Prenatal visit utilization and outcomes in pregnant women with type II and gestational diabetes

Effect of Prenatal Care on Perinatal Outcomes of Pregnant Women with Diabetes Mellitus: A Systematic Review

Objective: to evaluate the effect of prenatal care (PC) on perinatal outcomes of pregnant women with diabetes mellitus (DM). Methods: systematic review developed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines and conducted through the population, intervention, control, and outcomes (PICO) strategy. Clinical trials and observational studies were selected, with adult pregnant women, single-fetus pregnancy, diagnosis of DM, or gestational DM and who had received PC and/or nutritional therapy (NT). The search was carried out in PubMed, Scopus, and BIREME databases. The quality of the studies was evaluated using the tools of the National Heart, Lung and Blood Institute-National Institutes of Health (NHLBI-NIH). Results: We identified 5972 records, of which 15 (n=47 420 pregnant women) met the eligibility criteria. The most recurrent outcomes were glycemic control (14 studies; n=9096 participants), hypertensive disorders of pregnancy (2; n=39 282), prematurity (6; n=40 163), large for gestational age newborns (4; n=1556), fetal macrosomia (birth weight >4kg) (6; n=2980) and intensive care unit admission (4; n=2022). Conclusions: The findings suggest that PC interferes with the perinatal outcome, being able to reduce the risks of complications associated with this comorbidity through early intervention, especially when the NT is an integral part of this assistance.

Analysis of the Incidence of Macrosomia in Japan by Parental Nationalities at 5-year Intervals From 1995 to 2020

OBJECTIVES

We investigated trends in the incidence rate of macrosomia and its association with parental nationalities using Vital Statistics data in Japan.

METHODS

We used singleton birth data every 5 years from 1995 to 2020. The incidence rate of macrosomia was calculated according to specific attributes (maternal age, infant's sex, parental nationalities, parity, and household occupation) over time (years). In addition, a log-binomial model was used to investigate the relationship between the incidence of macrosomia and the attributes. This study compared Korea, China, the Philippines, Brazil, and other countries with Japan in terms of parental nationalities. "Other countries" indicates countries except for Japan, Korea, China, the Philippines, and Brazil.

RESULTS

The study included 6 180 787 births. The rate of macrosomia in Japan decreased from 1.43% in 1995 to 0.88% in 2020, and the decrease was observed across all parental nationalities. The rates for Japanese parents were the lowest values among parental nationalities during the timespan investigated. Multivariate regression analysis showed that mothers from Korea, China, the Philippines, Brazil, and other countries had a significantly higher risk of macrosomia than those from Japan (risk ratio, 1.91, 2.82, 1.59, 1.74, and 1.64, respectively). Furthermore, fathers from China, the Philippines, Brazil, and other countries had a significantly higher risk of macrosomia than those from Japan (risk ratio, 1.66, 1.38, 1.88, and 3.02, respectively).

CONCLUSIONS

The rate of macrosomia decreased from 1995 to 2020 in Japan for parents of all nationalities, and the risk of macrosomia incidence was associated with parental nationality.

The Impact of Neighborhood Deprivation on Glycemic Control for Patients with Type 2 Diabetes During Pregnancy

Background: The impact of neighborhood level factors on glycemic control and pregnancy outcomes is understudied. The primary objective was to determine whether there is an association between glycemic control during pregnancy and level of neighborhood deprivation, defined by area deprivation index (ADI). Materials and Methods: We conducted a retrospective cohort study of women with type 2 diabetes who received care at a tertiary referral center from 2007 to 2017. Patients living in more deprived neighborhoods (ADI >85th national percentile) were compared to those living in less deprived neighborhoods (ADI ≤85th percentile). The primary outcome was change in hemoglobin A1c (HbA1c) over time. Demographic characteristics were compared between groups, and trends in mean A1c through each trimester were tested with repeated measures analysis. Results: Of 237 women meeting study criteria, 93 (39.2%) lived in less deprived (low ADI) and 144 (60.8%) lived in more deprived neighborhoods (high ADI). Women living in more deprived neighborhoods were more likely to be Black (86.8% vs. 53.8%, p < 0.01), less likely to be married (11.3% vs. 31.2%, p < 0.01), and had more severe diabetes (p = 0.05). Both groups achieved significant improvement in HbA1c across each trimester using repeated measures analysis. Those living in more deprived neighborhoods had significantly more improvement in HbA1c from their initial visit to the third trimester compared to those in less deprived neighborhoods, (p = 0.01) such that there was no longer a statistically significant disparity in HbA1c by the third trimester (6.69 ± 0.97 Less deprived vs. 6.95 ± 1.22 more deprived, p = 0.19). Conclusions: Low-income women living in more deprived neighborhoods enter pregnancy with significantly worse glycemic control than those living in less deprived neighborhoods, but the gap in glycemic control largely closes by the end of pregnancy with similar maternal and neonatal outcomes.

