregnant First Nations women with diabetes. An interdisciplinary working group has recently been awarded a multi-year CIHR grant for continuing this work.
Hummelen R, Poirier J, Madden S, Kelly L, Asokan S, Matsumoto C, Sodhi S, Gordon. Progression from gestational diabetes to Type 2 diabetes mellitus among First Nations women in northwest Ontario: a retrospective cohort study. Canadian Journal of Diabetes. May 2023 https://doi.org/10.1016/j.jcjd.2023.05.003
Kattini R, Kelly L, Hummelen R. The effectiveness of metformin treatment compared to insulin treatment for gestational diabetes within the context of a low resource environment: a systematic review. Can Journal of Rural Medicine 2023;28(2):59-65. DOI: 10.4103/cjrm.cjrm_40_22
Kattini R, Kelly L, Hummelen R. Early GDM screening with Glycosylated hemoglobin A1C: a systematic review. Journal of Obstetrics and Gynecology 2020;42(11):1379-84. DOI: 10.1016/j.jogc.2019.12.015
Kattini R, Poirier J, Kelly L, Madden S, Ockenden H, Dooley J, Hummelen R. Outcomes of pregnancies with diabetes in a rural First Nations obstetrical program in northwest Ontario. Canadian Journal of Diabetes 2020;44(7):624-627. DOI: 10.1016/j.jcjd.2020.01.001
Poirier J, Kattini R, Kelly L, Madden S, Dooley J, Hummelen R et al. Screening for gestational diabetes in pregnancy in Northwestern Ontario. Can Journal of Rural Medicine 2020;25:61-6. doi.org/10.4103/CJRM.CJRM_51_19
Hummelen R, Kattini R, Poirier J, Kelly L, Madden S, Ockenden H, Dooley J. Demographics, prevalence and outcomes of diabetes in pregnancy in NW Ontario and small Ontario obstetrical programs. Can Journal of Rural Medicine 2020;25(3):99-104. https://doi.org/10.4103/CJRM.CJRM_71_19