The health state of women pre-conception has a direct impact on pregnancy outcomes and the health of the child over the course of their lifetime. Ramey et al. explored the multi-level influences that lead to health disparities across diverse populations and through extensive community-based research developed The Preconception Stress and Resiliency Pathways Model (PSRP) to explore the diverse and complex ways our genetics, environment, community, physical and mental health weave together to contribute positively or negatively to the health of an individual beginning with the health of the mother prior to conception. The PSRP model is quite complex and attempts to investigate health determinants through a holistic and thorough lens including pre-conception health, the role of the father, maternal stress as well as community influences such as income, employment, and housing (Ramey et al., 2015).
The PSRP model addresses an area that is not typically focused on by main stream health care. This model focuses on the holistic pre-conception health state of the mother and the role her family members and community play in contributing to a state of health or lack thereof. One of the goals of the PSRP model is to improve maternal health before pregnancy therefore leading to improved pregnancy outcomes. The PSRP model proposes that by implementing multiple levels of preventative health strategies in the home and the community as well as working towards closing health care gaps and access to health care providers and by encouraging a more collaborative approach among the diverse health care disciplines we can begin to improve the health of an individual across their entire lifespan. The authors readily admit that the “tremendous breadth” of this model is likely the model’s biggest limitation and requires a major shift in the current delivery of most health care services from responding to the presence of disease to focusing more on prevention and improvement through education, access to community services such as mental health and nutrition counselling, creating positive family dynamics and manageable levels of stress before conception occurs (Ramey et al., 2015, pp. 717-719).
As a practicing midwife, one of my biggest frustrations is the lack of funding for health care providers to provide pre-conception health care to women contemplating pregnancy and an abysmal lack of community programming targeting the pre-pregnant population. This results in a glaring missed opportunity to make positive health changes prior to conception and pregnant women presenting to my clinic in a less optimal state of health than what could have been achieved with prenatal education as opposed to solely antenatal education. The PSRP model could well serve to improve this discrepancy.
Diabetes and gestational diabetes in particular is one of the most common chronic diseases that midwives routinely diagnose and treat in collaboration with endocrinology and diabetes education counsellors. According to the CDC presently approximately 6-9% of pregnant people will develop gestational diabetes during their pregnancy and 1-2% enter pregnancy with pre-existing diabetes either type 1 or type 2 worldwide. In Canada, the rate of type 1 diabetes has remained relatively stable, while rates of type 2 diabetes and gestational diabetes continue to creep up with the highest rates of gestational diabetes found in British Columbia and the lowest rates found in Nunavut. Rates of gestational diabetes were also highest in older women (Maternal Diabetes in Canada, 2014).
If we explore the topic of gestational diabetes through the PSRP model it quickly becomes apparent that women with pre-existing diabetes or those at increased risk of developing gestational diabetes would benefit greatly from pre-conception health care and education. Through the lens of the PSRP model one could even argue that through a multi-level approach to health care, the diabetic state of the mother could have been improved or prevented if the mother had had more access to preventative health care across her lifespan beginning during her own gestational period. One strategy that I use to encourage healthy lifestyle behaviours in my patients is to remind them that when a female is born, she is born with all the oocytes (eggs) that she will ever have. Women do not make more oocytes over their lifetime and of the roughly 2 million oocytes that are present at birth only a small portion will mature into an ovum and be released by the ovaries for conception to occur (Human Reproduction Anatomy and Gametogenesis). This means that women pregnant with a female fetus are also carrying the eggs that will eventually become their grandchildren. I have found that by sharing this simple explanation of inter-generational health, many women choose to cut out or reduce unhealthy lifestyle choices in their pregnancies as they begin to understand the ripple effect that their choices can have on future generations.
