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Prenatal Care and Pregnancies Complicated by Diabetes -- U.S. Reporting Areas, 1989

Women who are pregnant and who have diabetes (either established {i.e., diabetes mellitus diagnosed before conception} or gestational {i.e., carbohydrate intolerance of variable severity with onset or first recognition during pregnancy}) are at increased risk for adverse fetal and maternal outcomes (1,2). To reduce these risks, CDC, the American Diabetes Association, and other health-care professionals recommend that women who are of childbearing age and have diabetes undergo prepregnancy counseling and that all pregnant women receive early and continued prenatal care, including screening for gestational diabetes sometime during weeks 24-28 of pregnancy (3,4). Although appropriate prenatal-care practices, including screening for gestational diabetes, have been recommended by CDC and others, there is no system to routinely monitor national trends in prenatal practices among mothers with diabetes mellitus. This report summarizes an analysis of U.S. birth certificates in 1989 to characterize racial/ethnic differences in prenatal care for live births, including those among mothers whose pregnancies were complicated by diabetes.

The 1989 revision of the U.S. Standard Certificate of Live Birth lists the month of pregnancy in which prenatal care was initiated and demographic and medical information related to the pregnancy (5). Although the presence of diabetes is listed, the type of diabetes in pregnancy is not indicated. Rates of pregnancies complicated by diabetes were age-standardized to the aggregate population of all races/ethnicities, using the direct method. Rates with numerators less than 20 were not calculated because the numbers were too small to provide stable estimates.

During 1989, 3,600,184 (89.1%) of the 4,040,958 live-birth certificates reported on both Hispanic ethnicity and the presence of maternal diabetes. Because the District of Columbia, Rhode Island, Texas, and Virginia did not implement the revised certificates until March or April 1989, data on maternal diabetes were not available for those areas for all of 1989. In addition, Louisiana, New Hampshire, and Oklahoma did not require reporting of Hispanic ethnicity; and Louisiana, Nebraska, and Oklahoma did not require reporting of maternal diabetes.

The month of pregnancy in which prenatal care started was not reported for 2.1% of all women and 1.8% of women with diabetes. For all live births, 22.4% of mothers initiated delayed or late prenatal care *; 2.2% of mothers received no prenatal care. Delayed, late, or no prenatal care was more prevalent among women who were black, American Indian, Asian/Pacific Islander, Hispanic, and other minorities than among women who were non-Hispanic white (Table 1); those who received no prenatal care ranged from 1.1% (white women) to 5.2% (black women). The percentage who could not have been appropriately screened for gestational diabetes (i.e., received no care or initiated care after the 7th month of pregnancy) ranged from 2.1% (non-Hispanic white women) to 8.4% (American Indian women).

For all women, the rate of established or gestational diabetes was 211.0 per 10,000 live births. This rate increased proportionately with age of the mother (age-standardized rates range: 73.3 per 100,000 {women aged less than 20 years} to 649.3 {women aged 40-49 years}) (Table 2).

In addition, for all women, the rate of both diabetes and a lack of prenatal care was 1.4 per 10,000 live births; such pregnancies occurred approximately three times more often among women aged 40-49 years than among those aged less than or equal to 39 years (Table 3). Black, Asian/Pacific Islander, and Hispanic women experienced such pregnancies more often than did non-Hispanic white women.

Reported by: Epidemiology and Statistics Br, Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion; Natality, Marriage, and Divorce Statistics Br, Div of Vital Statistics, National Center for Health Statistics, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that in 1989 the likelihood of screening for gestational diabetes was lower and the risk of established or gestational diabetes was higher among women who were black, American Indian, Asian/Pacific Islander, or Hispanic. In addition, the risk of pregnancy complicated by diabetes and a lack of prenatal care was greater for women who were older.

The association between maternal diabetes mellitus and the risk of adverse outcomes is well established for pregnant women with diabetes (6). Preconception and prenatal care ensure the best outcomes for mothers with diabetes and their infants (1-3). Furthermore, prenatal care that is associated with hospital-based labor and delivery services has been linked to declines in rates of infant and maternal morbidity and mortality (7,8) and is cost-effective (8). Because the racial disparity in the timely receipt of prenatal care is substantial (9), race and other factors (e.g., socioeconomic status) must be considered when comparing incidence of gestational diabetes among populations (10).

The findings in this report are subject to at least four limitations. First, because gestational diabetes occurs in up to 3% of pregnancies (2), pregnancies complicated by diabetes may have been underreported on birth certificates in 1989. Second, the Hispanic population (as are births to Hispanic women) is concentrated in a few states (10). Third, diabetes during pregnancy has been overreported for women who are Chippewa Indians (Indian Health Service, unpublished data, 1992), and the exclusion of data for Oklahoma eliminated information for up to 24% of American Indian mothers with diabetes and for up to 22% of all American Indian mothers (Indian Health Service, unpublished data, 1985). Finally, because these measures do not include other outcomes of pregnancy (e.g., miscarriages and abortions), the total impact of lack of screening for gestational diabetes and prenatal care may be underestimated.

CDC is assessing the feasibility of national surveillance for diabetes in pregnancy. Ongoing analyses of national data from the current U.S. Standard Certificate of Live Birth can provide some measures of the occurrence of diabetes during pregnancy and associated negative outcomes. Also, additional information (e.g., prenatal care among pregnant women with established diabetes) may be available because birth-certificate forms now used by the departments of vital records in some states distinguish established and gestational diabetes as medical risk factors.

These findings underscore the need for physicians and other health-care professionals to 1) encourage patient participation in early and continued prenatal care, 2) record information about prenatal care on vital records such as birth certificates, and 3) develop prenatal programs that target women in populations at risk for not receiving prenatal care and gestational diabetes screening (e.g., older women). In addition, health-care professionals providing prenatal care are urged to identify, manage, and report on diabetes during pregnancy.

References

  1. Hare JW. Pregnancy and diabetes. In: Marble A, Krall LP, Bradley RF, Christlieb AR, Soeldner JS, eds. Joslin's diabetes mellitus. Philadelphia: Lea and Febiger, 1985:698-711.

  2. Schwartz R. The infant of the diabetic mother. In: Davidson JK, ed. Clinical diabetes mellitus. New York: Thieme Medical Publishers, 1991.

  3. CDC. Public health guidelines for enhancing diabetes control through maternal- and child-health programs. MMWR 1986;35:201- 8,213.

  4. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 1989;12:365-8.

  5. NCHS. Advance report of new data from the 1989 birth certificate. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1992. (Vital and health statistics; vol 40, no. 12, suppl).

  6. 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.

  7. Office of Technology Assessment. Healthy children: investing in the future. Washington, DC: US Congress, Office of Technology Assessment, 1988; document no. OTA-H-345.

  8. Brown SS. Drawing women into prenatal care. Fam Plann Perspect 1989;21:73-80,88.

  9. NCHS. Advance report of final natality statistics, 1989. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1991. (Monthly vital statistics report; vol 40, no. 8, suppl).

  10. Dooley SL, Metzger BE, Cho NH. Influence of race on disease prevalence and perinatal outcome in a U.S. population. Diabetes 1991;40:25-9.

    • Prenatal care was considered delayed if initiated in the second trimester and late if initiated in the third trimester.





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