DIABETES across the LIFECOURSE – Northern Australia Partnership

Improving systems of care and services for people with diabetes and their families in rural and remote Australia (NT, FNQ & Kimberley)

Diabetes In Pregnancy Partnership

Clinical Register & Models of Care (NT & FNQ)

The NT DIP Partnership 

The aim of the partnership is to improve systems of care and services for women with diabetes in pregnancy and their babies in rural and remote Australia (NT & FNQ).

Components of the NT DIP Partnership

  1. The establishment and development of the NT Diabetes in Pregnancy Clinical Register.
  2. Models of Care: Enhancement of models of care to improve health service delivery for women with DIP. Earlier work focused on the antenatal management of women with DIP before moving to the inter-pregnancy interval to encompass pre-conception management and post-partum follow-up.
  3. Research: PANDORA (Pregnancy and Neonatal Diabetes Outcomes in Remote Australia) is a longitudinal birth cohort study that will assess short-term and long-term pregnancy outcomes.

The Northern Territory DIP Clinical Register

The aims of the NT DIP clinical register are to improve the management and follow-up of women with DIP, assist with quality assurance and act as an epidemiological tool, to establish DIP burden and its variability over time, place and ethnicity. All women with diabetes in pregnancy, residing in the NT, are eligible for inclusion in the register. Women aged 16 years and below must have verbal approval from a parent or guardian to be registered. We have developed a partnership between researchers, health care providers, and policy organisations in the NT and have extended the partnership to Far North Queensland to address this issue. The aim of the partnership is to improve systems of care and services for women with diabetes in pregnancy (DIP) and their babies in rural and remote (NT & FNQ) Australia.

Partnership Benefits

The benefits of the partnership are wide-reaching for the broader community and the health of future generations.

A better understanding of antenatal and birth outcomes, as well as of challenges concerning antenatal and post-partum care in the setting of diabetes in pregnancy will inform design of policy, practice and future interventions. In particular, this partnership will continue to inform clinical guidelines regarding best practice care of mothers with diabetes in pregnancy and in the post-partum period, and their children.

Benefits to the individual will include improved care of women with diabetes in pregnancy and therefore improved outcomes for women and their babies. The outcomes of improving models of care for women with diabetes in pregnancy include both short and longer term benefits for the pregnancy and for the health of the mother and the baby.


To refer a women to the NT DIP Clinical Register, please provide relevant information for women using the standard template (electronic versions are available from PCIS and Communicare).

Removal from the register

Women can request to have their information removed from the register at any time.

Data Custodianship and Use

The data remains the property of the relevant partner organisation/health care provider. Biannual reports of aggregated (NT-wide) de-identified data are prepared by the NT & FNQ DIP Partnership Steering Committee for the purposes of quality assurance and are circulated to all relevant health care providers in their jurisdictions. Clinical audits in the NT, using NT clinical register information may be undertaken following an application for consideration by the NT & FNQ DIP Steering Committee.

Project Forms, Policies and Guidelines


For further information regarding the NT DIP Clinical Register, please email DIPClinicalRegister.THS@nt.gov.au

FNQ DIP Partnership objectives:

  1. To establish and maintain the FNQ DIP Clinical Register to improve systems of care
  2. To develop enhanced models of diabetes in pregnancy care suitable to the FNQ regions and to augment health care professionals’ capacity for managing diabetes in pregnancy across all health organisations.

The FNQ DIP Clinical Register

All FNQ women with diabetes in pregnancy will be invited to be included in the Clinical Register by their health care professional. A referral with routine antenatal information can be emailed or faxed through to the project team. Information from the Clinical Register will be used to assist with planning and improving models of healthcare and service delivery for women with diabetes in pregnancy. The Clinical Register will also be used to communicate key diabetes in pregnancy related information to women’s health care providers, including for women who require postpartum follow up after pregnancy.

Project Forms

Models of care

The Clinical Register is implemented alongside models of care activities to improve systems of care and services for women with diabetes in pregnancy and their babies. Formative work was undertaken in early 2017 using a mixed methods approach including a cross-sectional survey (101 respondents) and 8 focus groups (61 participants) to map FNQ health practitioners’ experiences and describe knowledge regarding screening and management of diabetes in pregnancy. Several challenges were identified including communication, care coordination and differing information technology systems when women accessed diabetes in pregnancy care between health services. Our five Models of Care Components are:

  1. Increasing workforce capacity, skills and knowledge, and improving health literacy of health professionals and women
  2. Improve access to culturally and clinically appropriate health care
  3. Improving information management and communication
  4. Enhancing policy and guidelines
  5. Embedding the Clinical Register as a component within the models of care


Please don’t hesitate to contact us if you have any questions about the project: FNQ DIP Partnership Coordinator DIPPINQ@menzies.edu.au Phone: 07 4226 4639 If you have any concerns about the ethical conduct of this project, you may also contact the Secretariat of the Far North Queensland Human Research Ethics Committee: Cairns_Ethics@health.qld.gov.au Phone: 07 4226 5513


Thank you to National Health and Medical Research Council and the Global Alliance of Chronic Diseases (grant # 1092968)