Mr Richard Magnus, Chairman, Temasek Foundation Cares, said, "Type 2 diabetes is one of the fastest growing chronic diseases worldwide and a major health problem in Singapore. The results of the Temasek Foundation GDM Care Programme have shown that awareness education, early intervention and regular screenings can help to address the complications of GDM and consequently, Type 2 diabetes among women and mothers. We are encouraged by the success of this pilot programme and heartened that the positive outcomes have led to better compliance for postnatal follow-up among women with GDM, which is important for their long term health."
GDM and its Risks
In Singapore, up to one in five women is at risk of developing diabetes during pregnancy. Data from KKH showed that about 15 to 20 per cent of pregnant women have GDM, and that up to 70 per cent of women will develop Type 2 diabetes at some point in their lifetime following delivery. In the long term, mother and child are at risk of developing obesity and Type 2 diabetes, among other negative health effects.
Women with uncontrolled GDM have a higher risk of developing complications during pregnancy. These include high blood pressure, preterm labour, caesarean section and birth trauma associated with giving birth to big babies weighing more than four kilogrammes at birth. GDM is also associated with an elevated risk of both maternal and fetal mortality.
With better management of GDM through the Temasek Foundation GDM Care programme, a 50 per cent reduction in poor birth outcomes was observed.
The Temasek Foundation GDM Care Programme
The Temasek Foundation GDM Care programme is a new model of care that enables early detection of, and intervention for, women with GDM. The programme supported and further promoted early screening of pregnant women for GDM at between 24 and 28 weeks of gestation. Over the three-year pilot, 4,864 pregnant women were screened and diagnosed with GDM, a 21 per cent increase from before the programme.
If the pregnant women were tested positive for GDM, they were encouraged to enroll in a one-day Supervised Blood Sugar Profile (SBSP) course or a Basic Intervention for GDM (BIG) course. These courses educate the mother on GDM – what the disease is, how to monitor blood sugar, and the lifestyle changes needed to control blood sugar. To help make these courses affordable to more mothers, Temasek Foundation offered subsidies for eligible patients (Singaporeans with a monthly household income of less than $1,800). The subsidies also covered any additional antenatal or postnatal visits. From February 2017 to September 2019, 424 patients received subsidies.
With SBSP and BIG, the Temasek Foundation GDM Care programme provided about 95 per cent of pregnant women with education on the management of GDM, compared to 68 per cent prior to the programme.
Pregnant mothers with GDM were also closely followed up and supported by KKH Diabetes Care Navigators, which comprise specially-trained nurses. This was provided through both in-person care as well as telephone calls.
With early intervention, increased education and close monitoring by the Diabetes Care Navigators, the programme was able to significantly reduce poor birth outcomes by 50 per cent.
Continuity of care
Under the programme, an 'I-Poly' system was developed to enable and enhance continuity of care for mothers with GDM. These mothers were offered a routine check-up six weeks after delivery to check if the GDM had been totally resolved. During the three-year pilot, about 59 per cent of women attended their six-week postnatal GDM screening, compared to about 20 per cent previously.
For smooth transition to care in the community, under I-Poly, the Diabetes Nurse Navigators will help ensure that patients with GDM receive appropriate follow-up care and support. They play a crucial role in helping them to get the right support and facilitate continuity of care including education on healthy lifestyle modifications to improve health outcomes for themselves as well as their families.
The Diabetes Care Navigators will arrange follow-up appointments for these women with GDM to a polyclinic of their choice and coordinate with the polyclinics to track their visits. For women whose GDM conditions have been resolved, they will receive an annual follow-up at the polyclinic for the next three years, as they may develop diabetes at some point in their lifetime following delivery.
For women who continue on to have Type 2 diabetes, they will also receive their follow-up at the polyclinic for optimal management of the condition. I-Poly enables the Diabetes Nurse Navigators to track their attendance at the polyclinics. Should the women miss their polyclinic appointments, the Diabetes Nurse Navigators will contact and remind them of their follow-up at the polyclinic. The primary goal is to create a seamless platform where women with GDM can continue to be followed-up by the Diabetes Nurse Navigators from the hospital to the community. This aims to prevent or delay the onset of diabetes as well as allow women to receive early intervention for at least three years. The system will continue to be enhanced.
Programme lead, Professor Tan Kok Hian, who is also Head and Senior Consultant, Perinatal Audit and Epidemiology Unit, Division of Obstetrics and Gynaecology, KKH, said, "Through this pilot, we have enabled early detection, timely intervention and close follow-up care for women with GDM through this structured care and education programme. In doing so, we are now closer to optimising prevention and management of diabetes and associated health risks for our future generations."
Part of the programme entails a research trial of an innovative monitoring system that aims to enhance care and compliance for women with GDM. In collaboration with IPRAMHO1 (Integrated Platform for Research in Advancing Metabolic Health Outcomes in Women and Children), the research trial will investigate the applicability, acceptability, compliance and validity of a wearable system in women with normal pregnancies and pregnant women with GDM. Recruitment of patients for this trial started in February 2019. The glucose profiles of patient participants will be tracked via the wearable device, throughout their pregnancies.
1 IPRAMHO is a seamless integrated model of care that seeks to optimise implementation of effective population prevention strategies and diabetes and weight reduction programmes, led by KKH in partnership with SingHealth Polyclinics and National Healthcare Group Polyclinics.
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