Reviewing performance of birth certificate and hospital discharge data to identify births complicated by maternal diabetes

Examining rurality and social determinants of health among women with GDM: a 15-year comprehensive population analysis

BACKGROUND

Gestational diabetes mellitus (GDM) is a common pregnancy complication with long-term health consequences for mothers and their children. The escalating trends of GDM coupled with the growing prevalence of maternal obesity, a significant GDM risk factor projected to approach nearly 60% by 2030 in Kansas, has emerged as a pressing public health issue.

METHODS

The aim of this study was to compare GDM and maternal obesity trends in rural and urban areas and investigate maternal demographic characteristics influencing the risk of GDM development over a 15-year period. Trend analyses and a binary logistic regression were employed utilizing 2005 to 2019 de-identified birth record vital statistics from the Kansas Department of Health and Environment (N = 589,605).

RESULTS

Over the cumulative 15-year period, a higher prevalence of GDM was observed across age, race/ethnicity, education, and insurance source. Throughout this period, there was an increasing trend in both GDM and obese pre-pregnancy BMI age-adjusted prevalence, with noticeable rural-urban disparities. From 2005 to 2019, women, including Asians (OR: 2.73, 95% CI 2.58%-2.88%), American Indian or Alaskan Natives (OR: 1.58, 95%, CI 1.44-1.73%), Hispanics (OR: 1.42, 95% CI 1.37%-1.48%), women residing in rural areas (OR: 1.09, 95%, CI 1.06-1.12%), with advanced maternal age (35-39 years, OR: 4.83 95% CI 4.47%-5.22%; ≥40 years, OR: 6.36 95%, CI 5.80-6.98%), with lower educational status (less than high school, OR: 1.15, 95% CI 1.10%-1.20%; high school graduate, OR: 1.10, 95% CI 1.06%-1.13%), Medicaid users (OR: 1.10, 95% CI 1.06%-1.13%), or with an overweight (OR: 1.78, 95% CI 1.72%-1.84%) or obese (OR: 3.61, 95% CI 3.50%-3.72%) pre-pregnancy BMI were found to be at an increased risk of developing GDM.

CONCLUSIONS

There are persistent rural-urban and racial/ethnic disparities present from 2005 to 2019 among pregnant women in Kansas with or at-risk of GDM. There are several socioeconomic factors that contribute to these health disparities affecting GDM development. These findings, alongside with prominent rising maternal obesity trends, highlight the need to expand GDM services in a predominantly rural state, and implement culturally-responsive interventions for at-risk women.

Gestational Diabetes Prevalence Estimates from Three Data Sources, 2018

INTRODUCTION

We investigated 2018 gestational diabetes mellitus (GDM) prevalence estimates in three surveillance systems (National Vital Statistics System, State Inpatient Database, and Pregnancy Risk Assessment Monitoring Survey).

METHODS

We calculated GDM prevalence for jurisdictions represented in each system; a subset of data was analyzed for people 18-39 years old in 22 jurisdictions present in all three systems to observe dataset-specific demographics and GDM prevalence using comparable categories.

RESULTS

GDM prevalence estimates varied widely by data system and within the data subset despite comparable demographics.

DISCUSSION

Understanding the differences between GDM surveillance data systems can help researchers better identify people and places at higher risk of GDM.

Maternal Epidemiology of Brachial Plexus Birth Injuries in California: 1996 to 2012

OBJECTIVE

This study aimed to evaluate the incidence of brachial plexus birth injury (BPBI) and its associations with maternal demographic factors. Additionally, we sought to determine whether longitudinal changes in BPBI incidence differed by maternal demographics.

STUDY DESIGN

We conducted a retrospective cohort study of over 8 million maternal-infant pairs using California's Office of Statewide Health Planning and Development Linked Birth Files from 1991 to 2012. Descriptive statistics were used to determine BPBI incidence and the prevalence of maternal demographic factors (race, ethnicity, age). Multivariable logistic regression was used to determine associations of year, maternal race, ethnicity, and age with BPBI. Excess population-level risk associated with these characteristics was determined by calculating population attributable fractions.

RESULTS

The incidence of BPBI between 1991 and 2012 was 1.28 per 1,000 live births, with peak incidence of 1.84 per 1,000 in 1998 and low of 0.9 per 1,000 in 2008. Incidence varied by demographic group, with infants of Black (1.78 per 1,000) and Hispanic (1.34 per 1,000) mothers having higher incidences compared with White (1.25 per 1,000), Asian (0.8 per 1,000), Native American (1.29 per 1,000), other race (1.35 per 1,000), and non-Hispanic (1.15 per 1,000) mothers. After controlling for delivery method, macrosomia, shoulder dystocia, and year, infants of Black (adjusted odds ratio [AOR] = 1.88, 95% confidence interval [CI] = 1.70, 2.08), Hispanic (AOR = 1.25, 95% CI = 1.18, 1.32), and advanced-age mothers (AOR = 1.16, 95% CI = 1.09, 1.25) were at increased risk. Disparities in risk experienced by Black, Hispanic, and advanced-age mothers contributed to a 5, 10, and 2% excess risk at the population level, respectively. Longitudinal trends in incidence did not vary among demographic groups. Population-level changes in maternal demographics did not explain changes in incidence over time.

CONCLUSION

Although BPBI incidence has decreased in California, demographic disparities exist. Infants of Black, Hispanic, and advanced-age mothers are at increased BPBI risk compared with White, non-Hispanic, and younger mothers.

KEY POINTS

· The incidence of BPBI has decreased over time.. · Demographic disparities in BPBI incidence and risk exist.. · Infants of Black, Hispanic, and advanced age mothers are at greatest risk of BPBI..

Gestational diabetes mellitus in pregnancies conceived after infertility treatment: a population-based study in the United States, 2015-2020

Objective

To evaluate the risk of gestational diabetes mellitus (GDM) in singleton pregnancies conceived using infertility treatment and examine the influence of race and ethnicity as well as prepregnancy body mass index (BMI).

Design

Cross-sectional study using the US vital records data of women that delivered singleton births.

Setting

United States, 2015-2020.

Interventions

Any infertility treatment was divided into two groups: those that used fertility-enhancing drugs, artificial insemination, or intrauterine insemination, and those that used assisted reproductive technology (ART).

Main Outcome Measuress

Gestational diabetes mellitus, defined as a diagnosis of diabetes mellitus during pregnancy, includes both diet-controlled GDM and medication-controlled GDM in singleton pregnancies conceived with infertility treatment or spontaneously and delivered between 20- and 44-weeks' gestation. We also examined whether the infertility treatment-GDM association was modified by maternal race and ethnicity as well as prepregnancy BMI. Associations were expressed as a rate ratio (RR) and 95% confidence interval (CI), derived from log-linear models after adjustment for potential confounders.

Results

A total of 21,943,384 singleton births were included, with 1.5% (n = 318,086) undergoing infertility treatment. Rates of GDM among women undergoing infertility treatment and those who conceived spontaneously were 11.0% (n = 34,946) and 6.5% (n = 1,398,613), respectively (adjusted RR 1.24, 95% CI 1.23, 1.26). The RRs were adjusted for maternal age, parity, education, race and ethnicity, smoking, BMI, chronic hypertension, and year of delivery. The risk of GDM was modestly increased for those using fertility-enhancing drugs (adjusted RR 1.28, 95% CI 1.27, 1.30) compared with ART (adjusted RR 1.18, 95% CI 1.17, 1.20), and this risk was especially apparent for non-Hispanic White women (adjusted RR 1.29, 95% CI 1.26, 1.31) and Hispanic women (adjusted RR 1.35, 95% CI 1.29, 1.41). The number of women who needed to be exposed to infertility treatment to diagnose one case of GDM was 46. Prepregnancy BMI did not modify the infertility treatment-GDM association overall and within strata of race and ethnicity. These general patterns were stronger after potential corrections for misclassification of infertility treatment and unmeasured confounding.

Conclusions

Infertility treatment, among those who received fertility-enhancing drugs, is associated with an increased GDM risk. The persistently higher risk of GDM among women who seek infertility treatment, irrespective of prepregnancy weight classification, deserves attention. Infertility specialists must be vigilant with preconception counseling and ensure that all patients, regardless of race and ethnicity or BMI, are adequately tested for GDM early in pregnancy using a fasting blood glucose level or a traditional 50-g oral glucose tolerance test. Testing may be completed by the infertility specialist or deferred to the primary prenatal care provider at the first prenatal visit.

Association of prenatal exposure to PM2.5 and NO2 with gestational diabetes in Western New York

BACKGROUND

Although many studies have examined the association between prenatal air pollution exposure and gestational diabetes (GDM), the relevant exposure windows remain inconclusive. We aim to examine the association between preconception and trimester-specific exposure to PM2.5 and NO2 and GDM risk and explore modifying effects of maternal age, pre-pregnancy body mass index (BMI), smoking, exercise during pregnancy, race and ethnicity, and neighborhood disadvantage.

METHODS

Analyses included 192,508 birth records of singletons born to women without pre-existing diabetes in Western New York, 2004-2016. Daily PM2.5 and NO2 at 1-km2 grids were estimated from ensemble-based models. We assigned each birth with exposures averaged in preconception and each trimester based on residential zip-codes. We used logistic regression to examine the associations and distributed lag models (DLMs) to explore the sensitive windows by month. Relative excess risk due to interaction (RERI) and multiplicative interaction terms were calculated.

RESULTS

GDM was associated with PM2.5 averaged in the first two trimesters (per 2.5 μg/m3: OR = 1.08, 95% CI: 1.01, 1.14) or from preconception to the second trimester (per 2.5 μg/m3: OR = 1.10, 95% CI: 1.03, 1.18). NO2 exposure during each averaging period was associated with GDM risk (per 10 ppb, preconception: OR = 1.10, 95% CI: 1.06, 1.14; first trimester: OR = 1.12, 95% CI: 1.08, 1.16; second trimester: OR = 1.10, 95% CI: 1.06, 1.14). In DLMs, sensitive windows were identified in the 5th and 6th gestational months for PM2.5 and one month before and three months after conception for NO2. Evidence of interaction was identified for pre-pregnancy BMI with PM2.5 (P-for-interaction = 0.023; RERI = 0.21, 95% CI: 0.10, 0.33) and with NO2 (P-for-interaction = 0.164; RERI = 0.16, 95% CI: 0.04, 0.27).

CONCLUSION

PM2.5 and NO2 exposure may increase GDM risk, and sensitive windows may be the late second trimester for PM2.5 and periconception for NO2. Women with higher pre-pregnancy BMI may be more susceptible to exposure effects.

Rural-urban disparities in pregestational and gestational diabetes in pregnancy: Serial, cross-sectional analysis of over 12 million pregnancies

OBJECTIVE

To compare trends in pregestational (DM) and gestational diabetes (GDM) in pregnancy in rural and urban areas in the USA, because pregnant women living in rural areas face unique challenges that contribute to rural-urban disparities in adverse pregnancy outcomes.

DESIGN

Serial, cross-sectional analysis.

SETTING

US National Center for Health Statistics (NCHS) Natality Files from 2011 to 2019.

