Knowledge of Preconception Care and Associated Factors among Pregnant Mothers with Pre-existing Diabetes Mellitus in selected Governmental Hospitals, Addis Ababa Ethiopia

Background: Many women with diabetes mellitus experience high rates of unintended pregnancies, infant morbidity and mortality and preventable birth defects.Thus, preconception care offers the potential for earlier risk assessment and intervention that can benefit women before pregnancy and ensure the healthiest possible start for the newborn child. The aim of this study is to assess the knowledge and experience of preconception care and associated factors among pregnant mothers with pre-existing diabetes mellitus. Methods: Facility based quantitative cross-sectional study design was employed among 142 conveniently selected pregnant women between March 11and April 12, 2018. Logistic regression including bivariate and multivariate analysis considering 95% CI was utilized to examine association between dependent and independent variables. P-value < 0.05 was considered statistically significant. Result: this study found that 67(42.7%) of pregnant women with pre-existing diabetes mellitus had good knowledge on preconception care. Educational level, occupation and duration of diabetes was associated with knowledge about preconception care AOR= 0.24 0.065, 0.828, AOR= 0.0420.102(0.011-0.918 and AOR= 0.035 3.599(.095-11.833 respectively. Conclusion: women’s knowledge on preconception care in this study is low. Education, occupation and duration of diabetes were factors associated with knowledge of preconception care. Establishment of preconception care strategies addressing all components of the care and increasing women’s knowledge about preconception care is an important component to ensure prevention of potential risks.


Introduction
Background Diabetes mellitus (DM) is a global epidemic and common medical conditions in pregnancy.
The incidence of the disease during pregnancy is rapidly increasing mainly in type two diabetes mellitus cases. The rise is associated with an increase in the prevalence of overweight and obesity in the population (1). An estimated 28 million women of reproductive age are suffering from diabetes mellitus worldwide. Majority of these women have type 2 diabetes and 80% of the burden is found in low and middle income countries (2). Normal pregnancy itself is regarded as a diabetogenic state in which postprandial glucose levels are elevated and insulin sensitivity is decreased due to the effects of placental hormones, growth factors, and cytokines (3). This complex hormonal adaptations that work to ensure adequate glucose availability and the relatively reduced insulin sensitivity contribute to hyperglycemia which makes pre-existing diabetes even worse during pregnancy. Diabetes mellitus increases risk of pregnancy related complications like: preeclampsia, infections, obstructed labor, postpartum hemorrhage, preterm births, stillbirths, macrosomia, carriage, intrauterine growth retardation, congenital anomalies, birth injuries and death in the pregnant mother and her unborn child (4)Pre-gestational diabetes occurs before pregnancy and this includes type one and type two diabetes mellitus, whereas, gestational diabetes mellitus (GDM) exists during pregnancy. Studies also reported that, the risk of development of type 2 diabetes in later life is 7-to 9.6times higher among gestational diabetic cases (5). Pregnant mothers with Pre-existing diabetes, (both type one and type two) are at greater risk of pregnancy complications and likewise pregnancy can make diabetes worse. Pregnancy in individuals with known diabetes requires planning and adherence to strict treatment regimens. Intensive management and normalization of the blood glucose level are essential for individuals with pre-existing diabetes who are planning pregnancy. Preconception care is a care needed to prepare a woman for pregnancy at least six months earlier to conception (6).
The care is provided to all diabetic mothers planning pregnancy for the first time or between consecutive pregnancies (7). According to some studies, pregnancy outcomes can be significantly improved by intensifying therapies, rigorous glycaemic control and avoidance of teratogenic medicines (8). A diabetic woman planning to conceive also needs to be aware about the implementation of preconception care components including medication review, folic acid supplementation, weight reduction, smoking cessation counseling, improved nutrition and exercise, as well as addressing other diabetes-related health problems (9). The care is particularly important as fetal development commences in the first trimester of pregnancy. As reported by some studies, diabetic women receiving preconception care more likely to have favorable pregnancy outcomes, including lower rates of congenital anomalies and spontaneous abortions (10). Therefore, this study was conducted to assess the knowledge level of preconception care and associated factors among pregnant mothers with pre-existing diabetes mellitus in selected governmental hospitals.

Methods
Facility based quantitative cross-sectional study design was employed in six governmental hospitals with diabetic follow-up services in Addis Ababa the capital city of Ethiopia were included. The hospitals were Black lion, Zeweditu memorial hospital, Yekatit 12, Ras Desta Damtew, Minlik II and St. Paul's hospitals. One hundred forty two pregnant mothers with pre-existing diabetes mellitus were conveniently included between March 11 and April 12, 2018. Selection of the hospitals was based on presence of follow-up services for diabetic patients and all hospitals having follow-up service were included. All pregnant mothers with pre-existing diabetes on diabetic follow up earlier than the current pregnancy were included. A structured adapted and modified data collection instrument prepared by reviewing different literatures was used to gather the information. The instrument was translated to the local language for ease of administration and later back translated to English. This instrument involved four parts which include: Socio-demographic, Obstetric history, maternal diabetic condition and knowledge about preconception care. Six data collectors were recruited and trained to gather the information and the principal investigator supervised the whole process of data collection. Ethical clearance and permission letter was obtained from responsible organizations and consent was obtained from respondents. Knowledge was measured based on respondent's correct response to preconception care knowledge questions. Those respondents who correctly respond to 50% or more of the preconception care knowledge questions were considered to have good knowledge and those who scored<50% were considered as having poor knowledge (11,12). The data was coded and entered into Epi-data version 4.2.0 then exported to statistical package for social science (SPSS) version 25. Descriptive statistics and logistic regression including bivarriate and multivariate analysis was used and a statistical significance was considered at p-value < 0.05, and 95%confidence interval.

