Original Article

CME Article: Pregnancy-Associated Diabetes Mellitus and Stillbirths by Race and Ethnicity among Hospitalized Pregnant Women in the United States

Authors: Jonnae Atkinson, MD, MS, Deepa Dongarwar, MS, Vicki Mercado-Evans, BA, Ayleen A. Hernandez, BA, Aisha V. Deslandes, BA, Monica A. Gonzalez, BS, Danielle A. Sherman, BS, Hamisu M. Salihu, MD, PhD


Objectives: Racial disparities in preexisting diabetes mellitus (PDM) and gestational diabetes mellitus (GDM) remain largely unexplored. We examined national PDM and GDM prevalence trends by race/ethnicity and the association between these conditions and fetal death.

Methods: This was a retrospective cross-sectional analysis of 69,539,875 pregnancy-related hospitalizations from 2002 to 2017 including 674,040 women with PDM (1.0%) and 2,960,797 (4.3%) with GDM from the US Nationwide Inpatient Sample Survey. Joinpoint regression was used to evaluate trends in prevalence. Survey logistic regression was used to evaluate the association between exposures (PDM and GDM) and outcome.

Results: Overall, the average annual increase in prevalence was 5.2% (95% confidence interval [CI] 4.2–6.2) for GDM and 1.0% (95% CI −0.1 to 2.0) for PDM, during the study period. Hispanic (average annual percentage change 5.3, 95% CI 3.6 − 7.1) and non-Hispanic Black (average annual percentage change 0.9, 95% CI 0.1 − 1.7) women had the highest average annual percentage increase in the prevalence of GDM and PDM, respectively. After adjustment, the odds of stillbirth were highest for Hispanic women with PDM (odds ratio 2.41, 95% CI 2.23–2.60) and decreased for women with GDM (odds ratio 0.51, 95% CI 0.50–0.53), irrespective of race/ethnicity.

Conclusions: PDM and GDM prevalence is increasing in the United States, with the highest average annual percentage changes seen among minority women. Furthermore, the reasons for the variation in the occurrence of stillbirths among mothers with PDM and GDM by race/ethnicity are not clear and warrant additional research.
Posted in: Endocrinology, Diabetes, and Metabolism30 Pregnancy23

