10








Key findings

 
 

10.1

 

The health of babies

 

Key finding 1

The babies of women with diabetes in the UK continue to have an increased risk of perinatal mortality and congenital malformations compared to the babies of mothers without diabetes.

 

This study is the largest nationwide study undertaken of pregnant women with diabetes in the UK and includes the largest coverage of women with pre-gestational type 2 diabetes. Nearly 15 years on from the St Vincent Declaration, babies born to women with diabetes in the UK continue to have high perinatal mortality rates, nearly four times greater than for those of women in the general population. The risk of congenital malformation in the babies of women with diabetes is nearly three times greater. Evidence for good periconceptional glycaemic control leading to improved perinatal outcome has been available since the 1980s and has been reinforced by randomised control evidence in 1996.1 Despite this, pregnancy outcomes for women with diabetes in England, Wales and Northern Ireland remain poor. Similar rates have also been found in Scotland.2

 
 

10.2

 

Type 2 diabetes – different needs, equivalent risks

 

Key Finding 2

Women with type 2 diabetes are more likely to:

  • live in a deprived area
  • come from a Black or Other ethnic minority.

The babies of women with type 2 diabetes have comparable risks of perinatal mortality and congenital malformation to those of babies of women with type 1 diabetes.

 

There is an increasing number of young women of childbearing age in the UK being diagnosed with type 2 diabetes. Half of the women with type 2 diabetes in this study came from an ethnic minority background and were more likely to live in a deprived area. Women with type 2 diabetes have different needs to women with type 1 diabetes and the majority will be required to change to insulin before or during pregnancy. Compared with women with type 1 diabetes, these women were less likely to have had a glycaemic control test prior to pregnancy, less likely to have received preconception counselling and less likely to have taken folic acid supplementation. Factors relating to the availability and accessibility of health services may be contributing to the observed suboptimal outcomes for people from ethnic minorities or disadvantaged groups. These issues need to be addressed, not only because of adverse pregnancy outcomes but because these women are at an increased risk of other serious health complications not related to pregnancy in their lifetime.

This study is the first with sizeable numbers (over 200 women) describing pregnancy outcomes for women with pre-gestational type 2 diabetes. It finds that perinatal mortality for the babies of women with type 2 diabetes are comparable to those with type 1 diabetes. Type 2 diabetes has traditionally been considered as a less serious condition than type 1 diabetes.3 Health professionals and women of childbearing age need to be aware of these increased risks and be just as vigilant with preconception planning and care as for women with type 1 diabetes.

 
 

10.3

 

Prevalence of type 2 diabetes in pregnancy – regional variation

 

Key Finding 3

The prevalence of type 2 diabetes in pregnancy varies considerably in England, Wales and Northern Ireland.

The areas in which the prevalence of type 2 diabetes in pregnancy is greatest do not necessarily coincide with those in which the prevalence of diabetes is greatest in the general population. Healthcare commissioners need to be aware of this when planning provision of services.

 

The prevalence of diabetes in pregnancy was one in 264 births in England, Wales and Northern Ireland. Type 2 diabetes accounts for 28% of pre-existing diabetes in pregnancy (one in 955 births) and varies from 13% in Wales to 45% in London. The regions in which the prevalence of type 2 diabetes in pregnancy is high do not necessarily coincide with the regions in which diabetes is most prevalent overall. The overall prevalence of diabetes is high where there is an ageing population such as the South West and coastal regions. Additional education, help and support for women with diabetes during childbearing years has resource implications. Healthcare commissioners in the regions of high prevalence of diabetes in pregnancy need to be aware of this.

 
 

10.4

 

Preconception care

 

Key Finding 4

Women with diabetes are poorly prepared for pregnancy:

  • only 39% took folic acid before conception
  • only 35% had documented prepregnancy counselling
  • only 37% were reported to have had a glycaemic control measurement before pregnancy.
 

Perhaps one of the most striking findings of this study is the apparently poor preparation of women with diabetes for pregnancy. This was demonstrated by the poor uptake of folic acid, the relatively small numbers of women who received prepregnancy counselling or had a documented glycaemic control test in the 6 months before pregnancy. Concerns regarding the effectiveness of the services delivering preconception care for these women were raised previously in the first CEMACH report on diabetes in pregnancy.4

The poor uptake of folic acid supplements parallels the position for pregnancy by women in general in the UK5 rather than being specific to women with diabetes. Not taking folic acid is linked to social deprivation. Some countries have introduced fortified food, notably flour with folic acid, to reduce neural tube defects rather than relying on health-seeking behaviour and supplementation periconceptionally.6 This approach may need to be debated by policy makers in the UK.