Racial and Ethnic Disparities in Health Care and Health Outcomes for Pregnant Women With Diabetes

This article summarizes the current literature on racial and ethnic differences among women with diabetes in pregnancy. The PubMed, Scopus, CINAHL, and Embase databases were searched for original qualitative or quantitative studies published in English from January 1, 2009, to May 31, 2020. Consensus statements were excluded. Results of this synthesis indicate that racial and ethnic differences exist among pregnant women with diabetes, including social determinants of health, disparities in maternity care and perinatal care, and maternal and neonatal health outcomes. Health care providers should implement tailored interventions that specifically target racial and ethnic disparities in maternal and neonatal health to promote health equity in pregnant women with diabetes and their offspring, including later in life.

The Association Between Continuity Of Marketplace Coverage During Pregnancy And Receipt Of Prenatal Care

Insurance disruptions before, during, and after pregnancy are common in the United States, but little is known about the enrollment patterns of pregnant people in the Affordable Care Act Marketplaces. Data from the Pregnancy Risk Assessment Monitoring System from the period 2016-18 show that among respondents enrolled in Marketplace coverage, approximately one-third reported continuous Marketplace enrollment from preconception through the postpartum period. Compared with respondents who were continuously enrolled in Marketplace coverage from preconception through postpartum, respondents who enrolled in Marketplace plans during pregnancy had a 10.8 percent lower rate of adequate prenatal care, a 6.4 percent lower rate of timely prenatal care initiation, and a 13.2 percent lower rate of having twelve or more prenatal care visits. Policies that promote continuity of coverage during pregnancy, such as designating pregnancy as a qualifying event for a Marketplace open enrollment period, may enable pregnant people to enroll in Marketplace coverage early in their pregnancies and thus enhance access to prenatal care.

Knowledge and Attitude regarding COVID-19 among Pregnant Women in Southwestern Iran in the Early Period of its Outbreak: A Cross-Sectional Study

Both knowledge and attitude can play key roles in the prevention of novel COVID-19. This cross-sectional study was conducted on a statistical sample of pregnant women in southwestern Iran between March and April 2020 to evaluate their knowledge and attitude toward this condition. So, pregnant mothers registered in antenatal clinics affiliated to Shiraz University of Medical Sciences were called and asked to fill in a three-part online questionnaire including sociodemographic characteristics, obstetric/medical history, and knowledge/attitude toward COVID-19. P-values < 0.05 were considered statistically significant. The mean score of knowledge among 540 respondents was 34 (±4.1) out of 43. Also, 44.3% answered more than 80% of the items correctly. Higher knowledge scores were accordingly associated with marriage duration, area of residence, health insurance coverage, socioeconomic status (SES), and self-rated health status. However, a strong relationship was found between knowledge, SES, and health insurance coverage with reference to multivariate analysis results. Moreover, majority of the pregnant women and their households expressed their concern about using preventive measures against COVID-19. Although most respondents were moderately worried about becoming infected with COVID-19, 264 (48.9%) cases reported that they were very much anxious about their newborns being infected with COVID-19 and 388 (71.9%) individuals asserted that they were worried about their mortality due to this infection. Besides, most mothers maintained that they had some degrees of rumination, which could interfere with their routine daily chores. Hence, health policy-makers should pay much focus on educating pregnant mothers to help them prevent mental exhaustion.

The Influence of Preeclampsia, Advanced Maternal Age and Maternal Obesity in Neonatal Outcomes Among Women with Gestational Diabetes

OBJECTIVE

 The present study aims to analyze adverse fetal or neonatal outcomes in women with gestational diabetes, including fetal death, preterm deliveries, birthweight, neonatal morbidity and mortality, as well as the synergic effect of concomitant pregnancy risk factors and poor obstetric outcomes, as advanced maternal age, maternal obesity and pre-eclampsia in their worsening.

METHODS

 The present cohort retrospective study included all pregnant women with gestational diabetes, with surveillance and childbirth at the Hospital da Senhora da Oliveira during the years of 2017 and 2018. The data were collected from the medical electronic records registered in health informatic programs Sclinico and Obscare, and statistical simple and multivariate analysis was done using IBM SPSS Statistics.

RESULTS

 The study participants included 301 pregnant women that contributed to 7.36% of the total institution childbirths of the same years, in a total of 300 live births. It was analyzed the influence of pre-eclampsia coexistence in neonatal morbidity (p = 0.004), in the occurrence of newborns of low and very low birthweight (p < 0.01) and in preterm deliveries (p < 0.01). The influence of maternal obesity (p = 0.270; p = 0.992; p = 0.684) and of advanced maternal age in these 3 outcomes was also analyzed (p = 0,806; p = 0.879; p = 0.985).Using a multivariate analysis, the only models with statistic significance to predict the three neonatal outcomes included only pre-eclampsia (p = 0.04; p < 0.01; p < 0.01).