POPULATION

A total of 12 401 888 singleton live births to nulliparous women aged 15-44 years.

METHODS

We calculated the frequency (95% confidence interval [CI]) per 1000 live births, the mean annual percentage change (APC), and unadjusted and age-adjusted rate ratios (aRR) of DM and GDM in rural compared with urban maternal residence (reference) per the NCHS Urban-Rural Classification Scheme overall, and by delivery year, reported race and ethnicity, and US region (effect measure modification).

MAIN OUTCOME MEASURES

The outcomes (modelled separately) were diagnoses of DM and GDM.

RESULTS

From 2011 to 2019, there were increases in both the frequency (per 1000 live births; mean APC, 95% CI per year) of DM and GDM in rural areas (DM: 7.6 to 10.4 per 1000 live births; APC 2.8%, 95% CI 2.2%-3.4%; and GDM: 41.4 to 58.7 per 1000 live births; APC 3.1%, 95% CI 2.6%-3.6%) and urban areas (DM: 6.1 to 8.4 per 1000 live births; APC 3.3%, 95% CI 2.2%-4.4%; and GDM: 40.8 to 61.2 per 1000 live births; APC 3.9%, 95% CI 3.3%-4.6%). Individuals living in rural areas were at higher risk of DM (aRR 1.48, 95% CI 1.45%-1.51%) and GDM versus those in urban areas (aRR 1.17, 95% CI 1.16%-1.18%). The increased risk was similar each year for DM (interaction p = 0.8), but widened over time for GDM (interaction p < 0.01). The rural-urban disparity for DM was wider for individuals who identified as Hispanic race/ethnicity and in the South and West (interaction p < 0.01 for all); and for GDM the rural-urban disparity was generally wider for similar factors (i.e. Hispanic race/ethnicity, and in the South; interaction p < 0.05 for all).

CONCLUSIONS

The frequency of DM and GDM increased in both rural and urban areas of the USA from 2011 to 2019 among nulliparous pregnant women. Significant rural-urban disparities existed for DM and GDM, and increased over time for GDM. These rural-urban disparities were generally worse among those of Hispanic race/ethnicity and in women who lived in the South. These findings have implications for delivering equitable diabetes care in pregnancy in rural US communities.

Chicago Neighborhood Context and Racial/Ethnic Disparities in Maternal Diabetes

OBJECTIVES

To determine if rates of maternal diabetes vary by race, ethnicity, and neighborhood hardship.

METHODS

We conducted a secondary analysis of live births in Chicago from 2010 to 2017. Our sample was restricted to Non-Hispanic White, Non-Hispanic Black, Mexican, Non-Hispanic Asian, and Other Hispanic mothers between the ages of 15 and 50, with singleton births. The addresses of mothers were geocoded to specific neighborhoods, which we stratified into tertiles using the Economic Hardship Index. We used generalized logit mixed models to examine the interaction between race/ethnicity, neighborhood economic hardship, and maternal diabetes.

RESULTS

In our cohort of 299,053 mothers, 4.75% were diagnosed with gestational diabetes. Asian mothers had the highest frequency of gestational diabetes (8.3%), followed by Mexican mothers (6.8%). Within their respective racial/ethnic groups, Asian and Mexican mothers living in medium hardship neighborhoods had the highest odds of gestational diabetes compared to the reference group (OR 2.80, 95%CI 2.53, 3.19; OR 2.30, 95%CI 2.12, 2.49 respectively). Overall rates of preexisting diabetes were 0.9% and were highest among Mexican and Black mothers (1.26% and 1.06%, respectively). Asian mothers in medium hardship neighborhoods had the greatest odds of preexisting diabetes, among all Asian mothers and compared to the reference (OR 4.71 95% CI 3.60, 6.16).

CONCLUSIONS

For racial and ethnic minoritized mothers, gestational and preexisting diabetes do not increase in a step-wise fashion with neighborhood hardship; rates were often higher in low and medium hardship neighborhoods.

Large-Scale Data Harmonization Across Prospective Studies

The Preconception Period Analysis of Risks and Exposures Influencing Health and Development (PrePARED) Consortium creates a novel resource for addressing preconception health by merging data from numerous cohort studies. In this paper, we describe our data harmonization methods and results. Individual-level data from 12 prospective studies were pooled. The crosswalk-cataloging-harmonization procedure was used. The index pregnancy was defined as the first postbaseline pregnancy lasting more than 20 weeks. We assessed heterogeneity across studies by comparing preconception characteristics in different types of studies. The pooled data set included 114,762 women, and 25,531 (22%) reported at least 1 pregnancy of more than 20 weeks' gestation during the study period. Babies from the index pregnancies were delivered between 1976 and 2021 (median, 2008), at a mean maternal age of 29.7 (standard deviation, 4.6) years. Before the index pregnancy, 60% of women were nulligravid, 58% had a college degree or more, and 37% were overweight or obese. Other harmonized variables included race/ethnicity, household income, substance use, chronic conditions, and perinatal outcomes. Participants from pregnancy-planning studies had more education and were healthier. The prevalence of preexisting medical conditions did not vary substantially based on whether studies relied on self-reported data. Use of harmonized data presents opportunities to study uncommon preconception risk factors and pregnancy-related events. This harmonization effort laid the groundwork for future analyses and additional data harmonization.

Association of Parity and Previous Birth Outcome With Brachial Plexus Birth Injury Risk

OBJECTIVE

To evaluate the association of maternal delivery history with a brachial plexus birth injury risk in subsequent deliveries and to estimate the effect of subsequent delivery method on brachial plexus birth injury risk.

METHODS

We conducted a retrospective cohort study of all live-birth deliveries occurring in California-licensed hospitals from 1996 to 2012. The primary outcome was recurrent brachial plexus birth injury in a subsequent pregnancy. The exposure was delivery history (parity, shoulder dystocia in a previous delivery, or previously delivering a neonate with brachial plexus birth injury). Multiple logistic regression was used to model adjusted associations of delivery history with brachial plexus birth injury in a subsequent pregnancy. The adjusted risk and adjusted risk difference for brachial plexus birth injury between vaginal and cesarean deliveries in subsequent pregnancies were determined, stratified by delivery history, and the number of cesarean deliveries needed to prevent one brachial plexus birth injury was determined.

RESULTS

Of 6,286,324 neonates delivered by 4,104,825 individuals, 7,762 (0.12%) were diagnosed with a brachial plexus birth injury. Higher parity was associated with a 5.7% decrease in brachial plexus birth injury risk with each subsequent delivery (adjusted odds ratio [aOR] 0.94, 95% CI 0.92-0.97). Shoulder dystocia or brachial plexus birth injury in a previous delivery was associated with fivefold (0.58% vs 0.11%, aOR 5.39, 95% CI 4.10-7.08) and 17-fold (1.58% vs 0.11%, aOR 17.22, 95% CI 13.31-22.27) increases in brachial plexus birth injury risk, respectively. Among individuals with a history of delivering a neonate with a brachial plexus birth injury, cesarean delivery was associated with a 73.0% decrease in brachial plexus birth injury risk (0.60% vs 2.21%, aOR 0.27, 95% CI 0.13-0.55) compared with an 87.9% decrease in brachial plexus birth injury risk (0.02% vs 0.15%, aOR 0.12, 95% CI 0.10-0.15) in individuals without this history. Among individuals with a history of brachial plexus birth injury, 48.1 cesarean deliveries are needed to prevent one brachial plexus birth injury.

CONCLUSIONS

Parity, previous shoulder dystocia, and previously delivering a neonate with brachial plexus birth injury are associated with future brachial plexus birth injury risk. These factors are identifiable prenatally and can inform discussions with pregnant individuals regarding brachial plexus birth injury risk and planned mode of delivery.

Assessing racial residential segregation as a risk factor for severe maternal morbidity

PURPOSE

To measure associations of area-level racial and economic residential segregation with severe maternal morbidity (SMM).

METHODS

We conducted a retrospective cohort study of births at two Philadelphia hospitals between 2018 and 2020 to analyze associations of segregation, quantified using the Index of Concentration at the Extremes (ICE), with SMM. We used stratified multivariable, multilevel, logistic regression models to determine whether associations of ICE with SMM varied by self-identified race or hospital catchment.

RESULTS

Of the 25,979 patients (44.1% Black, 35.8% White), 1381 (5.3%) had SMM (Black [6.1%], White [4.4%]). SMM was higher among patients residing outside (6.3%), than inside (5.0%) Philadelphia (P < .001). Overall, ICE was not associated with SMM. However, ICErace (higher proportion of White vs. Black households) was associated with lower odds of SMM among patients residing inside Philadelphia (aOR 0.87, 95% CI: 0.80-0.94) and higher odds outside Philadelphia (aOR 1.12, 95% CI: 0.95-1.31). Moran's I indicated spatial autocorrelation of SMM overall (P < .001); when stratified, autocorrelation was only evident outside Philadelphia.

CONCLUSIONS

Overall, ICE was not associated with SMM. However, higher ICErace was associated with lower odds of SMM among Philadelphia residents. Findings highlight the importance of hospital catchment area and referral patterns in spatial analyses of hospital datasets.

Impact of new labor management guidelines on Cesarean rates among low-risk births at New York City hospitals: A controlled interrupted time series analysis

PURPOSE

To examine the impact of the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (ACOG-SMFM) 2014 recommendations for preventing unnecessary primary Cesareans.

METHODS

In a population-based cohort of births in New York City from 2012 to 2016, we used controlled interrupted time series analyses to estimate changes in age-standardized Cesarean rates among nulliparous, term, singleton vertex (NTSV) deliveries.

RESULTS

Among 192,405 NTSV births across 40 hospitals, the age-standardized NTSV Cesarean rate decreased after the ACOG-SMFM recommendations from 25.8% to 24.0% (Risk ratio [RR]: 0.93; 95% CI 0.89, 0.97), with no change in the control series. Decreases were observed among non-Hispanic White women (RR: 0.89; 95% CI 0.82, 0.97), but not among non-Hispanic Black women (RR: 0.97; 95% CI 0.88, 1.07), Asian/Pacific Islanders (RR: 1.01; 95% CI 0.91, 1.12), or Hispanic women (RR: 0.94; 95% CI 0.86, 1.02). Similar patterns were observed at teaching hospitals, with no change at nonteaching hospitals.

CONCLUSIONS

While low-risk Cesarean rates may be modifiable through changes in labor management, additional research, and interventions to address Cesarean disparities, are needed.

Assessment of the Validity of Administrative Data for Gestational Diabetes Ascertainment

BACKGROUND

Administrative data, including International Classification of Diseases codes and birth certificate records, are often used for retrospective gestational diabetes research investigations to describe associations of gestational diabetes with perinatal complications and long-term outcomes, and to determine gestational diabetes prevalence. Research investigating the validity of using International Classification of Diseases codes and birth certificates for gestational diabetes ascertainment shows varying degrees of reliability.

OBJECTIVE

This study aimed to evaluate the accuracy of both International Classification of Diseases codes and birth certificate diagnosis for gestational diabetes ascertainment in a large hospital-based cohort of pregnant individuals, using laboratory criteria for gestational diabetes mellitus as the reference.