Results
Socio demographic characteristics and obstetric history of study participants A total of 145 participants were enrolled in this study, and 142 participants responded to the questions that makes the response rate 97.9%. Most participants were above 30 years old with mean age 36.65 and SD ±4.31. All respondents were married, 54 (38%) of respondents and 67 (47.1%) of their husbands completed college and above and 62 (41.3%) of the respondents were government employee (Table 1).
Maternal diabetic condition: More than half 79(55.6%) were type two diabetes with duration of diabetes mean 6.96, SD±2.12 and (range 3-15 years). Among those who were type two, 26(33.0%) of them were diagnosed as gestational diabetes. Sixty-five (45.7%) of them had less than one month diabetic follow up before current pregnancy, thirty-six (25.3%) have diabetic related complication or co-morbidity ( Knowledge about preconception care Preconception care knowledge level was measured based on correct response to eight preconception care knowledge questions. The minimum and maximum score of participants ranged between zero and seven. Of the total, 67 (47.2%) respondents scored greater than 50% and were considered to have good knowledge and the remaining 75 (52.8%) respondents score was less than 50% and regarded as having poor knowledge.  Table   4]

Discussion
This study have attempted to assess the level of knowledge of preconception care and associated factors among pregnant women with pre-existing diabetes attending diabetic follow up in selected governmental hospitals of the study area.
A total of 142 mothers were studied, of those 103 (72.5%) respondents reported that they know the preconception care service is provided in the selected hospitals. The study found that 47.2% of the study participants have good knowledge on preconception care. This finding is consistent with other study findings conducted in Zambia, Saudi Arabia and USA among women with pre-gestational diabetes which reported that the proportion of participants having good knowledge about preconception care is low (13)(14)(15). Another study conducted in Brazil also found that 51.5% study participants demonstrated good knowledge on preconception care (16). The narrow discrepancy might be due to differences in socio demographic and/or socio economic characteristics between the two countries.
In this study, education, occupation and duration were found to be the factors associated with women's knowledge about preconception care. Women who attended primary school were less likely to have good knowledge on preconception care than those who attended college and above AOR = 0.233 [0.065, 0.828]. This finding is supported by a study finding in Zambia where participants who attended primary level of education were 4.54 times more likely to have poor knowledge on preconception care than those with tertiary education (18). Another study in France also showed that those who attended above secondary school were 4.6 times more likely to have good knowledge on preconception care (19). In this study occupation was also found to be associated with women's knowledge about preconception care among pre-existing diabetic patients., Those government employee women were less likely to have good knowledge than those students and market trade vendors AOR = 0.102 [0.011, 0.918]. The finding is inconsistent with the study in Zambia, where the employees showed no significant association with knowledge on preconception care P-value (0.131)(20). This may be due to the fact that government employees had limited access to attending educational sessions in the current study. The other factor which showed association with knowledge about preconception care among diabetic women was duration of illness/diabetes. Women with duration of diabetes less than five years were more than three times more likely to have good knowledge on preconception care than those with greater than five years duration AOR = 3.599 [ 0.095,11.833]. This finding is inconsistent with a study result in France, where participants with duration of diabetes greater than five year were two times more likely to have good knowledge than those less than five years (21).

Limitation of the study
The study used non-probability sampling technique as the accessible population is limited.
The cross-sectional nature of the design limits to show cause and effect relationship and it is also prone to recall bias as women's were asked about pre-pregnancy care for the current pregnancy and since the sample size was small, all this may limit generalizability of finding beyond the study settings.

Conclusion
The level of knowledge about preconception care among pregnant mothers with preexisting diabetes mellitus in this study is low. Education, occupation and duration of diabetes were factors associated with knowledge of preconception care. Establishing preconception care strategies that can address all components of the care and increasing women's knowledge regarding preconception care may help to reduce risk of maternal and fetal complications. Further large scale studies may be recommended.

Implications for practice
It has been shown that knowledge of preconception care among women with preexisting diabetes mellitus in this study was low. A diabetic women planning to conceive needs to be aware about the implementation of preconception care (9). Pregnancy in women with known diabetes mellitus requires planning and adherence to strict treatment regimens.
The care is needed to prepare a woman planning pregnancy at least six months earlier to her conception, to reduce risk of pregnancy related complications like: preeclampsia, infections, obstructed labor, postpartum hemorrhage, preterm births, stillbirths, macrosomia, carriage, intrauterine growth retardation, congenital anomalies, birth injuries and death in the pregnant mother and her unborn child (6).Therefore, the findings of this study will provide direction for health care providers and policy makers to design and implement strategy to address the problem.

Declarations
Ethics: Ethical clearance was obtained from Addis Ababa University, College of Health Sciences, institutional review committee, permission from Addis Ababa regional health Bureau and from the selected hospital administrative offices. An informed verbal consent was obtained from study subjects confidentiality of information was assured.