CONCLUSION

 Only coexistence of pre-eclampsia showed an association with adverse neonatal outcomes (neonatal morbidity, newborns of low and very low birthweight and preterm deliveries) and can be used as a predictor of them in women with gestational diabetes.

Perinatal outcomes of frequent attendance in midwifery care in the Netherlands: a retrospective cohort study

BACKGROUND

Over the last decade, a trend towards high utilisation of primary maternity care was observed in high-income countries. There is limited research with contradictory results regarding frequent attendance (FA) and perinatal outcomes in midwifery care. Therefore, this study examined possible associations between FA in midwifery care and obstetric interventions and perinatal outcomes.

METHODS

A retrospective cohort study was performed in a medium-sized midwifery-led care practice in an urban region in the Netherlands. Frequent attenders (FAs) were categorised using the Kotelchuck-Index Revised. Regression analyses were executed to examine the relationship between FAs and perinatal outcomes, stratified by antenatal referral to an obstetrician. Main outcomes of interest were Apgar score ≤ 7 and perinatal death, birth weight, mode of delivery, haemorrhage, place of birth, transfer during labour, and a requirement for pain relief.

RESULTS

The study included 1015 women, 239 (24%) FAs and 776 (76%) non-FAs, 538 (53%) were not referred and 447 (47%) were referred to an obstetrician. In the non-referred group, FA was significantly associated with a requirement for pain relief (OR 1.98, 95% CI 1.24-3.17) and duration of dilatation (OR 1.20, 95% CI 1.04-1.38). In the referred group, FA was significantly associated with induction of labour (OR 1.86, 95% CI 1.17-2.95), ruptured perineum (OR 0.50, 95% CI 0.27-0.95) and episiotomy (OR 0.48, 95% CI 0.24-0.95). In the non-referred and the referred group, FA was not associated with the other obstetric and neonatal outcomes. Due to small numbers, we could not measure possible associations of FA with an Apgar score ≤ 7 and perinatal death.

CONCLUSION

In our study, perinatal outcomes differed by FA and antenatal referral to an obstetrician. In the non-referred group, FA was significantly associated with medical pain relief and duration of dilatation. In the referred group, FA was significantly associated with induction of labour, ruptured perineum, and episiotomy. Further research with a larger study population is needed to look for a possible association between FA and primary adverse birth outcomes such as perinatal mortality.

Adherence to self-glucose monitoring recommendations and perinatal outcomes in pregnancies complicated by diabetes mellitus

BACKGROUND

Self-glucose monitoring is critical for the management of diabetes mellitus in pregnancy; yet, validated reports of adherence to testing recommendations and associated perinatal outcomes are limited.

OBJECTIVE

Using cloud-based, self-glucose monitoring technology, we sought to answer the following questions: (1) Are there differences in the rates of testing adherence based on type of diabetes mellitus in pregnancy? (2) Is adherence to glucose monitoring recommendations associated with perinatal outcomes in pregnancies that are complicated by diabetes mellitus? We hypothesized that adherence to glucose testing recommendations varies by type of diabetes mellitus and that increased adherence to testing recommendations would be associated with improved perinatal outcomes.

STUDY DESIGN

This single-center, prospective cohort study included women with type 2 diabetes mellitus and gestational diabetes mellitus who were enrolled in a perinatal diabetes program at <29 weeks gestation between December 2015 and June 2018. All women received a cellular-enabled glucometer that uploaded glucose values to a cloud-based, Health Insurance Portability and Accountability Act-compliant platform in real time that ensured transmission of accurate glucose values. The primary outcome was adherence to self-glucose monitoring recommendations. Four glucose checks were advised daily, and percentage of adherence was calculated. Secondary outcomes were preeclampsia, cesarean delivery, large-for-gestational-age neonates, and neonatal hypoglycemia. The study was powered to detect a 10% difference in the primary outcome of adherence to advised self-glucose monitoring by diabetes mellitus type. Adjusted risk ratios and 95% confidence intervals were generated with the use of logistic regression.

RESULTS

This study included 103 eligible women. Baseline characteristics differed between groups, with women with type 2 diabetes mellitus having higher initial HgbA1c and body mass index when compared with women with gestational diabetes mellitus. No differences were noted in age or parity. Adherence was calculated over 20±6 weeks for women with type 2 diabetes mellitus compared with 9±4 weeks for women with gestational diabetes mellitus. Overall adherence to glucose monitoring was significantly less for women with type 2 diabetes mellitus compared with those with gestational diabetes mellitus. Mean testing adherence rates were 51%, 66%, and 70% for type 2 diabetes mellitus, and gestational diabetes mellitus, class A1 and A2, respectively (P=.016). We found that, for every 10% increase in adherence to testing recommendations, the odds of cesarean delivery, neonatal hypoglycemia, and large-for-gestational-age fetuses decreases by 15-20%. There was no association between adherence and rates of preeclampsia.