Babies of mothers with diabetes were at greater risk (3.1-fold) of neural tube defects than the general population (see Chapter 7). Although the minimum effective dose of folic acid needed to reduce this risk is not established, national guidelines recommend that women with diabetes should take a higher dose (5 mg) before conception up to the 12th week of pregnancy.7,8

The majority of women in England, Wales and Northern Ireland in 2002/03 commenced pregnancy with suboptimal control of blood glucose. Education regarding the importance of preparation for pregnancy is a priority. Structured education packages are being introduced in the UK. Dose Adjustment for Normal Eating (DAFNE)9 is aimed at people with type 1 diabetes and a programme for 11–14 year olds is being piloted. Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND)10 is aimed at people with type 2 diabetes. It does not yet include pregnancy but, with the increasing numbers of young women of childbearing age being diagnosed with type 2 diabetes, this gap needs to be bridged.

The annual review conducted by the adult diabetes service is also an opportunity for ensuring women with diabetes of childbearing age are educated regarding the benefits of preparing for pregnancy. Primary and secondary care services should aim to develop joint protocols based on national guidelines to ensure that all women with diabetes receive consistent preconception care of a high standard.

 
 

10.5

 

Glycaemic control

 

Key Finding 5

Only 38% of women with an HbA1c value measured by 13 weeks of gestation had a value of less than 7%.

All mothers, regardless of type of diabetes or ethnic group, should be entering pregnancy with substantially better glycaemic control, while taking hypoglycaemic risk into account.

 

All mothers, regardless of type of diabetes, should be entering pregnancy with substantially better glycaemic control than that observed in this study. Seventy-two percent of women in this study had a documented HbA1c test by 13 weeks of gestation. Of these women, 38% managed to achieve glycaemic levels within the recommended range of less than 7%. This does not compare well with other European countries, such as The Netherlands, where 75% of women with type 1 diabetes achieved HbA1c of 7% or less by the first trimester.11 It suggests that considerable improvements in periconceptional glycaemic control can be achieved in the UK population.

It is accepted that good glycaemic control reduces the risk of adverse perinatal outcomes. The evidence is better established for reducing congenital anomalies than for unexplained stillbirths. This study shows a higher average HbA1c throughout pregnancy in mothers who went on to have normally formed stillbirth or neonatal death than in mothers who had a good pregnancy outcome. This supports the importance of striving for good control during pregnancy.

Can the St Vincent Declaration be achieved? Good control does not necessarily equate with good outcome. Of mothers who had a HbA1c of less than 7% by the first trimester, one-quarter of their babies had a congenital anomaly. The study from The Netherlands in which 75% of women with type 1 diabetes had a HbA1c of 7% or less reported a high perinatal mortality rate, comparable to that observed in this study. The study in The Netherlands was, however, based on small numbers and the women reported a high proportion of hypoglycaemic episodes. HbA1c value acts as a surrogate for ‘control’ but it does not measure fluctuations of glucose levels. Further research in this area is needed to identify other markers that may give better insight into how to reduce adverse perinatal outcomes.

 
 

10.6

 

High preterm delivery rate and caesarean section rate

 

Key Finding 6

There is a 36% preterm delivery rate and 67% caesarean section rate for women with diabetes.

 

The experience of pregnancy and childbirth for women with diabetes is very different to that of the general maternity population. Women with diabetes are at greater risk of experiencing preterm (prior to 37 weeks of gestation) and caesarean delivery. Two-thirds of women underwent caesarean section and more than half of those were emergency procedures. Behind these high intervention rates is the conflict experienced by health professionals and women between continuing the pregnancy in order to achieve a normal delivery versus expediting delivery to avoid an unexpected stillbirth. In recent years, there has been a tendency in uncomplicated pregnancies to carry on to as near 40 weeks as possible and this is reflected in the consensus standard for the study on the timing of delivery. The decision for optimum timing for delivery rests with the woman and the health professionals providing her maternity care and should be based on the most accurate evidence of risks to her and the baby.

 
 

10.7

 

Large babies and difficult deliveries

 

Key Finding 7

Over half of singleton babies' birth weights were over the 90th centile for birth weight.

Incidence of shoulder dystocia and Erb's palsy was increased.

 

Women with diabetes gave birth to larger babies than the general maternity population of England, Wales and Northern Ireland, with half of the babies being above the 90th centile for birth weight.

These large babies are subject to increasing risk of birth trauma. The risk of Erb's palsy was 4.5 per 1000 births, representing a ten-fold increase over that for babies delivered in the general maternity population. The risk of shoulder dystocia was 79 per 1000 vaginal births, a two-fold increase over that for babies delivered in the general maternity population.

 
 

10.8

 

Neonatal care

 

Key Finding 8

One-third of term babies were admitted to a neonatal unit for special care.

Healthy babies of women with diabetes should not be routinely admitted to the neonatal unit. The results suggest that there should be alternative strategies to routine neonatal unit admission of babies of mothers with diabetes.

There was frequent failure to use reliable glucose tests in babies.

Intention to breastfeed was lower among mothers with diabetes than the breastfeeding rate in the general population.

 

One-third of term babies were admitted to a neonatal unit for special care and separated at birth from their mothers for an average of 3 days. This compares with less than 10% for term births in the UK.12 Two-thirds of these separations were considered potentially avoidable. Care could have been delivered in an alternative environment such as a postnatal ward with adequate clinical support or a transitional-care nursery, which would avoid separation of the mother and the baby. Local services need to review the type of care provided.