STUDY DESIGN

We studied individuals who received prenatal care at an academic hospital and affiliated community health centers between 1998 and 2016. In the setting of universal 2-step screening for gestational diabetes, pregnant individuals were classified as having gestational diabetes if ≥2 oral glucose tolerance test values met or exceeded National Diabetes Data Group thresholds. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value for International Classification of Diseases code and birth certificate ascertainment of gestational diabetes, and their exact binomial 95% confidence intervals.

RESULTS

In a cohort of 51,059 pregnancies with complete glucose screening, 1303 (2.6%) met National Diabetes Data Group laboratory criteria for gestational diabetes. Gestational diabetes International Classification of Diseases codes had moderate sensitivity of 70.5% (95% confidence interval, 67.9-72.9), high specificity of 99.3% (95% confidence interval, 99.3-99.4), a positive predictive value of 73.3% (95% confidence interval, 70.8-75.8), and a negative predictive value of 99.2% (95% confidence interval, 99.1-99.3). In the 46,512 pregnancies linked to birth certificate data, birth certificate diagnosis had moderate sensitivity (66.3% [95% confidence interval, 63.6-69.0]), high specificity (98.9% [95% confidence interval, 98.8-99.0]), moderate positive predictive value (62.1% [95% confidence interval, 59.8-64.4]), and high negative predictive value (99.1% [95% confidence interval, 99.0-99.2]).

CONCLUSION

Ascertainment of gestational diabetes using administrative data, including International Classification of Diseases codes or birth certificates, has moderate sensitivity, moderate positive predictive value, high specificity, and high negative predictive value. Our findings provide context for interpreting the validity of studies that depend on administrative data for ascertainment of gestational diabetes and comparing them with prospective studies that use laboratory-based gestational diabetes criteria.

Trends in gestational diabetes mellitus among nulliparous pregnant individuals with singleton live births in the United States between 2011 to 2019: an age-period-cohort analysis

BACKGROUND

The rate of gestational diabetes mellitus has increased over the past decade. An age, period, and cohort epidemiologic analysis can be used to understand how and why disease trends have changed over time.

OBJECTIVE

This study aimed to estimate the associations of age (at delivery), period (delivery year), and cohort (birth year) of the pregnant individual with trends in the incidence of gestational diabetes mellitus in the United States.

STUDY DESIGN

We conducted an age, period, and cohort analysis of nulliparous pregnant adults aged 18 to 44 years with singleton live births from the National Vital Statistics System from 2011 to 2019. Generalized linear mixed models were used to calculate the adjusted rate ratios for the incidence of gestational diabetes mellitus for each 3-year maternal age span, period, and cohort group compared with the reference group for each. We repeated the analyses with stratification according to self-reported racial and ethnic group (non-Hispanic Asian-Pacific Islander, non-Hispanic Black, Hispanic, and non-Hispanic White) because of differences in the incidence of and risk factors for gestational diabetes mellitus by race and ethnicity.

RESULTS

Among 11,897,766 pregnant individuals, 5.2% had gestational diabetes mellitus. The incidence of gestational diabetes mellitus was higher with increasing 3-year maternal age span, among those in the more recent delivery period, and among the younger birth cohort. For example, individuals aged 42 to 44 years at delivery had a 5-fold higher risk for gestational diabetes mellitus than those aged 18 to 20 years (adjusted rate ratio, 5.57; 95% confidence interval, 5.43-5.72) after adjusting for cohort and period. Individuals who delivered between 2017 and 2019 were at higher risk for gestational diabetes mellitus than those who delivered between 2011 and 2013 (adjusted rate ratio, 1.24; 95% confidence interval, 1.23-1.25) after adjusting for age and cohort. Individuals born between 1999 and 2001 had a 3-fold higher risk for gestational diabetes mellitus than those born between 1969 and 1971 (adjusted rate ratio, 3.12; 95% confidence interval, 2.87-3.39) after adjusting for age and period. Similar age, period, and cohort effects were observed for the assessed racial and ethnic groups, with the greatest period effects observed among Asian and Pacific Islander individuals.

CONCLUSION

Period and birth cohort effects have contributed to the rising incidence of gestational diabetes mellitus in the United States from 2011 to 2019.

PM2.5 Constituents and Onset of Gestational Diabetes Mellitus: Identifying Susceptible Exposure Windows

Fine particulate matter (PM_2.5) has been linked to gestational diabetes mellitus (GDM). However, PM_2.5 is a complex mixture with large spatiotemporal heterogeneities, and women with early-onset GDM (i.e., diagnosed before 24^th gestation week) have distinct maternal characteristics and a higher risk of worse health outcomes compared with those with late-onset GDM (i.e., diagnosed in or after 24^th gestation week). We aimed to examine differential impacts of PM_2.5 and its constituents on early- vs. late-onset GDM, and to identify corresponding susceptible exposure windows. We leveraged statewide linked electronic health records and birth records data in Florida in 2012-2017. Exposures to PM_2.5 and its constituents (i.e., sulfate [SO₄ ^2-], ammonium [NH₄ ⁺], nitrate [NO₃ ^-], organic matter [OM], black carbon [BC], mineral dust [DUST], and sea-salt [SS]) were spatiotemporally linked to pregnant women based on their residential histories. Cox proportional hazards models and multinomial logistic regression were used to examine the associations of PM_2.5 and its constituents with GDM and its onsets. Distributed non-linear lag models were implemented to identify susceptible exposure windows. Exposures to PM_2.5, SO₄ ^2-, NH₄ ⁺, and BC were statistically significantly associated with higher hazards of GDM. Exposures to PM_2.5 during weeks 1-12 of gestation were positively associated with GDM. Associations of early-onset GDM with PM_2.5 in the 1^st and 2^nd trimesters, SO₄ ^2- in the 1^st and 2^nd trimesters, and NO₃ ^- in the preconception and 1^st trimester were considerably stronger than observations for late-onset GDM. Our findings suggest there are differential associations of PM_2.5 and its constituents with early- vs. late-onset GDM, with different susceptible exposure windows. This study helps better understand the impacts of air pollution on GDM accounting for its physiological heterogeneity.

Association between gestational diabetes and 6-year incident diabetes: results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

OBJECTIVE

Type 2 diabetes and gestational diabetes (GDM) disproportionately affect those of Hispanic/Latino heritage. This study examined the association between GDM and prevalent and incident diabetes in a community-based study of Hispanic/Latina women living in the USA.

METHODS

Participants were women aged 18-74 years in the Hispanic Community Health Study/Study of Latinos who had at least one pregnancy and had information on self-reported history of GDM at baseline (n=6389). Logistic regression was used to determine the association between GDM and prevalent (2008-2011) and incident (2014-2017) diabetes and interactions between GDM and risk factors for incident diabetes.

RESULTS

At baseline, 8.7% of participants reported a history of GDM and 18.6% had prevalent diabetes. Women with Mexican heritage had the highest prevalence of GDM history (11.3%) vs women of Cuban (5.0%), Central American (4.9%), and South American (3.8%) heritage (p&lt;0.001 for each comparison to Mexican heritage). Women with self-reported GDM were four times more likely to have prevalent diabetes compared with women without GDM, after adjusting for sociodemographic characteristics and cardiometabolic risk factors (adjusted OR (aOR)=3.94, 95% CI 2.75 to 5.64). Overall incidence of diabetes was 14.3/100 women. Women with GDM at baseline increased their odds of incident diabetes by threefold compared with women without GDM (aOR=3.25, 95% CI 2.09 to 5.05). Women with Cuban or Puerto Rican heritage and GDM had significantly higher odds of incident diabetes compared with women with Mexican heritage (aOR=2.15, 95% CI 1.17 to 3.95; aOR=1.95, 95% CI 1.07 to 3.55, respectively).

CONCLUSION

Self-reported GDM was significantly associated with a threefold higher risk of incident diabetes among Hispanic/Latino women in the USA even after adjusting for several significant predictors of diabetes.

Risk of Adverse Pregnancy Outcomes Among Pregnant Individuals With Gestational Diabetes by Race and Ethnicity in the United States, 2014-2020

IMPORTANCE

Gestational diabetes, which increases the risk of adverse pregnancy outcomes, has been increasing in frequency across all racial and ethnic subgroups in the US.

OBJECTIVE

To assess whether the frequency of adverse pregnancy outcomes among those in the US with gestational diabetes changed over time and whether the risk of these outcomes differed by maternal race and ethnicity.

DESIGN, SETTING, AND PARTICIPANTS

Exploratory serial, cross-sectional, descriptive study using US National Center for Health Statistics natality data for 1 560 822 individuals with gestational diabetes aged 15 to 44 years with singleton nonanomalous live births from 2014 to 2020 in the US.

EXPOSURES

Year of delivery and race and ethnicity, as reported on the birth certificate, stratified as non-Hispanic American Indian, non-Hispanic Asian/Pacific Islander, non-Hispanic Black, Hispanic/Latina, and non-Hispanic White (reference group).

MAIN OUTCOMES AND MEASURES

Maternal outcomes of interest included cesarean delivery, primary cesarean delivery, preeclampsia or gestational hypertension, intensive care unit (ICU) admission, and transfusion; neonatal outcomes included large for gestational age (LGA), macrosomia (>4000 g at birth), small for gestational age (SGA), preterm birth, and neonatal ICU (NICU) admission, as measured by the frequency (per 1000 live births) with estimation of mean annual percentage change (APC), disparity ratios, and adjusted risk ratios.

RESULTS

Of 1 560 822 included pregnant individuals with gestational diabetes (mean [SD] age, 31 [5.5] years), 1% were American Indian, 13% were Asian/Pacific Islander, 12% were Black, 27% were Hispanic/Latina, and 48% were White. From 2014 to 2020, there was a statistically significant increase in the overall frequency (mean APC per year) of preeclampsia or gestational hypertension (4.2% [95% CI, 3.3% to 5.2%]), transfusion (8.0% [95% CI, 3.8% to 12.4%]), preterm birth at less than 37 weeks (0.9% [95% CI, 0.3% to 1.5%]), and NICU admission (1.0% [95% CI, 0.3% to 1.7%]). There was a significant decrease in cesarean delivery (-1.4% [95% CI, -1.7% to -1.1%]), primary cesarean delivery (-1.2% [95% CI, -1.5% to -0.9%]), LGA (-2.3% [95% CI, -2.8% to -1.8%]), and macrosomia (-4.7% [95% CI, -5.3% to -4.0%]). There was no significant change in maternal ICU admission and SGA. In comparison with White individuals, Black individuals were at significantly increased risk of all assessed outcomes, except LGA and macrosomia; American Indian individuals were at significantly increased risk of all assessed outcomes except cesarean delivery and SGA; and Hispanic/Latina and Asian/Pacific Islander individuals were at significantly increased risk of maternal ICU admission, preterm birth, NICU admission, and SGA. Differences in adverse outcomes by race and ethnicity persisted through these years.

CONCLUSIONS AND RELEVANCE

From 2014 through 2020, the frequency of multiple adverse pregnancy outcomes in the US increased among pregnant individuals with gestational diabetes. Differences in adverse outcomes by race and ethnicity persisted.

