At every health care encounter, a woman of childbearing age should be informed about the importance of preconception care and, if she has diabetes, the steps required to maintain appropriate blood glucose control [15, 28, 29]. Unfortunately, however, reaching women who may be in need of preconception care has proven to be difficult, with only a quarter to a third of women with diagnosed diabetes receiving this care [25, 28].

There are many barriers to providing and/or receiving preconception care. Among them are: 1) Many women with diabetes do not know that they have the illness and, thus, they are undiagnosed [1], 2) Approximately 50% of all pregnancies are unintended [28, 30, 31], 3) Even among women planning to become pregnant, lack of health insurance or a regular care primary care or obstetric provider reduces contact with the health care system [32–34], 4) Many primary care practices do not have or use established guidelines for providing preconception care, or identifying women with risk factors [32, 34], 5) Some women and health care providers may not know about about the existence or the importance of preconception care or do not see it as a high priority [15, 32, 34, 35], and 6) Women with incomplete health care coverage, lack of child care or transportation, geographic isolation, distrust of health care providers or other social and economic challenges have additional barriers to receiving preconception care [15, 32, 34–36].

Women are more likely to receive preconception care if they are married or in a stable relationship, are comparatively older, are nonsmokers, are non-Hispanic whites, are more educated, have annual incomes above $20,000, have private medical insurance, and have a positive bond with their prepregnancy care provider [25, 26, 28, 33, 35]. Younger women with diabetes and those who are single, have low income, or are less educated may be particularly vulnerable to unplanned pregnancies, which greatly reduces the chances that they will receive any form of diabetes-related preconception counseling [16, 32, 36].

Since the establishment of preconception care programs, health care centers have employed numerous marketing approaches geared toward physicians, and for patients in need of preconception care intervention. Janz et al. [28] identified marketing approaches which were employed in five Michigan medical centers to encourage the use of preconception care programs in treating high-risk women. These included journal advertisements, newsletters, brochures, flyers, posters, and patient education programs. However, the results of these outreach efforts were “generally disappointing [28].”

In a Maine study, a diabetes registry was developed to promote the availability of preconception care programs [27]. In addition, health care providers formed a network to enhance the care of pregnant women using locally developed patient care guidelines. From 1987–1990, there were a total of 185 pregnancies in women with diagnosed diabetes. Of the total pregnancies, only 34% of these women received preconception care. These findings support those of Janz et al. [28], which demonstrate that very few women with diabetes are receiving preconception care. Additional innovative strategies are needed to increase awareness of the availability of preconception care.

The National Public Health Initiative on Diabetes and Women’s Health (cosponsored by the American Diabetes Association, the American Public Health Association, the Association of State and Territorial Health Officials, and the Centers for Disease Control and Prevention) is a partnership devoted to increasing public and provider awareness of the importance of interventions such as preconception care in the prevention and management of diabetes for women [37, 38]. Using a life stage approach, the Initiative’s cosponsors and partners developed and disseminated a national action plan, The National Agenda for Public Health Action [39], to identify 10 priority action steps to improve the lives of women with or at risk of diabetes, from adolescence to the older years (see Table 1). The National Agenda serves as a blueprint to guide the nation in implementing strategies related to diabetes and women’s health. Given the devastating effects that diabetes can have on women’s health, the National Agenda recognizes and identifies the need for effective interventions, such as quality health care and programs, public health research and surveillance, and specific policies to address the burden of this chronic illness on the lives of women and their families [37, 38].Table 1

The National Agenda’s 10 priority recommendations for action

Several of the National Agenda’s recommendations support the need for preconception care and follow-up care for women with or at risk for diabetes through community intervention efforts and policy development. These recommendations identify the need to: 1) expand our outreach to communities where women live, learn, work, and play by offering health promotion, education, activities and other incentives; 2) provide sufficient funding, tools, training, and materials to fortify community programs that focus on women’s health needs; 3) educate community members and leaders about diabetes prevention and control and the roles that they can play in promoting healthy environments; 4) encourage healthcare providers to promote risk assessment and quality care for women, including preconception care; and 5) conduct public health research to better understand multiple factors that influence diabetes and women’s health.

One of the community-focused strategies from the National Agenda, is the need to “identify and develop links with community agencies that interface with women at greatest risk for diabetes, including organizations in the non-health related sectors [39].” Given that preconception care programs have had difficulty reaching high-risk women, nontraditional approaches to outreach and preconception care should be explored [32, 36].

Community health organizations and community health workers (CHWs) appreciate and understand the social, political, environmental, and cultural factors that affect individuals within their own neighborhoods and have the potential to influence the consumers’ relationship with the health care system [33]. They serve as “bridges”—connecting community members who have traditionally lacked access to the appropriate services needed [40, 41]. The Institute of Medicine (IOM) recommends supporting the use of CHWs. The IOM identifies CHWs as an integral component of the health care system that help to address racial and ethnic disparities in access to care [41, 42].

Many community-based projects funded by the Centers for Disease Control and Prevention have included CHWs in community-based programs aimed at health intervention for people with diabetes [43]. Programs employing CHWs have reported that they improve access and health outcomes for persons with chronic diseases, including diabetes, particularly in minority and underserved populations [44–48]. Although, no empirical studies have been published that assess the effectiveness or impact of CHWs in providing preconception care services for women with diabetes, CHWs have also played an important role in maternal and child health care. Thus, studying the methods for, and outcomes of an expanded role for CHWs with preconception outreach and education for women with, or at risk for diabetes, is recommended.

Community health workers could play a vital role in linking women to preconception care services in the following manner: 1) increasing women’s awareness about the importance of preconception care programs, 2) providing culturally and linguistically appropriate diabetes-related health information and education, 3) reminding women about scheduled health provider visits, 4) providing a communication bridge linking women and providers in terms of patients’ needs and providers’ recommendations.

The prevalence of diabetes among women of childbearing age is rising, particularly in communities with ethnic minorities and low resources [4, 8]. There is a strong relationship between these conditions and adverse maternal, child and subsequent adult health outcomes. Assessing the processes and effects of preconception care interventions implemented by providers and CHWs, especially in those communities with varied ethnic and socioeconomic backgrounds, is a critical first step toward identifying and promoting effective preconception care [18, 49–55].