Babies should have a test of blood glucose concentration by 4–6 hours of age before a feed. Although most (83%) babies had a glucose measurement within 6 hours, the method used was not always reliable. Despite glucose reagent strips being contraindicated for use in neonates, they were used in 35% of cases.

Breast milk is the food of choice for babies of mothers with diabetes. Fifty-three percent of women with diabetes intended to breastfeed. This compares with an initial breastfeeding rate of 69% in the general population. Local services should support practices and education that encourage women to consider breastfeeding, as for all groups of babies, especially those vulnerable to neonatal complications or risk of diabetes in later life.

 
 

10.9

 

What do these findings mean for the future?

The high perinatal mortality rate in the UK parallels findings from other European countries, which range from 27.8 to 48 per 1000 births.2,11,13–15 There has been little success, universally, in achieving the St Vincent Declaration and translating evidence into practice. More work is required to elucidate how women with diabetes, regardless of type, can be best enabled to improve the outcomes of their pregnancy. This applies in particular to preconception preparation. The best outcomes will be achieved if there is an effective partnership between the women and the health professionals responsible for her. The challenge for the health professional is how best to empower women with diabetes to fully participate in this partnership.

There are increasing numbers of young women in the UK being diagnosed with type 2 diabetes. In addition to this, the prevalence of type 1 diabetes in children under five is also increasing, so the issues identified in 2002/03 are likely to become more problematic in the next two decades unless concerted action is taken now. The delivery strategy for the National Service Framework for Diabetes was released in 2003 and the findings from this study will act as a reference for future progress in addressing this public health concern.7

Enhanced preconception services and future research on understanding the biological and sociological reasons as to why these women have adverse pregnancy outcomes are a priority. This study has demonstrated a clear need to develop and implement effective strategies for the education, wellbeing and health care of women with diabetes of childbearing age.

 
     

References

  1. Diabetes Control and Complications Trial Research Group. Pregnancy outcomes in the Diabetes Complications Trial. Am J Obstet Gynecol 1996;174:1343–53. The Diabetes Control and Complications Trial Research Group. Pregnancy outcomes in the Diabetes Complications Trial. Am J Obstet Gynaecol 1996;174:1343–1353
  2. Penney GC, Mair G, Pearson DW, Scottish Diabetes in Pregnancy Group. Outcomes of pregnancy in women with type 1 diabetes in Scotland: a national population-based study. BJOG 2003;110:315–18.
  3. Dunne F. Type 2 diabetes and pregnancy. Semin Fetal Neonatal Med 2005;10:333–40.
  4. Confidential Enquiry into Maternal and Child Health. Maternity Services in 2002 for Women with Type 1 and Type 2 Diabetes, England, Wales and Northern Ireland. London; RCOG Press; 2004.
  5. Ray JG, Singh G, Burrows RF. Evidence for suboptimal use of perinconceptional folic acid supplements globally. BJOG 2004;111:399–408.
  6. Relton CL, Hammal DM, Rankin J, Parker L. Folic acid supplementation and social deprivation. Public Health Nutr 2005;8:338–40.
  7. Department of Health. National Service Framework for Diabetes (England) Standards. London: The Stationery Office; 2001 [www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4002951&chk=09Kkz1].
  8. Scottish Intercollegiate Guidelines Network. Management of Diabetes. SIGN Publication No. 55. Edinburgh: SIGN; 2001 [www.sign.ac.uk/guidelines/fulltext/55/index.html].
  9. DAFNE (Dose Adjustment for Normal Eating). Delivering the NSF: Diabetes Education in your Service. North Shields: DAFNE; 2004 [www.cgsupport.nhs.uk/downloads/NDST/DAFNE_Delivering_the_NSF.pdf]
  10. Department of Health. DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) Structured Education for people with Type 2 Diabetes: Providing the DESMOND newly diagnosed programme in PCTs in England. London: DH [www.cgsupport.nhs.uk/downloads/NDST/Providing_DESMOND_info.pdf].
  11. Evers IM, de Valk HW, Visser GHA. Risk of complications of pregnancy in women with type 1 diabetes: nationwide prospective study in the Netherlands. BMJ 2004;328:915–18.
  12. Macfarlane A, Mugford M. Birth Counts: Statistics of Pregnancy and Childbirth. 2nd ed. Oxford: National Perinatal Epidemiology Unit; 2000.
  13. Jensen DM, Damm P, Moelsted-Pedersen L, Ovesen P, Westergaard JG, Moeller M, Beck-Nielsen H. Outcomes in type 1 diabetic pregnancies: a nationwide, population-based study. Diabetes Care 2004;27:2819–23.
  14. Dunne F, Brydon P, Smith K, Gee H. Pregnancy in women with Type 2 diabetes: 12 years outcome data 1990–2002. Diabet Med 2003;20:734–8.
  15. S Suhonen L, Hiilesmaa V, Teramo K. Glycaemic control during early pregnancy and fetal malformations in women with type I diabetes mellitus. Diabetologia 2000;43:79–82.