Gestational Diabetes and Hypertensive Disorders of Pregnancy by Maternal Birthplace

INTRODUCTION

Gestational diabetes mellitus and hypertensive disorders of pregnancy increase the risk for future adverse health outcomes in the pregnant woman and baby, and disparities exist in the rates of gestational diabetes mellitus and hypertensive disorders of pregnancy by race/ethnicity. The objective of this study is to identify the differences in gestational diabetes mellitus and hypertensive disorders of pregnancy rates by maternal place of birth within race/ethnicity groups.

METHODS

In women aged 15-44 years at first live singleton birth in U.S. surveillance data between 2014 and 2019, age-standardized rates of gestational diabetes mellitus and hypertensive disorders of pregnancy and the rate ratios of gestational diabetes mellitus and hypertensive disorders of pregnancy in women born outside versus those born in the U.S. were evaluated, stratified by race/ethnicity. Analyses were conducted in 2021.

RESULTS

Of 8,574,264 included women, 6,827,198 were born in the U.S. (mean age=26.2 [SD 5.7] years), and 1,747,066 were born outside the U.S. (mean age=28.2 [SD=5.8] years). Overall, the gestational diabetes mellitus rate was higher in women born outside than in those born in the U.S. (70.3, 95% CI=69.9, 70.7 vs 53.2, 95% CI=53.0, 53.4 per 1,000 live births; rate ratio=1.32, 95% CI=1.31, 1.33), a pattern observed in most race/ethnic groups. By contrast, the overall hypertensive disorders of pregnancy rate was lower in those born outside than in those born in the U.S. (52.5, 95% CI=52.2, 52.9 vs 90.1, 95% CI=89.9, 90.3 per 1,000 live births; rate ratio=0.58, 95% CI=0.58, 0.59), a pattern observed in most race/ethnic groups.

CONCLUSIONS

In the U.S., gestational diabetes mellitus rates were higher and hypertensive disorders of pregnancy rates were lower in women born outside the U.S. than in those born in the U.S. in most race/ethnicity groups.

Exposure to air pollutant mixture and gestational diabetes mellitus in Southern California: Results from electronic health record data of a large pregnancy cohort

BACKGROUND

Epidemiological findings are inconsistent regarding the associations between air pollution exposure during pregnancy and gestational diabetes mellitus (GDM). Several limitations exist in previous studies, including potential outcome and exposure misclassification, unassessed confounding, and lack of simultaneous consideration of air pollution mixtures and particulate matter (PM) constituents.

OBJECTIVES

To assess the association between GDM and maternal residential exposure to air pollution, and the joint effect of the mixture of air pollutants and PM constituents.

METHODS

Detailed clinical data were obtained for 395,927 pregnancies in southern California (2008-2018) from Kaiser Permanente Southern California (KPSC) electronic health records. GDM diagnosis was based on KPSC laboratory tests. Monthly average concentrations of fine particulate matter < 2.5 μm (PM_2.5), <10 μm (PM₁₀), nitrogen dioxide (NO₂), and ozone (O₃) were estimated using kriging interpolation of Environmental Protection Agency's routine monitoring station data, while PM_2.5 constituents (i.e., sulfate, nitrate, ammonium, organic matter and black carbon) were estimated using a fine-resolution geoscience-derived model. A multilevel logistic regression was used to fit single-pollutant models; quantile g-computation approach was applied to estimate the joint effect of air pollution and PM component mixtures. Main analyses adjusted for maternal age, race/ethnicity, education, median family household income, pre-pregnancy BMI, smoking during pregnancy, insurance type, season of conception and year of delivery.

RESULTS

The incidence of GDM was 10.9% in the study population. In single-pollutant models, we observed an increased odds for GDM associated with exposures to PM_2.5, PM₁₀, NO₂ and PM_2.5 constituents. The association was strongest for NO₂ [adjusted odds ratio (OR) per interquartile range: 1.176, 95% confidence interval (CI): 1.147-1.205)]. In multi-pollutant models, increased ORs for GDM in association with one quartile increase in air pollution mixtures were found for both kriging-based regional air pollutants (NO₂, PM_2.5, and PM₁₀, OR = 1.095, 95% CI: 1.082-1.108) and PM_2.5 constituents (i.e., sulfate, nitrate, ammonium, organic matter and black carbon, OR = 1.258, 95% CI: 1.206-1.314); NO₂ (78%) and black carbon (48%) contributed the most to the overall mixture effects among all krigged air pollutants and all PM_2.5 constituents, respectively. The risk of GDM associated with air pollution exposure were significantly higher among Hispanic mothers, and overweight/obese mothers.

CONCLUSION

This study found that exposure to a mixture of ambient PM_2.5, PM₁₀, NO₂, and PM_2.5 chemical constituents was associated with an increased risk of GDM. NO₂ and black carbon PM_2.5 contributed most to GDM risk.

Trends in Gestational Diabetes at First Live Birth by Race and Ethnicity in the US, 2011-2019

IMPORTANCE

Gestational diabetes is associated with adverse maternal and offspring outcomes.

OBJECTIVE

To determine whether rates of gestational diabetes among individuals at first live birth changed from 2011 to 2019 and how these rates differ by race and ethnicity in the US.

DESIGN, SETTING, AND PARTICIPANTS

Serial cross-sectional analysis using National Center for Health Statistics data for 12 610 235 individuals aged 15 to 44 years with singleton first live births from 2011 to 2019 in the US.

EXPOSURES

Gestational diabetes data stratified by the following race and ethnicity groups: Hispanic/Latina (including Central and South American, Cuban, Mexican, and Puerto Rican); non-Hispanic Asian/Pacific Islander (including Asian Indian, Chinese, Filipina, Japanese, Korean, and Vietnamese); non-Hispanic Black; and non-Hispanic White.

MAIN OUTCOMES AND MEASURES

The primary outcomes were age-standardized rates of gestational diabetes (per 1000 live births) and respective mean annual percent change and rate ratios (RRs) of gestational diabetes in non-Hispanic Asian/Pacific Islander (overall and in subgroups), non-Hispanic Black, and Hispanic/Latina (overall and in subgroups) individuals relative to non-Hispanic White individuals (referent group).

RESULTS

Among the 12 610 235 included individuals (mean [SD] age, 26.3 [5.8] years), the overall age-standardized gestational diabetes rate significantly increased from 47.6 (95% CI, 47.1-48.0) to 63.5 (95% CI, 63.1-64.0) per 1000 live births from 2011 to 2019, a mean annual percent change of 3.7% (95% CI, 2.8%-4.6%) per year. Of the 12 610 235 participants, 21% were Hispanic/Latina (2019 gestational diabetes rate, 66.6 [95% CI, 65.6-67.7]; RR, 1.15 [95% CI, 1.13-1.18]), 8% were non-Hispanic Asian/Pacific Islander (2019 gestational diabetes rate, 102.7 [95% CI, 100.7-104.7]; RR, 1.78 [95% CI, 1.74-1.82]), 14% were non-Hispanic Black (2019 gestational diabetes rate, 55.7 [95% CI, 54.5-57.0]; RR, 0.97 [95% CI, 0.94-0.99]), and 56% were non-Hispanic White (2019 gestational diabetes rate, 57.7 [95% CI, 57.2-58.3]; referent group). Gestational diabetes rates were highest in Asian Indian participants (2019 gestational diabetes rate, 129.1 [95% CI, 100.7-104.7]; RR, 2.24 [95% CI, 2.15-2.33]). Among Hispanic/Latina participants, gestational diabetes rates were highest among Puerto Rican individuals (2019 gestational diabetes rate, 75.8 [95% CI, 71.8-79.9]; RR, 1.31 [95% CI, 1.24-1.39]). Gestational diabetes rates increased among all race and ethnicity subgroups and across all age groups.

CONCLUSIONS AND RELEVANCE

Among individuals with a singleton first live birth in the US from 2011 to 2019, rates of gestational diabetes increased across all racial and ethnic subgroups. Differences in absolute gestational diabetes rates were observed across race and ethnicity subgroups.

Trends in prepregnancy cardiovascular health in the United States, 2011-2019

Objective

To evaluate contemporary patterns in prepregnancy cardiovascular health (CVH) in the United States (US).

Methods

We conducted a serial, cross-sectional study of National Center for Health Statistics Natality Data representing all live births in the US from 2011 to 2019. We assigned 1 point for each of four ideal prepregnancy metrics (nonsmoking and ideal body mass index [18.5-24.9 kg/m²] provided by maternal self-report, and absence of hypertension and diabetes ascertained by the healthcare professional at delivery) to construct a prepregnancy clinical CVH score ranging from 0 to 4. We described the distribution of prepregnancy CVH, overall and stratified by self-reported race/ethnicity, age, insurance status, and receipt of the Women, Infants, and Children program (WIC) for supplemental nutrition. We examined trends by calculating average annual percent changes (AAPCs) in optimal prepregnancy CVH (score of 4).

Results

Of 31,643,982 live births analyzed between 2011 and 2019, 53.6% were to non-Hispanic White, 14.5% non-Hispanic Black, 23.3% Hispanic, and 6.6% non-Hispanic Asian women. The mean age (SD) was 28.5 (5.8) years. The prevalence (per 100 live births) of optimal prepregnancy CVH score of 4 declined from 42.1 to 37.7 from 2011 to 2019, with an AAPC (95% CI) of -1.4% per year (-1.3,-1.5). While the relative decline was observed across all race/ethnicity, insurance, and WIC subgroups, significant disparities persisted by race, insurance status, and receipt of WIC. In 2019, non-Hispanic Black women (28.7 per 100 live births), those on Medicaid (30.4), and those receiving WIC (29.1) had the lowest prevalence of optimal CVH.

Conclusions

Overall, less than half of pregnant women had optimal prepregnancy CVH, and optimal prepregnancy CVH declined in each race/ethnicity, age, insurance, and WIC subgroup between 2011-2019 in the US. However, there were persistent disparities by race/ethnicity and socioeconomic status.

Associations between the chemical composition of PM2.5 and gestational diabetes mellitus

BACKGROUND

Fine particulate matter (PM_2.5) is a complex mixture of fine particulates with large spatiotemporal heterogeneities in chemical compositions. While PM_2.5 has been associated with gestational diabetes mellitus (GDM), little is known about the relationship between specific chemical components of PM_2.5 and GDM. We examined the associations between GDM and pregnancy exposures to PM_2.5 and its compositions, including sulfate (SO₄^2-), ammonium (NH₄⁺), nitrate (NO₃^-), organic matter (OM), black carbon (BC), mineral dust (DUST), and sea-salt (SS), and to identify critical windows of exposure.

METHODS

We used data from the 2005-2015 Florida Vital Statistics Birth Records. A well-validated geoscience-derived model was used to estimate women's pregnancy exposures to PM_2.5 and its compositions. Distributed lag models were used to examine the associations and to identify the critical windows of exposure.

RESULTS

A total of 2,078,669 women were included. In single-pollutant models, after controlling for potential confounders, positive associations between PM_2.5 and GDM were observed during the second trimester of pregnancy. We found positive associations between SO₄^2-, NH₄⁺, NO₃^-, OM and BC, with largest effect sizes observed in the 21-24 weeks of pregnancy. Negative associations were observed for DUST and SS. Consistent results for NH₄⁺, OM, DUST and SS were observed in the multi-pollutant models.