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1. Lapolla A, Metzger BE. Gestational Diabetes. A Decade after the HAPO Study. Frontiers in Diabetes. Basel: S. Karger; 2020:1–10.
2. American College of Obstetrics and Gynecology. Practice bulletin no. 190: gestational diabetes mellitus. Obstet Gynecol 2018;131:e49–e64.
3. Plows JF, Stanley JL, Baker PN, et al. The pathophysiology of gestational diabetes mellitus. Int J Mol Sci 2018;19:3342.
4. Szmuilowicz ED, Josefson JL, Metzger BE. Gestational diabetes mellitus. Endocrinol Metab Clin North Am 2019;48:479–493.
5. Vounzoulaki E, Khunti K, Abner SC, et al. Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis. BMJ 2020;369:m1361.
6. Peng TY, Ehrlich SF, Crites Y, et al. Trends and racial and ethnic disparities in the prevalence of pregestational type 1 and type 2 diabetes in northern California: 1996–2014. Am J Obstet Gynecol 2017;216:177.e1–177.e8.
7. Deputy NP, Kim SY, Conrey EJ, et al. Prevalence and changes in preexisting diabetes and gestational diabetes among women who had a live birth — United States, 2012–2016. MMWR Morb Mortal Wkly Rep 2018;67:1201–1207.
8. Ikedionwu CA, Dongarwar D, Yusuf KK, et al. Pre-pregnancy maternal obesity, macrosomia, and risk of stillbirth: a population-based study. Eur J Obstet Gynecol Reprod Biol 2020;252:1–6.
9. Bardenheier BH, Imperatore G, Devlin HM, et al. Trends in pre-pregnancy diabetes among deliveries in 19 U.S. states, 2000–2010. Am J Prev Med 2015;48:154–161.
10. Correa A, Bardenheier B, Elixhauser A, et al. Trends in prevalence of diabetes among delivery hospitalizations, United States, 1993–2009. Matern Child Health J 2015;19:635–642.
11. Rackham O, Paize F, Weindling AM. Cause of death in infants of women with pregestational diabetes mellitus and the relationship with glycemic control. Postgrad Med 2009;121:26–32. .
12. Tennant PWG, Glinianaia SV, Bilous RW, et al. Pre-existing diabetes, maternal glycated haemoglobin, and the risks of fetal and infant death: a population-based study. Diabetologia 2014;57:285–294.
13. Starikov R, Dudley D, Reddy UM. Stillbirth in the pregnancy complicated by diabetes. Curr Diabetes Rep 2015;15:1–9.
14. Page JM, Allshouse AA, Cassimatis I, et al. Characteristics of stillbirths associated with diabetes in a diverse U.S. cohort. Obstet Gynecol 2020; 136:1095–1102.
15. Gortazar L, Goday A, Flores-Le Roux JA, et al. Trends in prevalence of pre-existing diabetes and perinatal outcomes: a large, population-based study in Catalonia, Spain, 2006–2015. BMJ Open Diabetes Res Care 2020;8:1254.
16. Kim SY, Sharma AJ, Sappenfield W, et al. Preventing large birth size in women with preexisting diabetes mellitus: the benefit of appropriate gestational weight gain. Prev Med 2016;91:164–168.
17. Kitzmiller JL, Ferrara A, Peng T, et al. Preexisting diabetes and pregnancy. In: Cowie CC, Stark Casagrande S, Menke A, et al, eds., Diabetes in America, 3rd ed. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases; 2018, chap. 5.
18. Hedderson M, Ehrlich S, Sridhar S, et al. Racial/ethnic disparities in the prevalence of gestational diabetes mellitus by BMI. Diabetes Care 2012; 35:1492–1498.
19. Pu J, Zhao B, Wang EJ, et al. Racial/ethnic differences in gestational diabetes prevalence and contribution of common risk factors. Paediatr Perinat Epidemiol 2015;29:436–443.
20. Mayorga ME, Reifsnider OS, Neyens DM, et al. Simulated estimates of prepregnancy and gestational diabetes mellitus in the US: 1980 to 2008. PLoS One 2013;8:73437.
21. Nguyen BT, Cheng YW, Snowden JM, et al. The effect of race/ethnicity on adverse perinatal outcomes among patients with gestational diabetes mellitus. Am J Obstetr Gynecol 2012;207:322.e1–322.e6.
22. Verheijen ECJ, Critchley JA, Whitelaw DC, et al. Outcomes of pregnancies in women with pre-existing type 1 or type 2 diabetes, in an ethnically mixed population. BJOG: An Int J Obstet Gynaecol 2005;112:1500–1503.
23. Esakoff TF, Caughey AB, Block-Kurbisch I, et al. Perinatal outcomes in patients with gestational diabetes mellitus by race/ethnicity. J Matern Fetal Neonatal Med 2011;24:422–426.
24. Joinpoint Regression Program, Version Statistical Methodology and Applications Branch, Surveillance Research Program. National Cancer Institute. 2022.
