Women with established diabetes mellitus * (EDM) or gestational diabetes mellitus ** (GDM) are at increased risk for maternal complications during pregnancy; infants born to women with diabetes also are at increased risk for adverse outcomes, including infant death, congenital malformation, birth injury, and hyaline membrane disease/respiratory distress syndrome (1). These health problems may be prevented in women with diabetes through improved glycemic control and through preconception and prenatal care (2,3). Population-based surveillance of EDM and GDM can assist in measuring the burden of diabetes during pregnancy and in identifying target groups for interventions (4). To determine the prevalence of pregnancies complicated by diabetes in North Dakota, the North Dakota State Department of Health and Consolidated Laboratories (NDSDH) studied birth certificate data for 1980-1992. This report summarizes the results of that assessment.

NDSDH compiled data from all North Dakota birth certificates for live infants. On birth certificates issued during 1980-1988, diabetes (specified as either EDM or GDM) was recorded as a line item under concurrent conditions affecting pregnancy on the U.S. Standard Certificate of Live Birth. In 1989, the U.S. Standard Certificate of Live Birth was revised to collect information about several medical risk factors, including diabetes. A check box on this revised certificate indicated whether the mother had concurrent diabetes but did not specify EDM or GDM. During 1989-1991, NDSDH contacted health-care providers to determine this information and enter it into the vital record. In 1992, North Dakota revised this standard certificate to include separate check boxes for EDM and GDM.

From 1980 through 1992, a total of 140,720 infants were born to women who were North Dakota residents. Of these pregnancies, 1433 (1.0%) were complicated by diabetes -- 324 (0.2%) by EDM and 1109 (0.8%) by GDM. The age-standardized prevalence of EDM was unchanged from 1980 (0.2%) to 1988 (0.2%) but increased in 1991 (0.3%) and 1992 (0.4%) (Figure_1). During the study period, the age-standardized prevalence of GDM increased substantially and in 1988 (0.9%) was approximately four times greater than that in 1980 (0.2%). Compared with 1980-1988, the prevalence of GDM further increased during 1989-1991 (1989 prevalence: 1.5%) and increased again in 1992 (1.7% prevalence).

Among women aged less than 30 years, the prevalence of pregnancy complicated by EDM increased from 0.2% in 1980 to 0.3% in 1992; among women aged greater than or equal to 30 years, the prevalence increased from 0.4% in 1980 to 0.5% in 1992. The prevalence of GDM among women aged less than 30 years increased from 0.1% in 1980 to 1.5% in 1992; among women aged greater than or equal to 30 years, the prevalence increased from 0.2% in 1980 to 2.8% in 1992. Reported by: DR Schaubert, MS, DA Mayer, LA Shireley, MPH, State Epidemiologist, Div of Disease Control, North Dakota State Dept of Health and Consolidated Laboratories. Epidemiology and Statistics Br, Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report indicate increases in the proportion of pregnancies complicated by diabetes in North Dakota during 1980-1992 and, consistent with previous studies, a higher prevalence of diabetes-complicated pregnancies among older mothers (5). To increase preconception and nutritional counseling and appropriate prenatal care, the North Dakota Diabetes and Pregnancy Program is using the findings from this report to promote awareness among health-care providers about the increasing burden of diabetes-complicated pregnancies and to obtain health insurance reimbursement for pregnancy services for women with diabetes (4,6).

The secular increase in prevalence of diabetes-complicated pregnancies documented in North Dakota may have been associated with at least three factors. First, revisions of the U.S. Standard Certificate of Live Birth may have resulted in increased reporting of diabetes-complicated pregnancies, particularly the nearly nine-fold increase in GDM. Second, the increase may reflect increased awareness of GDM by health-care providers, especially during the 1980s when risk factors for this condition were described and screening recommendations published (7,8). Third, the increases in EDM and GDM since 1980 may reflect an increasing secular trend in some associated risk factors. For example, in the United States, the prevalence of obesity among women of reproductive age increased substantially during 1976-1991 (9).

Although hospital- or institution-based prevalence studies can provide useful information about EDM and GDM, they cannot provide population-based estimates that enable public health programs to target intervention efforts. As part of a comprehensive program to reduce the burden of diabetes at both state and national levels, CDC has recommended the expanded use of data from the U.S. Standard Certificate of Live Birth to assess the prevalence of diabetes-complicated pregnancies. In addition, CDC has recommended the incorporation into birth certificates of separate check boxes for EDM and GDM (1).

References

1. CDC. Pregnancy complications and perinatal outcomes among women with diabetes -- North Carolina, 1989-1990. MMWR 1993;42:847-51.

2. Rowe BR, Rowbotham CJ, Barnett AH. Pre-conception counselling, birthweight, and congenital abnormalities in established and gestational diabetic pregnancies. Diabetes Res 1987;6:33-5.

3. Willhoite MB, Bennert HW Jr, Palomaki GE, et al. The impact of preconception counselling on pregnancy outcomes. Diabetes Care 1993;16:450-5.

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

5. Barden TP, Knowles HC. Diagnosis of diabetes in pregnancy. Clin Obstet Gynecol 1981;3:447-52.

6. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes 1994;17:616-23.

7. Miller E, Hare JW, Cloherty JP, et al. Elevated maternal hemoglobin A subscript 1c subscript in early pregnancy and major congenital anomalies in infants of diabetic mothers. N Engl J Med 1981;304:1331-4.

8. Summary and recommendations of the Second International Workshop -- Conference on Gestational Diabetes Mellitus. Diabetes 1985;34(suppl 2):123-6.

9. Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing prevalence of overweight among US adults: the national health and nutritional examination surveys, 1960 to 1991. JAMA 1994;272:205-11.

* Insulin-dependent or noninsulin-dependent diabetes mellitus diagnosed before pregnancy. 

** Diabetes that develops or is first diagnosed during pregnancy.

Figure_1


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