CONCLUSIONS

Exposures to PM_2.5 and its compositions (mainly NH₄⁺, OM) during the second trimester are positively associated with GDM, especially for exposures during the 21-24 weeks of pregnancy. Further studies are needed to confirm the findings and examine the underlying mechanisms.

Racial/Ethnic Differences in Socioeconomic Status and Medical Correlates of Trial of Labor After Cesarean and Vaginal Birth After Cesarean

Objectives: Black and Latinx women have higher rates of trial of labor after cesarean (TOLAC) compared with White women, but lower rates of vaginal birth after cesarean (VBAC). This study examined potential racial/ethnic differences in correlates of TOLAC and VBAC. Materials and Methods: The analytic sample includes term, singleton hospital births to women with one prior cesarean in birth certificate data for 2016. We estimated associations between medical factors (diabetes, hypertension, and prepregnancy obesity) and socioeconomic status (education level and insurance type) and TOLAC and VBAC using logistic regression, stratifying by race/ethnicity and testing whether coefficients differed across models. Results: Hypertension and obesity were more strongly related to reduced chances of TOLAC among White women than among women of color. For example, having a body mass index (BMI) between 30 and 39 (vs. normal BMI) was associated with a 6.3 percentage-point (pp) lower probability of TOLAC for White women, a 5.9 pp lower probability for Black women, and 2.9 pp lower probability for Latinx women. Paying out-of-pocket for birth was associated with a 5.5 pp increase in the probability of TOLAC among White women, versus a 3.2 pp decrease among Black women. Overweight and obesity were associated with lower probability of VBAC, but the magnitude of this association was smaller for Black and Latinx women than for White women. Conclusions: More research is needed to elucidate the underlying decision-making processes that lead to these associations. Future work should focus on ensuring equity in access to VBAC-supportive providers and hospitals and fostering informed decision-making after a prior cesarean.

Particle air pollution and gestational diabetes mellitus in Houston, Texas

BACKGROUND

There is mixed evidence implicating prenatal exposure to particulate matter <2.5 μm in aerodynamic diameter (PM_2.5) in the risk of gestational diabetes mellitus (GDM) and only one study has examined exposure to PM_2.5 constituents, which vary with location because of different emission sources.

METHODS

We conducted a retrospective cohort study of singleton live births in Harris County, Texas from 2008 to 2013. With data from the Texas Commission on Environmental Quality (TCEQ), we spatially interpolated maternal exposures to total and speciated PM_2.5, nitrogen dioxide (NO₂) and ozone (O₃) over the 12-week preconception period and trimesters 1 and 2. We estimated odds ratios (OR) and 95% confidence intervals (CI) for the association between pre-conception and pregnancy exposures to total and speciated PM_2.5 and odds of GDM, adjusted for temperature and maternal covariates. We also evaluated confounding from NO₂ and O₃ exposures in multi-pollutant models.

RESULTS

An interquartile range (IQR) increase in total PM_2.5 exposure was associated with elevated odds for developing GDM over the preconception (adjusted OR = 1.09, 95% CI: 1.06, 1.12), first trimester (OR = 1.13, 95% CI: 1.10, 1.17) and second trimester (OR = 1.13, 95% CI: 1.09, 1.17) periods. Effect estimates increased with adjustment for NO₂ and O₃. We observed modest increases in odds of GDM for IQR increases in first trimester ammonium ion PM_2.5 (OR = 1.03, 95% CI: 1.00, 1.05) and sulfate PM_2.5 (OR = 1.03, 95% CI: 1.00, 1.05) exposures, as well as preconception Cr PM_2.5 exposures (OR = 1.05, 95% CI: 1.02, 1.07).

CONCLUSION

Exposures to PM_2.5, before and during pregnancy were associated with elevated odds of GDM. Mitigating air pollution exposures may reduce the risk of GDM and its long-term implications for maternal and child health.

Risk factors and time trends for isolated craniosynostosis

BACKGROUND

We sought to investigate associations between maternal/infant characteristics and isolated craniosynostosis as well as its subtypes sagittal, metopic, and coronal synostosis, and assess trends in the prevalence of these conditions.

METHODS

We identified cases in the Texas Birth Defects Registry from 1999 to 2014. We used Poisson regression to identify associations between maternal/infant characteristics and craniosynostosis. We used joinpoint regression and unadjusted Poisson regression to evaluate temporal trends. Finally, we computed adjusted Poisson models to evaluate whether temporal trends were evident after accounting for changes in the population distributions of maternal/infant characteristics over time.

RESULTS

Relative to all live births in the general population, cases were more frequently male or preterm. Mothers of cases were more frequently non-Hispanic white and more frequently obese. Non-Hispanic black or Hispanic maternal race/ethnicity was associated with a lower prevalence of all craniosynostosis subtypes. Previous live births were associated with sagittal synostosis; residence on the U.S.-Mexico border was associated with sagittal and coronal synostosis. The prevalence of any isolated craniosynostosis increased (average annual percent change estimated from joinpoint regression [AAPC]: 2.9%), as did the prevalences of sagittal (AAPC: 3.3%) and metopic synostosis (AAPC: 5.4%). In crude Poisson models, the same temporal trends were observed, however these were attenuated after adjusting for maternal/infant characteristics.

CONCLUSIONS

Prevalence of isolated craniosynostosis increased from 1999 to 2014. The largest AAPC was observed for metopic synostosis. Changes in the population distribution of associated maternal/infant characteristics may explain these trends.

Comprehensive assessment of the associations between maternal diabetes and structural birth defects in offspring: a phenome-wide association study

PURPOSE

Our objective was to comprehensively evaluate the risk of a broad range of birth defects among offspring of women with diabetes, overall and stratified by pregestational versus gestational diagnosis, using the phenome-wide association (PheWAS) methodology.

METHODS

We performed a registry linkage study of all live births (>6,500,000) and birth defects cases (>290,000) in Texas, 1999-2015. We ascertained diabetes from birth and fetal death certificates. We calculated prevalence rate ratios (PRR) for phenotypes with ≥10 cases among exposed offspring (n = 130).

RESULTS

Diabetes was associated with the prevalence of any defect (PRR 1.40, 95% confidence interval [CI] 1.38-1.42), multiple defects (PRR 1.86, 95% CI 1.81-1.91), and 60 specific phenotypes, including novel (hypospadias, mitral stenosis) and previously reported phenotypes (renal a-/dysgenesis, spinal anomalies). Pregestational diabetes was a stronger risk factor for any defect (PRR 2.00, 95% CI 1.93-2.07), multiple defects (PRR 3.27, 95% CI 3.11-3.44), and the 60 specific phenotypes evaluated. Gestational diabetes was associated with any defect (PRR 1.21, 95% CI 1.19-1.23) and 47 specific birth defects phenotypes, although associations were weaker than for pregestational diabetes.

CONCLUSIONS

The PheWAS is an efficient way to identify risk factors for disease using population-based registry data. Pregestational diabetes is associated with a broader range of phenotypes than previously reported. Because diabetes is diagnosed in 1% of women prior to pregnancy and 6%-9% during pregnancy, our results highlight a significant public health concern.

Timing of delivery in women with diabetes: A population-based study

INTRODUCTION

Women with diabetes, and their infants, have an increased risk of adverse events due to excess fetal growth. Earlier delivery, when fetuses are smaller, may reduce these risks. This study aimed to evaluate the week-specific risks of maternal and neonatal morbidity/mortality to assist with obstetrical decision making.

MATERIAL AND METHODS

In this population-based cohort study, women with type 1 diabetes (n = 5889), type 2 diabetes (n = 9422) and gestational diabetes (n = 138 917) and a comparison group without diabetes (n = 2 553 243) who delivered a singleton infant at ≥36 completed weeks of gestation between 2004 and 2014 were identified from the Canadian Institute of Health Information Discharge Abstract Database. Multivariate logistic regression was used to determine the week-specific rates of severe maternal and neonatal morbidity/mortality among women delivered iatrogenically vs those undergoing expectant management.

RESULTS

For all women, the absolute risk of severe maternal morbidity/mortality was low, typically impacting less than 1% of women, and there was no significant difference in gestational age-specific severe maternal morbidity/mortality between iatrogenic delivery and expectant management among women with any form of diabetes. Among women with gestational diabetes, iatrogenic delivery was associated with an increased risk of neonatal morbidity/mortality compared with expectant management at 36 and 37 weeks' gestation (76.7 and 27.8 excess cases per 1000 deliveries, respectively) and a lower risk of neonatal morbidity/mortality at 38, 39 and 40 weeks' gestation (7.9, 27.3 and 15.9 fewer cases per 1000 deliveries, respectively). Increased risks of severe neonatal morbidity following iatrogenic delivery compared with expectant management were also observed for women with type 1 diabetes at 36 (98.3 excess cases per 1000 deliveries) and 37 weeks' gestation (44.5 excess cases per 1000 deliveries) and for women with type 2 diabetes at 36 weeks' gestation (77.9 excess cases per 1000 deliveries) weeks.

CONCLUSIONS

The clinical decision regarding timing of delivery is complex and contingent on maternal-fetal wellbeing, including adequate glycemic control. This study suggests that delivery at 38, 39 or 40 weeks' gestation may optimize neonatal outcomes among women with diabetes.

A Population-Based Study of Diabetes During Pregnancy in Spain (2009-2015): Trends in Incidence, Obstetric Interventions, and Pregnancy Outcomes

(1) Background: We examined trends in incidence and outcomes in women with existing type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM) and gestational diabetes mellitus (GDM) compared with a control group without diabetes. (2) Methods: This was an observational, retrospective epidemiological study using the National Hospital Discharge Database. (3) Results: There were 2,481,479 deliveries in Spain between 2009 and 2015 (5561 mothers with T1DM, 4391 with T2DM, and 130,980 with GDM). Incidence and maternal age of existing diabetes and GDM increased over time. Women with T2DM were more likely to have obstetric comorbidity (70.12%) than those with GDM (60.28%), T1DM (59.45%), and no diabetes (41.82%). Previous cesarean delivery, preeclampsia, smoking, hypertension, and obesity were the most prevalent risk factors in all types of diabetes. Women with T1DM had the highest rate of cesarean delivery (Risk Ratio (RR) 2.34; 95% Confidence Interval (CI) 2.26-2.43) and prolonged maternal length of stay. Labor induction was higher in T2DM (RR 1.99; 95% CI 1.89-2.10). Women with T1DM had more severe maternal morbidity (RR 1.97; 95% CI 1.70-2.29) and neonatal morbidity (preterm birth, RR 3.32; 95% CI 3.14-3.51, and fetal overgrowth, RR 8.05; 95% CI 7.41-8.75). (4) Conclusions: existing and GDM incidence has increased over time. We found differences in the prevalence of comorbidities, obstetric risk factors, and the rate of adverse obstetric outcomes among women with different types of diabetes. Pregnant women with diabetes have the highest risk of adverse pregnancy outcomes.

Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data

OBJECTIVE

To describe variation in payer and outcomes in Veterans' births.

DATA/SETTING

Secondary data analyses of deliveries in California, 2000-2012.

STUDY DESIGN

We performed a retrospective, population-based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and variations in outcomes among: (1) Veterans using VA coverage and (2) Veteran vs. all other births. We calculated odds ratios (aOR) adjusted for age, race, ethnicity, education, and obstetric demographics.

METHODS

We anonymously linked VA administrative data for all female VA enrollees with California birth records.

PRINCIPAL FINDINGS

From 2000 to 2012, we identified 17,495 births to Veterans. VA covered 8.6 percent (1,508), Medicaid 17.3 percent, and Private insurance 47.6 percent. Veterans who relied on VA health coverage had more preeclampsia (aOR 1.4, CI 1.0-1.8) and more cesarean births (aOR 1.2, CI 1.0-1.3), and, despite similar prematurity, trended toward more neonatal intensive care (NICU) admissions (aOR 1.2, CI 1.0-1.4) compared to Veterans using other (non-Medicaid) coverage. Overall, Veterans' birth outcomes (all-payer) mirrored California's birth outcomes, with the exception of excess NICU care (aOR 1.15, CI 1.1-1.2).

CONCLUSIONS

VA covers a higher risk fraction of Veterans' births, justifying maternal care coordination and attention to the maternal-fetal impacts of Veterans' comorbidities.

Prevalence of gestational diabetes and subsequent Type 2 diabetes among U.S. women

AIMS

The true prevalence of gestational diabetes (GDM) in the United States is unknown. This study determined the prevalence of GDM and a subsequent diagnosis of diabetes in a nationally representative sample of U.S. women.

METHODS

The crude and age-adjusted prevalence of GDM and subsequent diabetes were evaluated by sociodemographic and health-related characteristics among women age ≥20 years in the National Health and Nutrition Examination Surveys, 2007-2014 (N = 8185). Logistic regression analyzed independent factors associated with GDM and subsequent diabetes.

RESULTS

The prevalence of GDM was 7.6%. Women who were Mexican American (vs. non-Hispanic white), had ≥4 live births (vs. 1), had a family history of diabetes, or were obese (vs. normal weight) had a higher age-standardized prevalence of GDM (each p < 0.04). Among women with a history of GDM, 19.7% had a subsequent diagnosis of diabetes; subsequent diabetes diagnosis was higher for those with health insurance, more time since GDM diagnosis, greater parity, family history of diabetes, and obesity, and lower for those with higher education and income (all p ≤ 0.005). By logistic regression, significant factors associated with GDM were age at first birth, parity, family history of diabetes, and obesity; significant factors for subsequent diabetes were older age, greater years since GDM diagnosis, less education, family history of diabetes, and obesity (each p < 0.01).

CONCLUSIONS

The prevalence of GDM in the U.S. was 7.6%, with 19.7% of these women having a subsequent diabetes diagnosis. Women with a history of GDM, family history of diabetes, and obesity should be carefully monitored for dysglycemia.

Diabetes During Pregnancy: Surveillance, Preconception Care, and Postpartum Care

Diabetes during pregnancy can adversely affect the health of women and infants. In this report, we provide an overview of the state of the science, and highlight Centers for Disease Control and Prevention (CDC) activities related to (1) surveillance of preexisting and gestational diabetes mellitus (GDM); (2) preconception care for women with preexisting diabetes; (3) postpartum diabetes screening among women with GDM-affected pregnancies; and (4) preventing the progression to Type 2 diabetes among women with GDM-affected pregnancies through lifestyle intervention programs. Improving preconception care, increasing postpartum diabetes screening rates, and promoting lifestyle interventions in the postpartum period all provide opportunities to improve the health of women and their infants.

Autism spectrum disorder and birth spacing: Findings from the study to explore early development (SEED)

Previous studies of autism spectrum disorder (ASD) and birth spacing had limitations; few examined phenotypic case subtypes or explored underlying mechanisms for associations and none assessed whether other (non-ASD) developmental disabilities (DDs) were associated with birth spacing. We assessed associations between inter-pregnancy interval (IPI) and both ASD and other DDs using data from the Study to Explore Early Development, a multi-site case-control study with rigorous case-finding and case-classification methods and detailed data collection on maternal reproductive history. Our sample included 356 ASD cases, 627 DD cases, and 524 population (POP) controls born in second or later births. ASD and DD cases were further sub-divided according to whether the child had intellectual disability (ID). ASD cases were also sub-divided by ASD symptom severity, and DD cases were subdivided by presence of some ASD symptoms (indicated on an autism screener). Odds ratios, adjusted for maternal-child sociodemographic factors, (aORs) and 95% confidence intervals were derived from logistic regression models. Among term births, ASD was associated with both IPI <18 months (aOR 1.5 [1.1-2.2]) and ≥60 months (1.5 [0.99-2.4]). Both short and long IPI associations were stronger among ASD cases with high severity scores (aORs 2.0 [1.3-3.3] and 1.8 [0.99-3.2], respectively). Associations were unchanged after adding several factors potentially related to the causal pathway to regression models. DD was not associated with either short or long IPI-overall, among term births, or in any subgroup examined. These findings extend those from previous studies and further inform recommendations on optimal pregnancy spacing. Autism Res 2018, 11: 81-94. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

LAY SUMMARY

We investigated whether the amount of time between pregnancies was associated autism spectrum disorder (ASD) or other developmental disabilities (DD) in children. ASD was increased in second and later-born children who were conceived less than 18 months or 60 or more months after the mother's previous birth. Other DDs were not associated with birth spacing.

Trends in Obstetric Intervention and Pregnancy Outcomes of Canadian Women With Diabetes in Pregnancy From 2004 to 2015

Context:

Multiple consensus statements decree that women with diabetes mellitus should have comparable birth outcomes to women without diabetes mellitus; however, there is a scarcity of contemporary population-based studies on this issue.

Objective:

To examine temporal trends in obstetric interventions and perinatal outcomes in a population-based cohort of women with type 1, type 2, or gestational diabetes mellitus compared with a control population.

Design:

Cross-sectional study.

Setting:

National hospitalization data (Canada except Quebec) from 2004 to 2015.

Patients:

Pregnant women with type 1 (n = 7362), type 2 (n = 11,028), and gestational diabetes mellitus (n = 149,780) and women without diabetes mellitus (n = 2,688,231).

Main Outcome Measures:

Rates of obstetric intervention, maternal morbidity, and neonatal morbidity/mortality.

Results:

A consistent relationship was generally observed between diabetes mellitus subtype and obstetric outcomes, with women with type 1 diabetes mellitus having the highest rate of intervention and the highest rates of adverse perinatal outcomes followed by women with type 2 diabetes mellitus and women with gestational diabetes mellitus. Rates of severe preeclampsia were 1.2% among women without diabetes mellitus, 2.1% among women with gestational diabetes mellitus, 4.2% among women with type 2 diabetes mellitus, and 7.5% among women with type 1 diabetes mellitus (P < 0.001). The rate of neonatal morbidity ranged from 8.7% in women without diabetes mellitus to 11.0%, 17.4%, and 24.1% in women with gestational, type 2, and type 1 diabetes mellitus, respectively (P < 0.001).

Conclusions:

In a contemporary obstetric population, women with diabetes mellitus remain at increased risk of adverse pregnancy outcomes compared with women without diabetes mellitus.

Original Findings and Updated Meta-Analysis for the Association Between Maternal Diabetes and Risk for Congenital Heart Disease Phenotypes

Maternal diabetes is associated with congenital heart defects (CHDs) as a group, but few studies have assessed risk for specific CHD phenotypes. We analyzed these relationships using data from the Texas Birth Defects Registry and statewide vital records for deliveries taking place in 1999-2009 (n = 48,249 cases). We used Poisson regression to calculate prevalence ratios for the associations between maternal diabetes (pregestational or gestational) and each CHD phenotype, adjusting for potential confounders. Analyses were repeated by type of diabetes. To address the potential for misclassification bias, we performed logistic regression, using malformed controls. We also conducted meta-analyses, combining our estimates of the association between pregestational diabetes and each CHD phenotype with previous estimates. The prevalence of every CHD phenotype was greater among women with pregestational diabetes than among nondiabetic women. Most of these differences were statistically significant (adjusted prevalence ratios = 2.47-13.20). Associations were slightly attenuated for many CHD phenotypes among women with gestational diabetes. The observed associations did not appear to be the result of misclassification bias. In our meta-analysis, pregestational diabetes was significantly associated with each CHD phenotype. These findings contribute to a better understanding of the teratogenic effects of maternal diabetes and improved counseling for risk of specific CHD phenotypes.

Establishment of Legal Paternity for Children of Unmarried American Women : Trade-Offs in Male Commitment to Paternal Investment

The establishment of a legal father for children of unmarried parents reflects both high paternity confidence and male willingness to commit to paternal investment. Whether an unmarried man voluntarily acknowledges paternity after a child is born has important consequences for both the mother and child. This paper brings to bear a life history perspective on paternity establishment, noting that men face trade-offs between mating and parental effort and that women will adjust their investment in children based on expected male investment. I predict that paternity establishment will be more likely when the mother has high socioeconomic status, when maternal health is good, and when the child is male, low parity, or a singleton (versus multiple) birth. I further predict that establishment of paternity will be associated with increased maternal investment in offspring, resulting in healthier babies with higher birthweights who are more likely to be breastfed. These predictions are tested using data on 5.4 million births in the United States from 2009 through 2013. Overall the results are consistent with the hypothesis that the trade-offs men face between reproductive and parental investment influence whether men voluntarily acknowledge paternity when a child is born.

Patterns of gestational diabetes diagnosis inside and outside of clinical guidelines

Background

Hospital discharge codes are often used to determine the incidence of gestational diabetes mellitus (GDM) at state and national levels. Previous studies demonstrate substantial variability in the accuracy of GDM reporting, and rarely report how the GDM was diagnosed. Our aim was to identify deliveries coded as gestational diabetes, and then to determine how the diagnosis was assigned and whether the diagnosis followed established guidelines.

Methods

We identified which deliveries were coded at discharge as complicated by GDM at the Brigham and Women’s Hospital in Boston, MA for the year 2010. We reviewed medical records to determine whether the codes were appropriately assigned.

Results

Of 7883 deliveries, coding for GDM was assigned with 98% accuracy. We identified 362 cases assigned GDM delivery codes, of which 210 (58%) had oral glucose tolerance test (OGTT) results available meeting established criteria. We determined that 126 cases (34%) received a GDM delivery code due to a clinician diagnosis documented in the medical record, without an OGTT result meeting established guidelines for GDM diagnosis. We identified only 15 cases (4%) that were coding errors.

Conclusions

Thirty four percent of women assigned GDM delivery codes at discharge had a medical record diagnosis of GDM but did not meet OGTT criteria for GDM by established guidelines. Although many of these patients may have met guidelines if guideline-based testing had been conducted, our findings suggest that clinician diagnosis outside of published guidelines may be common. There are many ramifications of this approach to diagnosis, including affecting population-level statistics of GDM prevalence and the potential impact on some women who may be diagnosed with GDM erroneously.