In the context of gestational diabetes, a non-diabetic woman temporarily becomes diabetic as her pancreas cannot keep up with the increased insulin demands of pregnancy and results in higher blood sugars which can negatively impact the health and well-being of the mother and child (Living with Gestational Diabetes). The short term risks of diabetes in pregnancy include delivery of a macrosomic infant, higher rates of shoulder dystocia, assisted vaginal delivery, perineal trauma and caesarian section largely attributed to macrosomia, higher risk of stillbirth and higher rates of placental dysfunction including preeclampisa (Berger et al., 2016). According to Diabetes Canada, women who developed gestational diabetes are at an increased risk of developing type 2 diabetes with as many as 40 per cent of women who have had gestational diabetes going on to develop type 2 diabetes later in life. Additionally babies born to diabetic mothers appear to also have an increased risk of developing diabetes in their lifetime. (Reproductive Health-Diabetes in Pregnancy, 2018)
If we employed the PSRP model in an attempt to reduce the occurrence of diabetes it is my opinion that we could greatly slow or reduce the spread of this chronic disease. As Bryant, et al. discuss, there is a direct correlation between income and health in Canada which has “increasingly led to a “privatization of security” whereby security is (financially) guaranteed for the wealthy and rather less so for the poor and disadvantaged” (Bryant et al. 2010). While diabetes impacts people from all races and socioeconomic backgrounds it is also an illness disproportionately represented by people of non-white ethnicities, specifically those of Arab, Asian, Hispanic, South Asian and Indigenous descent and diabetes is more prevalent among those from lower socioeconomic backgrounds (Maternal Diabetes in Canada). While genetics contribute to the development of diabetes, lifestyle choices can increase or decrease an individual’s risk, especially in the development of gestational or type 2 diabetes. People from poorer socioeconomic backgrounds in Canada are more likely to come from a population that is already genetically predisposed to diabetes and this population also faces more barriers in accessing education, nutritious food and health care services leading to a greater health disparity between the primarily white population with more means to access and sustain healthy lifestyles than those living in poverty. The social determinants of health have a large influence over an individual’s risk of developing diabetes as well as other chronic illnesses over their lifetime (Bryant et al., 2010).
Through the PSRP lens, imagine a model of health care where every woman contemplating pregnancy had access to a health care provider knowledgeable in pre-conception health with individualized recommendations for health promotion, access to community programming targeting ways to improve pregnancy outcomes, education and funding on how to purchase and prepare healthy meals, community lead activities promoting exercise and stress reduction as well as education for fathers and family members to encourage healthy pregnancy behaviours and positive parenting approaches. While complex and not easily attainable, I believe that through the PSRP model we could see a dramatic improvement in public health and a reduction in the percentage of the population living with diabetes.
Clearly working towards closing the inequities in health across diverse populations is an enormous challenge. Improving health for all is indeed a daunting task and all areas of health care will have to collaborate in the long term for positive health changes to take root. It is my hope that health care providers in Canada will work towards adopting the PSRP model in an attempt to address all aspects of an individual’s health that go well beyond simply treating physical illnesses and grow to incorporate a multi-level approach which includes more emphasis on disease prevention while addressing the social determinants that contribute to our most vulnerable populations carrying a disproportionate amount of the disease burden.
References:
Berger, H., Gagnon, R., & Sermer, M. (2016). Diabetes in Pregnancy. Journal of Obstetrics and Gynaecology Canada, 38(7), 667-679.
Bryant T, et al. Canada: A land of missed opportunity for addressing the social deter-minants of health. Health Policy (2010), doi:10.1016/j.healthpol.2010.08.022
Cultural Diversity and Ethnic Minority Psychology, Vol 25(1), Jan, 2019. Special Issue: Understanding, Unpacking and Eliminating Health Disparities: A Prescription for Health Equity Promotion Through Behavioral and Psychological Research. pp. 1-5
Living with Gestational Diabetes. (n.d.). Retrieved from
Maternal Diabetes in Canada. (2014, October 09). Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/maternal-diabetes-canada.html
Ramey, S.L., Schafer, P., DeClerque, J.L. et al. Maternal Child Health J (2015) 19: 707.https://0-doi-org.aupac.lib.athabascau.ca/10.1007/s10995-014-1581-1
Reading, C.L. & Wien, F. (2009). Health Inequalities and Social Determinants of Aboriginal Peoples’ Health. Prince George, BC: National Collaborating Centre for Aboriginal Health.
Human Reproduction Anatomy and Gametogenesis. (n.d.). Retrieved from https://courses.lumenlearning.com/boundless-biology/chapter/human-reproductive-anatomy-and-gametogenesis/
Reproductive Health - Diabetes in Pregnancy. (2018, June 12). Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/diabetes-during-pregnancy.htm
Strutz, K. L., Hogan, V. K., Siega-Riz, A. M., Suchindran, C. M., Halpern, C. T., & Hussey, J. M. (2014). Preconception stress, birth weight, and birth weight disparities among US women. American journal of public health, 104(8), e125-32.
What is Gestational Diabetes. (n.d.). Retrieved from www.diabetes-pregnancy.ca/gdm/overview/
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