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Perinatal Mortality and Congenital Malformations in Infants Born to Women with Insulin-Dependent Diabetes Mellitus -- United States, Canada, and Europe, 1940-1988

Women with insulin-dependent diabetes mellitus account for approximately five per 1000 pregnancies. Because there is no national surveillance of pregnancies among women with insulin-dependent diabetes, national trends in the rates of perinatal mortality (PNM) and congenital malformations associated with maternal diabetes cannot be monitored.

This report uses data from 225 U.S., Canadian, and European hospital-based reports* published from 1940 through 1988 of pregnancies of women with insulin-dependent diabetes to evaluate the relationship of congenital malformations and PNM in such pregnancies. These data were compared with published hospital-based data for all women for the same years. The only reports included were those that had identified women with insulin-dependent diabetes and had calculated the PNM rate and/or the proportion of PNM from congenital malformations for women with insulin-dependent diabetes.

From 1940 through 1988, in the United States and Canada and in many European countries, the PNM rate for infants of women with insulin-dependent diabetes decreased from 250-300 per 1000 births to 30-50 per 1000. The rates of decline were similar in the United States and Canada and in Europe (Figure 1). For all infants, however, the PNM rate did not decrease as much. In the United States, for example, the overall PNM rate decreased from about 60 per 1000 in the 1940s to 15 per 1000 in the 1980s.

Progress in the prevention of all causes of PNM has not proceeded evenly; serious congenital malformations have continued to be proportionately more frequent among perinatal deaths among infants of women in both the diabetes and overall groups (Figure 2).

In the United States and Canada and in Europe, the proportion of perinatal deaths associated with congenital malformations in the 1950s and 1960s (13%-17%) was almost identical for infants of women with insulin-dependent diabetes and for infants of all women. However, although the mortality rate for infants of women with diabetes declined faster than that for all infants, the percentage of congenital malformation-associated deaths in the diabetes group surpassed the percentage of such deaths in the overall population. For infants of women with diabetes, the frequency of such deaths increased to greater than 30% in the 1970s and to 45%-50% in the 1980s; in contrast, for infants overall, it remained less than 30% in the 1970s and 1980s. Despite the demographic distinctions between the two regions, incidence rate trends were similar in the United States and Canada and in Europe (Figure 2). Reported by: H Kalter, PhD, Children's Hospital Research Foundation, Dept of Pediatrics, Univ of Cincinnati College of Medicine, Cincinnati, Ohio. Div of Birth Defects and Developmental Disabilities, Center for Environmental Health and Injury Control, CDC.

Editorial Note

Editorial Note: Women with insulin-dependent diabetes are at increased risk for a variety of adverse pregnancy outcomes such as stillbirths, obstetric complications, and congenital malformations. General improvements in prenatal care and in obstetric management of women with diabetes have led to a substantial decline in PNM rates among their infants. With these improvements, however, congenital malformations have emerged as the most common cause of PNM for infants of women with insulin-dependent diabetes, accounting for approximately 50% of all perinatal deaths.

The excess risk for congenital malformations among infants of mothers with diabetes has been estimated in population-based studies, such as a recent case-control study conducted by CDC (1). Although the genesis of congenital malformations among infants of women with insulin-dependent diabetes is not well understood, other factors may be involved in addition to glycemic control (2). Further research on the mechanisms of teratogenesis associated with diabetes should improve pregnancy outcomes for women with this form of diabetes.


  1. Becerra JE, Khoury MJ, Cordero JF, Erickson JD. Diabetes mellitus during pregnancy and the risks for specific birth defects: a population-based case-control study. Pediatrics 1990;85:1-9.

  2. Mills JL, Knopp RH, Simpson JL, et al. Lack of relation of increased malformation rates in infants of diabetic mothers to glycemic control during organogenesis. N Engl J Med 1988; 318:671-6. *References are available on request from CDC's Division of Birth Defects and Developmental Disabilities, Center for Environmental Health and Injury Control; telephone (404) 639-4706.

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