Validity of hospital discharge records to identify pregestational diabetes in an Italian population

AIMS

In recent years, the prevalence of pregestational diabetes (PGDM) and the concern about the possibility of adverse pregnancy outcomes in affected women have been increasing. Routinely collected health data represent a timely and cost-efficient approach in PGDM epidemiological research. This study aims to evaluate the reliability of hospital discharge (HD) coding to identify a population-based cohort of pregnant women with PGDM and to assess trends in prevalence in two provinces of Northern Italy.

METHODS

We selected all deliveries occurred in the period 1997-2010 with ICD-9-CM codes for PGDM in HD record and we matched up to 5 controls from mothers without diabetes. We used Diabetes Registers (DRs) as the gold standard for validation analysis.

RESULTS

We selected 3800 women, 653 with diabetes and 3147 without diabetes. The agreement between HD records and DRs was 90.7%, with K=0.58. We detected 350 false positives and only 1 false negative. Sensitivity was 99.3%, specificity 90.0%, positive predictive value 46.4% and negative predictive value 99.9%. Of the false positives, 48.6% had gestational diabetes and 2.3% impaired glucose tolerance. After the validation process, PGDM prevalence decreased from 4.4 to 2.0 per 1000 deliveries.

CONCLUSIONS

Our results show that HD facilitate detection of almost all PGDM cases, but they also include a large number of false positives, mainly due to gestational diabetes. This misclassification causes a large overestimation of PGMD prevalence. Our findings require accuracy evaluation of ICD-9-CM codes, before they can be widely applied to epidemiological research and public health surveillance related to PGDM.

Maternal pre-pregnancy and gestational diabetes, obesity, gestational weight gain, and risk of cancer in young children: a population-based study in California

PURPOSE

We aimed to examine the influence of pre-pregnancy diabetes, pre-pregnancy body mass index (BMI), gestational diabetes, and gestational weight gain on childhood cancer risk in offspring.

METHODS

We identified cancer cases (n = 11,149) younger than age 6 years at diagnosis from the California Cancer Registry registered between 1988 and 2013. Controls (n = 270,147) were randomly sampled from California birth records, and frequency matched by year of birth to all childhood cancers during the study period. Exposure and covariate information were extracted from birth records. Unconditional logistic regression models were generated to assess the importance of pre-pregnancy diabetes, pre-pregnancy BMI, gestational diabetes, and gestational weight gain on childhood cancer risk.

RESULTS

We observed increased risks of acute lymphoblastic leukemia and Wilms' tumor in children of mothers with pre-pregnancy diabetes [odds ratio (OR) 95 % confidence interval (CI) 1.37 (1.11, 1.69); OR (95 % CI) 1.45 (0.97, 2.18), respectively]. When born to mothers who were overweight prior to pregnancy (BMI 25-<30), children were at increased risk of leukemia [OR (95 % CI) 1.27 (1.01, 1.59)]. Insufficient gestational weight gain increased the risk of acute myeloid leukemia [OR (95 % CI) 1.50 (0.92, 2.42)] while excessive gestational weight gain increased the risk of astrocytomas [OR (95 % CI) 1.56 (0.97, 2.50)]. No associations were found between gestational diabetes and childhood cancer risk in offspring.

CONCLUSIONS

We estimated elevated risks of several childhood cancers in the offspring of mothers who had diabetes and were overweight prior to pregnancy, as well as mothers who gained insufficient or excessive weight. Since few studies have focused on these factors in relation to childhood cancer, replication of our findings in future studies is warranted.

Preventing large birth size in women with preexisting diabetes mellitus: The benefit of appropriate gestational weight gain

OBJECTIVE

To estimate the percentage of infants with large birth size attributable to excess gestational weight gain (GWG), independent of prepregnancy body mass index, among mothers with preexisting diabetes mellitus (PDM).

STUDY DESIGN

We analyzed 2004-2008 Florida linked birth certificate and maternal hospital discharge data of live, term (37-41weeks) singleton deliveries (N=641,857). We calculated prevalence of large-for-gestational age (LGA) (birth weight-for-gestational age≥90th percentile) and macrosomia (birth weight>4500g) by GWG categories (inadequate, appropriate, or excess). We used multivariable logistic regression to estimate the relative risk (RR) of large birth size associated with excess compared to appropriate GWG among mothers with PDM. We then estimated the population attributable fraction (PAF) of large birth size due to excess GWG among mothers with PDM (n=4427).

RESULTS

Regardless of diabetes status, half of mothers (51.2%) gained weight in excess of recommendations. Large birth size was higher in infants of mothers with PDM than in infants of mothers without diabetes (28.8% versus 9.4% for LGA, 5.8% versus 0.9% for macrosomia). Among women with PDM, the adjusted RR of having an LGA infant was 1.7 (95% CI 1.5, 1.9) for women with excess GWG compared to those with appropriate gain; the PAF was 27.7% (95% CI 22.0, 33.3). For macrosomia, the adjusted RR associated with excess GWG was 2.1 (95% CI 1.5, 2.9) and the PAF was 38.6% (95% CI 24.9, 52.4).

CONCLUSION

Preventing excess GWG may avert over one-third of macrosomic term infants of mothers with PDM. Effective strategies to prevent excess GWG are needed.

Association of missing paternal demographics on infant birth certificates with perinatal risk factors for childhood obesity

BACKGROUND

The role of fathers in the development of obesity in their offspring remains poorly understood. We evaluated associations of missing paternal demographic information on birth certificates with perinatal risk factors for childhood obesity.

METHODS

Data were from the Linked CENTURY Study, a database linking birth certificate and well-child visit data for 200,258 Massachusetts children from 1980-2008. We categorized participants based on the availability of paternal age, education, or race/ethnicity and maternal marital status on the birth certificate: (1) pregnancies missing paternal data; (2) pregnancies involving unmarried women with paternal data; and (3) pregnancies involving married women with paternal data. Using linear and logistic regression, we compared differences in smoking during pregnancy, gestational diabetes, birthweight, breastfeeding initiation, and ever recording a weight for length (WFL) ≥ the 95th percentile or crossing upwards ≥2 WFL percentiles between 0-24 months among the study groups.

RESULTS

11,989 (6.0 %) birth certificates were missing paternal data; 31,323 (15.6 %) mothers were unmarried. In adjusted analyses, missing paternal data was associated with lower birthweight (β -0.07 kg; 95 % CI: -0.08, -0.05), smoking during pregnancy (AOR 4.40; 95 % CI: 3.97, 4.87), non-initiation of breastfeeding (AOR 0.39; 95 % CI: 0.36, 0.42), and with ever having a WFL ≥ 95th percentile (AOR 1.10; 95 % CI: 1.01, 1.20). Similar associations were noted for pregnancies involving unmarried women with paternal data, but differences were less pronounced.

CONCLUSIONS

Missing paternal data on the birth certificate is associated with perinatal risk factors for childhood obesity. Efforts to understand and reduce obesity risk factors in early life may need to consider paternal factors.

Are Birth Certificate and Hospital Discharge Linkages Performed in 52 Jurisdictions in the United States?

OBJECTIVES

The purpose of this study was to determine the number and characteristics of US State Registrars of Vital Statistics (Vital Registrars) and State Systems Development Initiative (SSDI) Coordinators that link birth certificate and hospital discharge data as well as using linkage processes.

METHODS

Vital Registrars and SSDI Coordinators in all 52 vital records jurisdictions (50 states, District of Columbia, and New York City) were asked to complete a 41-question survey. We examined frequency distributions among completed surveys using SAS 9.3.

RESULTS

The response rate was 100% (N = 52) for Vital Registrars and 96% (N = 50) for SSDI Coordinators. Nearly half of Vital Registrars (n = 22) and SSDI Coordinators (n = 23) reported that their jurisdiction linked birth certificate and hospital discharge records at least once in the last 4 years. Among those who link, the majority of Vital Registrars (77.3%) and SSDI Coordinators (82.6) link both maternal and infant hospital discharge records to the birth certificate. Of those who do not link, 43% of the Vital Registrars and 55% of SSDI Coordinators reported an interest in linking birth certificate and hospital discharge data. Reasons for not linking included lack of staff time, inability to access raw data, high cost, and unavailability of personal identifiers to link the two sources.

CONCLUSIONS

Results of our analysis provide a national perspective on data linkage practices in the US. Our findings can be used to promote further data linkages, facilitate sharing of data and linkage methodologies, and identify uses of the resulting linked data.

Air pollution exposure and gestational diabetes mellitus among pregnant women in Massachusetts: a cohort study

BACKGROUND

Rodent and human studies suggest an association between air pollution exposure and type 2 diabetes mellitus, but the extent to which air pollution is associated with gestational diabetes mellitus (GDM) is less clear.

METHODS

We used the Massachusetts Registry of Vital Records to study primiparous women pregnant from 2003-2008 without pre-existing diabetes. We used satellite-based spatiotemporal models to estimate first and second trimester residential particulate (PM2.5) exposure and geographic information systems to estimate neighborhood traffic density. We obtained GDM status from birth records. We performed logistic regression analyses adjusted for sociodemographics on the full cohort and after stratification by maternal age and smoking habits.

RESULTS

Of 159,373 women, 5,381 (3.4 %) developed GDM. Residential PM2.5 exposure ranged 1.3-19.3 μg/m(3) over the second trimester. None of the exposures were associated with GDM in the full cohort [e.g. OR 0.99 (95 % CI: 0.95, 1.03) for each interquartile range (IQR) increment in second trimester PM2.5]. There were also no consistent associations after stratification by smoking habits. When the cohort was stratified by maternal age, women less than 20 years had 1.36 higher odds of GDM (95 % CI: 1.08, 1.70) for each IQR increment in second trimester PM2.5 exposure.

CONCLUSIONS

Although we found no evidence of an association between air pollution exposure and GDM among all women in our study, greater exposure to PM2.5 during the second trimester was associated with GDM in the youngest age stratum.

Lost opportunities to prevent early onset type 2 diabetes mellitus after a pregnancy complicated by gestational diabetes

OBJECTIVES

Gestational diabetes mellitus (GDM) greatly increases the risk of developing diabetes in the decade after delivery, but few women receive appropriately timed postpartum glucose testing (PPGT) or a referral to primary care (PC) for continued monitoring. This qualitative study was designed to identify barriers and facilitators to testing and referral from patient and providers' perspectives.

METHODS

We interviewed patients and clinicians in depth about knowledge, values, priorities, challenges, and recommendations for increasing PPGT rates and PC linkage. Interviews were coded with NVIVO data analysis software, and analyzed using an implementation science framework.

RESULTS

Women reported motivation to address GDM for the health of the fetus. Most women did not anticipate future diabetes for themselves, and focused on delivery outcomes rather than future health risks. Patients sought and received reassurance from clinicians, and were unlikely to discuss early onset following GDM or preventive measures. PPGT barriers described by patients included provider not mentioning the test or setting it up, transportation difficulties, work responsibilities, fatigue, concerns about fasting while breastfeeding, and timing of the test after discharge from obstetrics, and no referral to PC for follow-up. Practitioners described limited communication among multiple care providers during pregnancy and delivery, systems issues, and separation of obstetrics from PC.