25. Arroyo-Johnson C, Mincey KD. Obesity epidemiology worldwide. Gastroenterol Clin North Am 2016;45:571–579.
26. Ibe A, Smith TC. Diabetes in US women on the rise independent of increasing BMI and other risk factors; a trend investigation of serial crosssections. BMC Public Health 2014;14:954.
27. Fryar CD, Ostchega Y, Hales CM, et al. Hypertension prevalence and control among adults: United States, 2015–2016. https://www.cdc.gov/nchs/data/databriefs/db289.pdf. Published October 2017. Accessed May 1, 2022.
28. Cameron NA, Molsberry R, Pierce JB, et al. Pre-pregnancy hypertension among women in rural and urban areas of the United States. J Am Coll Cardiol 2020;76:2611–2619. 1.
29. Saffer H, Dave D, Grossman M, et al. Racial, ethnic, and gender differences in physical activity. J Hum Cap 2013;7:378–410.
30. Siahpush M, Robbins RE, Ramos AK, et al. Does difference in physical activity between Blacks and Whites vary by sex, income, education, and region of residence? Results from 2008 to 2017 National Health Interview Surveys. J Racial Ethn Health Disparities 2019;6:883–891.
31. Choe SA, Eliot M, Savitz D, et al. Ambient air pollution during pregnancy and risk of gestational diabetes in New York City. Environ Res 2019;175: 414–420.
32. Rewers M, Ludvigsson J. Environmental risk factors for type 1 diabetes. Lancet 2016;387:2340–2348.
33. Cabacungan ET, Ngui EM, McGinley EL. Racial/ethnic disparities in maternal morbidities: a statewide study of labor and delivery hospitalizations in Wisconsin. Matern Child Health J 2012;16:1455–1467. .
34. Moyer VA. Screening for gestational diabetes mellitus: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014; 160:414–420.
35. Martin JA, Hamilton BE, Osterman MJ, et al. National Vital Statistics Reports births: final data for 2013. Statistics 2015;64:1–104.
36. Albrecht SS, Kuklina EV, Bansil P, et al. Diabetes trends among delivery hospitalizations in the U.S., 1994–2004. Diabetes Care 2010;33:768–773.
37. Williams MA, Emanuel I, Kimpo C, et al. A population-based cohort study of the relation between maternal birthweight and risk of gestational diabetes mellitus in four racial/ethnic groups. Paediatr Perinat Epidemiol 1999;13: 452–465.
38. Young C, Laurent O, Chung JH, et al. Geographic distribution of healthy resources and adverse pregnancy outcomes. Matern Child Health J 2016; 20:1673–1679. .
39. Wier LM, Witt E, Burgess J, et al. Hospitalizations Related to Diabetes in Pregnancy, 2008: Statistical Brief #102. Rockville, MD: Agency for Healthcare Research and Quality; 2006.
40. Tucker Edmonds B, Ahlberg C, McPherson K, et al. Predictors and adverse pregnancy outcomes associated with antepartum discharge against medical advice. Matern Child Health J 2014;18:640–647.
41. Bateman BT, Bansil P, Hernandez-Diaz S, et al. Prevalence, trends, and outcomes of chronic hypertension: a nationwide sample of delivery admissions. Am J Obstet Gynecol 2012;206:134.e1–134.e8.
42. James AH, Jamison MG, Brancazio LR, et al. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol 2006;194:1311–1315.
43. James AH, Bushnell CD, Jamison MG, et al. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol 2005;106:509–516.
44. Mackin ST, Nelson SM, Wild SH, et al. Factors associated with stillbirth in women with diabetes. Diabetologia 2019;62:1938–1947.
45. Lavery J, Friedman A, Keyes K, et al. Gestational diabetes in the United States: temporal changes in prevalence rates between 1979 and 2010. BJOG 2017;124:804–813.
46. Lawrence JM, Contreras R, Chen W, et al. Trends in the prevalence of preexisting diabetes and gestational diabetes mellitus among a racially/ ethnically diverse population of pregnant women, 1999–2005. Diabetes Care 2008;31:899–904.
47. Lynch CP, Baker N, Korte JE, et al. Increasing prevalence of diabetes during pregnancy in South Carolina. J Womens Health (Larchmt) 2015;24:316–323.
48. Murphy HR, Rayman G, Duffield K, et al. Changes in the glycemic profiles of women with type 1 and type 2 diabetes during pregnancy. Diabetes Care 2007;30:2785–2791.
49. Khera R, Angraal S, Couch T, et al. Adherence to methodological standards in research using the National Inpatient Sample. JAMA 2017; 318:2011–2018.