CONCLUSION

This study shows that overall adherence to testing recommendations differs by diabetes mellitus type and is associated with neonatal outcomes. Improved outcomes with higher adherence may reflect more timely medication adjustments in response to real-time glucose values. Programs aimed at improving adherence could prove beneficial.

Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States

IMPORTANCE

Hospital-based obstetric services have decreased in rural US counties, but whether this has been associated with changes in birth location and outcomes is unknown.

OBJECTIVE

To examine the relationship between loss of hospital-based obstetric services and location of childbirth and birth outcomes in rural counties.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study, using county-level regression models in an annual interrupted time series approach. Births occurring from 2004 to 2014 in rural US counties were identified using birth certificates linked to American Hospital Association Annual Surveys. Participants included 4 941 387 births in all 1086 rural counties with hospital-based obstetric services in 2004.

EXPOSURES

Loss of hospital-based obstetric services in the county of maternal residence, stratified by adjacency to urban areas.

MAIN OUTCOMES AND MEASURES

Primary outcomes were county rates of (1) out-of-hospital births; (2) births in hospitals without obstetric units; and (3) preterm births (<37 weeks' gestation).

RESULTS

Between 2004 and 2014, 179 rural counties lost hospital-based obstetric services. Of the 4 941 387 births studied, the mean (SD) maternal age was 26.2 (5.8) years. A mean (SD) of 75.9% (23.2%) of women who gave birth were non-Hispanic white, and 49.7% (15.6%) were college graduates. Rural counties not adjacent to urban areas that lost hospital-based obstetric services had significant increases in out-of-hospital births (0.70 percentage points [95% CI, 0.30 to 1.10]); births in a hospital without an obstetric unit (3.06 percentage points [95% CI, 2.66 to 3.46]); and preterm births (0.67 percentage points [95% CI, 0.02 to 1.33]), in the year after loss of services, compared with those with continual obstetric services. Rural counties adjacent to urban areas that lost hospital-based obstetric services also had significant increases in births in a hospital without obstetric services (1.80 percentage points [95% CI, 1.55 to 2.05]) in the year after loss of services, compared with those with continual obstetric services, and this was followed by a decreasing trend (-0.19 percentage points per year [95% CI, -0.25 to -0.14]).

CONCLUSIONS AND RELEVANCE

In rural US counties not adjacent to urban areas, loss of hospital-based obstetric services, compared with counties with continual services, was associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year; the latter also occurred in urban-adjacent counties. These findings may inform planning and policy regarding rural obstetric services.

Trends in Early Prenatal Care Among Women with Pre-Existing Diabetes: Have Income Disparities Changed?

BACKGROUND

Women with pre-existing diabetes are at high maternal risk for comorbidities and death, particularly when early prenatal care is not received. Low income is a known barrier to early prenatal care. It is unknown whether recent policies to expand access to prenatal care have reduced income disparities. We hypothesized that income disparities would be minimized and that the odds of receipt of first trimester prenatal care among women with pre-existing diabetes would become similar across income strata over time.

MATERIAL AND METHODS

Using the Colorado birth certificate registry from 2007 to 2014, receipt of prenatal care was assessed retrospectively in 2,497 women with pre-existing diabetes. Logistic regression was used to examine the association between high (>$50,000), medium ($25,000-50,000), and low (<$25,000) income strata and receipt of first trimester prenatal care by birth year, adjusted for demographics.

RESULTS

High, medium, and low income represented 29.5%, 19.0%, and 51.5% of the cohort, respectively. Women with high income were more likely to receive first trimester care than women with low income from 2007 [adjusted odds ratio, 95% confidence interval: 2.16 (1.18, 3.96)] through 2013 [1.66 (1.01, 2.73)], but significant differences were no longer observed in 2014 [1.59 (0.89, 2.84)]. The likelihood of receiving first trimester prenatal care was not significantly different between medium- and low-income strata from 2007 [1.07 (0.66, 1.74)] through 2014 [0.77 (0.48, 1.23)].

CONCLUSIONS

From 2007 to 2013, women in Colorado with diabetes were more likely to receive early prenatal care if they were in the highest income stratum than in the lowest stratum. In 2014, receipt of first trimester care became equitable across all income strata. Future work should examine national patterns of income with receipt of prenatal care and outcomes among women with pre-existing diabetes.