CONCLUSIONS

Patients' barriers to PPGT included low motivation for self-care, structural obstacles, and competing priorities. Providers reported the need to balance risk with reassurance, and identified systems failures related to test timing, limitations of electronic medical record systems (EMR), lack of referrals to PC, and inadequate communication between specialties. Prevention of early onset has great potential for medical cost savings and improvements in quality of life.

Prevalence of Adverse Pregnancy Outcomes, by Maternal Diabetes Status at First and Second Deliveries, Massachusetts, 1998-2007

Introduction

Understanding patterns of diabetes prevalence and diabetes-related complications across pregnancies could inform chronic disease prevention efforts. We examined adverse birth outcomes by diabetes status among women with sequential, live singleton deliveries.

Methods

We used data from the 1998–2007 Massachusetts Pregnancy to Early Life Longitudinal Data System, a population-based cohort of deliveries. We restricted the sample to sets of parity 1 and 2 deliveries. We created 8 diabetes categories using gestational diabetes mellitus (GDM) and chronic diabetes mellitus (CDM) status for the 2 deliveries. Adverse outcomes included large for gestational age (LGA), macrosomia, preterm birth, and cesarean delivery. We computed prevalence estimates for each outcome by diabetes status.

Results

We identified 133,633 women with both parity 1 and 2 deliveries. Compared with women who had no diabetes in either pregnancy, women with GDM or CDM during any pregnancy had increased risk for adverse birth outcomes; the prevalence of adverse outcomes was higher in parity 1 deliveries among women with no diabetes in parity 1 and GDM in parity 2 (for LGA [8.5% vs 15.1%], macrosomia [9.7% vs. 14.9%], cesarean delivery [24.7% vs 31.3%], and preterm birth [7.7% vs 12.9%]); and higher in parity 2 deliveries among those with GDM in parity 1 and no diabetes in parity 2 (for LGA [12.3% vs 18.2%], macrosomia [12.3% vs 17.2%], and cesarean delivery [27.0% vs 37.9%]).

Conclusions

Women with GDM during one of 2 sequential pregnancies had elevated risk for adverse outcomes in the unaffected pregnancy, whether the diabetes-affected pregnancy preceded or followed it.

The influence of maternal BMI and gestational diabetes on pregnancy outcome

AIMS

To evaluate the effect of maternal body mass index (BMI) on gestational diabetes (GDM) and the risk of adverse pregnancy outcomes in women who are overweight or obese.

METHODS

A prospective cohort study nested within the LIMIT randomised controlled trial. A total of 1030 women were recruited between 10 and 20 weeks' gestation, with a BMI≥25 kg/m(2), and were grouped into BMI subclasses utilising World Health Organisation criteria. Women underwent a fasting oral glucose tolerance test at 26-28 weeks' gestation, and a diagnosis of GDM was made if fasting blood glucose was ≥5.5 mmol/L or ≥7.8 mmol/L after 2h. Maternal and neonatal health outcomes were evaluated.

RESULTS

The prevalence of GDM increased with increasing maternal BMI (6.74% overweight vs 13.42% obese subclass 1 vs 12.79% obese subclass 2 vs 20.00% obese subclass 3). Women who were diagnosed with GDM were significantly less likely to give birth to an infant with birth weight above 4 kg (RR 0.60; 95% CI 0.36 to 1.00; p=0.05). The need for caesarean delivery (RR 1.27; 95% CI 1.07 to 1.50; p=0.006) and incidence of birth weight >90% (RR 1.38; 95% CI 1.07 to 1.77; p=0.01) was significantly increased in women who were obese, independent of GDM.

CONCLUSION

Increasing maternal BMI is a significant risk factor for the development of GDM, and our findings demonstrate a considerably higher prevalence than has been previously described. Raised maternal BMI is a risk factor for high infant birth weight, which may be modified by lifestyle intervention.

Validation of selected items on the 2003 U.S. standard certificate of live birth: New York City and Vermont

OBJECTIVE

We assessed the validity of selected items on the 2003 revised U.S. Standard Certificate of Live Birth to understand the accuracy of new and existing items.

METHODS

We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of select variables reported on the birth certificate using the medical record as the gold standard for a representative sample of live births in New York City (n=603) and Vermont (n=664) in 2009.

RESULTS

In both sites, sensitivity was excellent (>90%) for Medicaid coverage at delivery, any previous live births, and current method of delivery; sensitivity was moderate (70%-90%) for gestational diabetes; and sensitivity was poor (<70%) for premature rupture of the membranes and gestational hypertension. In both sites, PPV was excellent for Medicaid coverage, any previous live births, previous cesarean delivery, and current method of delivery, and poor for premature rupture of membranes. In both sites, almost all items had excellent (>90%) specificity and NPV.

CONCLUSION

Further research is needed to determine how best to improve the quality of data on the birth certificate. Future revisions of the birth certificate may consider removing those items that have consistently proven difficult to report accurately.

Trends in prevalence of diabetes among delivery hospitalizations, United States, 1993-2009

To describe recent trends in prevalence of pre-existing diabetes mellitus (PDM) (i.e., type 1 or type 2 diabetes) and gestational diabetes mellitus (GDM) among delivery hospitalizations in the United States. Data on delivery hospitalizations from 1993 through 2009 were obtained from the Health Care Cost and Utilization Project (HCUP) Nationwide Inpatient Sample. Diagnosis-Related Group codes were used to identify deliveries and diagnosis codes on presence of diabetes. Rates of hospitalizations with diabetes were calculated per 100 deliveries by type of diabetes, hospital geographic region, patient's age, degree of urbanicity of patient's residence, categorized median household income for patient's ZIP Code, expected primary payer, and type of delivery. From 1993 to 2009, age-standardized prevalence of diabetes per 100 deliveries increased from 0.62 to 0.90 for PDM (trend p < 0.001) and from 3.09 to 5.57 for GDM (trend p < 0.001). In 2009, correlates of PDM at delivery included older age [40-44 vs. 15-24: odds ratio 6.45 (95 % CI 5.27-7.88)], Medicaid/Medicare versus private payment sources [1.77 (95 % CI 1.59-1.98)], patient's ZIP Code with a median household income in bottom quartile versus other quartiles [1.54 (95 % CI 1.41, 1.69)], and C-section versus vaginal delivery [3.36 (95 % CI 3.10-3.64)]. Correlates of GDM at delivery were similar. Among U.S. delivery hospitalizations, the prevalence of diabetes is increasing. In 2009, the prevalence of diabetes was higher among women in older age groups, living in ZIP codes with lower household incomes, or with public insurance.

Trends in pre-pregnancy diabetes among deliveries in 19 U.S. states, 2000-2010

BACKGROUND

Trends in state-level prevalence of pre-pregnancy diabetes mellitus (PDM; i.e., type 1 or type 2 diabetes diagnosed before pregnancy) among delivery hospitalizations are needed to inform healthcare delivery planning and prevention programs.

PURPOSE

To examine PDM trends overall, by age group, race/ethnicity, primary payer, and with comorbidities such as pre-eclampsia and pre-pregnancy hypertension, and to report changes in prevalence over 11 years.

METHODS

In 2014, State Inpatient Databases from the Agency for Healthcare Research and Quality were analyzed to identify deliveries with PDM and comorbidities using diagnosis-related group codes and ICD-9-CM codes. General linear regression with a log-link and binomial distribution was used to assess the annual change.

RESULTS

Between 2000 and 2010, PDM deliveries increased significantly in all age groups, all race/ethnicity groups, and in all states examined (p<0.01). The age-standardized prevalence of PDM increased from 0.65 per 100 deliveries in 2000 to 0.89 per 100 deliveries in 2010, with a relative change of 37% (p<0.01). Although PDM rates were highest in the South, some of the largest relative increases occurred in five Western states (≥69%). Non-Hispanic blacks had the highest PDM rates and the highest absolute increase (0.26 per 100 deliveries). From 2000 to 2010, the proportion of PDM deliveries with pre-pregnancy hypertension increased significantly (p<0.01) from 7.4% to 14.1%.

CONCLUSIONS

PDM deliveries are increasing overall and particularly among those with PDM who have hypertension. Effective diabetes prevention and control strategies for women of childbearing age may help protect their health and that of their newborns.

Prevalence estimates of gestational diabetes mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007-2010

INTRODUCTION

The true prevalence of gestational diabetes mellitus (GDM) is unknown. The objective of this study was 1) to provide the most current GDM prevalence reported on the birth certificate and the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire and 2) to compare GDM prevalence from PRAMS across 2007-2008 and 2009-2010.

METHODS

We examined 2010 GDM prevalence reported on birth certificate or PRAMS questionnaire and concordance between the sources. We included 16 states that adopted the 2003 revised birth certificate. We also examined trends from 2007 through 2010 and included 21 states that participated in PRAMS for all 4 years. We combined GDM prevalence across 2-year intervals and conducted t tests to examine differences. Data were weighted to represent all women delivering live births in each state.

RESULTS

GDM prevalence in 2010 was 4.6% as reported on the birth certificate, 8.7% as reported on the PRAMS questionnaire, and 9.2% as reported on either the birth certificate or questionnaire. The agreement between sources was 94.1% (percent positive agreement = 3.7%, percent negative agreement = 90.4%). There was no significant difference in GDM prevalence between 2007-2008 (8.1%) and 2009-2010 (8.5%, P = .15).

CONCLUSION

Our results indicate that GDM prevalence is as high as 9.2% and is more likely to be reported on the PRAMS questionnaire than the birth certificate. We found no statistical difference in GDM prevalence between the 2 phases. Further studies are needed to understand discrepancies in reporting GDM by data source.

The relation of a woman’s impaired in utero growth and association of diabetes during pregnancy

Small for gestational age (weight for gestational age <10th percentile, SGA) birth status and adulthood susceptibility to diabetes is well established, but the relationship to diabetes during pregnancy is incompletely understood. The authors investigated the association between women's impaired fetal growth (as measured by SGA status) and diabetes mellitus (DM) during pregnancy. Stratified and multivariable binomial regression analyses were performed on the Illinois transgenerational dataset. Former SGA (n = 13,934) mothers had a greater prevalence of DM during pregnancy than former appropriate for gestational age (AGA) mothers (n = 116,683): 2.7 versus 1.9 %, relative prevalence (RP) equaled 1.4 [95 % confidence interval (CI)1.3, 1.6]. In a multivariable binomial regression model, the adjusted RP (95 %CI) (controlling for maternal age, education, parity, plurality, marital status, and race/ethnicity) for DM during pregnancy for former SGA (compared to AGA) mothers equaled 1.5 (1.3, 1.6). When stratified by race/ethnicity, the adjusted RP (95 % CI) of DM during pregnancy for former SGA (compared to AGA), non-Latina White, African-American, and Mexican-American mothers was 1.4 (1.3, 1.6), 1.6 (1.2, 2.1), and 2.3 (1.1, 4.7), respectively. The authors conclude that impaired fetal growth (as measured by SGA status) is a risk factor for DM during pregnancy among the leading racial/ethnic groups in the United States.