Pract Diab Int May 2006 Vol. 23 No. 4 Copyright © 2006 John Wiley & Sons, Ltd. 145

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Historically, pregnancy outcomes for women with diabeteshave been poor. In 1989, the St Vincent Declaration set afive-year target to achieve similar pregnancy outcomes inwomen with diabetes to those without the condition;1 how-ever, population studies have shown that babies of womenwith type 1 diabetes in the UK continue to have a signifi-cantly higher risk of perinatal death and congenital anom-aly than the general maternity population.2–5 The latestnational initiative to improve outcomes was the DiabetesNational Service Framework, which in 2001 set a series ofstandards for pre-conception and pregnancy care forwomen with diabetes, to be achieved by the NHS over a 10-year period.6,7

Current situationWithin this context, a national programme to evaluateservice provision and clinical care, and to providenational pregnancy outcomes, was commenced by theConfidential Enquiry into Maternal and Child Health(CEMACH). This is the largest ever study of pregnancy inwomen with type 1 and type 2 diabetes. In total, 231maternity units in England, Wales and Northern Irelandparticipated, and all women identified during pregnancyor at delivery to have had diabetes for at least one yearbefore their estimated delivery date, were included. Datawere collected on 3808 pregnant women with type 1 andtype 2 diabetes identified in England, Wales andNorthern Ireland between 1 March 2002 and 28 February2003. The results of the study ‘Pregnancy in women withtype 1 and type 2 diabetes, 2002–2003’ were published byCEMACH in October 20058 and key findings onpregnancy outcomes will shortly be published in theBritish Medical Journal.9

Compared with the general maternity population,women with pre-gestational diabetes who deliveredbetween 1 March 2002 and 28 February 2003 had:• A five-fold increase in stillbirth rate (death in utero of ababy delivering after 24 weeks). (Table 1.)• A four-fold increase in perinatal mortality rate (stillbirthsand deaths of live births up to seven days after birth).• A two-fold increase in the prevalence of major congeni-tal anomalies (41.8/1000 total births).

Possible factors behind the poor outcomesThe study has identified three problem areas:• Poor preparation for pregnancy.• Changing demography, with increasing numbers ofpregnant women with type 2 diabetes who are more likelyto come from ethnic minority groups and areas of depriva-tion than women with type 1 diabetes. • Ineffective preconception specialist services.

Good preconception glycaemic control is associated withgood pregnancy outcomes.10 It is also a national recom-mendation that women with diabetes should commencehigh dose folic acid before pregnancy to decrease the riskof fetal neural tube defects.6,11 The CEMACH study paintsa picture of poor preparation for pregnancy across theboard, and significantly more so in the women with type 2diabetes. Only a third of all women in the study were doc-umented to have taken folic acid (at any dose) before preg-nancy; only a third had a test of blood glucose control inthe six months before conception; and only a third hadpre-pregnancy counselling. In addition, only a third of thewomen who did have a test of blood glucose control beforepregnancy achieved the standard of a HbA1c value less than7%, suggesting that the majority of women are enteringpregnancy with poor glucose control.

Women with type 2 diabetes The prevalence of type 2 diabetes in women of child-bear-ing age in the UK is increasing, driven by an increase in eth-nic minority groups within the population and in obesity.Type 2 diabetes now accounts for more than a quarter ofpregnant women with pre-gestational diabetes in England,Wales and Northern Ireland, and this increases to 35% and45% in the West Midlands and London respectively. Therisks of perinatal death are just as high for the babies ofwomen with type 2 diabetes (32.3/1000 live and stillbirths),as for babies of women with type 1 diabetes (31.7/1000).

There is over-representation of black, Asian and otherminority ethnic groups in women with type 2 diabetes(49% compared with only 9% of women with type 1 dia-betes), and a strong association between type 2 diabetesand social deprivation, particularly in black, Asian and

Outcomes of pregnancy in women with pre-gestational type 1 and type 2 diabetes

Table 1. Maternal age-adjusted stillbirth, perinatal and neonatal mortality in babies born to women with type 1 andtype 2 diabetes in England, Wales and Northern Ireland, 1 March 2002 to 28 February 2003

Frequency Rate National rate† Rate ratio(95%CI) (n=620 841) (95%CI)

Stillbirth* 63 26.8 (19.8–33.8) 5.7 4.7 (3.7–6.0)Perinatal death* 75 31.8 (24.2–39.4) 8.5 3.8 (3.0–4.7)Neonatal death** 22 9.3 (5.2–13.1) 3.6 2.6 (1.7–3.9)

* Rate per 1000 live births + stillbirths; ** Rate per 1000 live births; † Source for national data: CEMACH 2005.

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other minority ethnic groups (60% are in the mostdeprived fifth of the population compared with 31% ofwhite women).

Lack of specialist pre-conception servicesWomen with diabetes should have multidisciplinary spe-cialist pre-pregnancy counselling and care in order toachieve as good glycaemic control as possible prior to con-ception. They should also be referred to a specialist ante-natal clinic as soon as pregnancy is diagnosed. The presentpicture of poor preparation for pregnancy on a nationalscale shows that current preconception targeting of womenwith diabetes is ineffective. Interestingly in 2002 less than afifth of NHS trusts in England, Wales and Northern Irelandhad a multidisciplinary preconception service.12

What can be done? The report suggests that rethinking the care of the womanwith diabetes is long overdue. Education of both womenand health professionals is of paramount importance.

Health professionals need to discuss pregnancy withwomen and girls who have diabetes, long before they areconsidering pregnancy. Pregnancy and family planningshould be covered in all annual reviews, both for womenwith type 1 diabetes and for those with type 2 diabetes. Allthese women should be made aware of the potential diffi-culties in pregnancy but also that they can minimise theserisks, by continuing contraception until they have goodblood glucose control, commencing high dose folic acidbefore conception, and getting an early referral to special-ist services if they are considering pregnancy. Consultationsfor contraception offer further opportunities for patienteducation. It must, however, be recognised that many preg-nancies are not planned, and strategies should be in placefor rapid access to appropriate specialist care as soon as thewoman is pregnant.

During pregnancy, women should be treated accordingto protocols agreed between primary and secondary careto ensure the best possible standard of care. The difficultiespresented by the increasing numbers of pregnant womenwith type 2 diabetes need to be addressed, particularly asthey appear to be concentrated within socially deprivedand ethnic minority groups, with the attendant issues ofcultural perceptions of diabetes, and access to health ser-vices. As part of the ongoing work of CEMACH and its pro-fessional advisory group, practical steps have been taken:• An information leaflet is being developed for womenwith diabetes. It will be available at www.cemach.org.uk• A set of recommendations has been prepared for pri-mary care. Briefly stated these include:

– Appropriate blood glucose targets.– The importance of effective and reliable contraception.– Regular HbA1c tests. – Review of medication prior to pregnancy.– High dose folic acid prior to pregnancy.– Need for increased frequency of blood glucose testingin women wishing to become pregnant.– Early referral to the local specialist diabetes team, ide-ally before pregnancy.

• The full recommendations will be circulated via PCTsand will be available at www.cemach.org.uk.

ConclusionCurrent pregnancy outcomes for women with diabetes areunsatisfactory. There are important tasks here for primarycare services: education of the women; ensuring effectivecontraception; high dose folic acid for women planningpregnancy; and early referral for pre-conceptual coun-selling by the specialist diabetes team, to include assess-ment of glycaemic control and complications. Primary careproviders also need to liaise with secondary care to ensurethat antenatal care is being appropriately provided.

Improving preconception and pregnancy care forwomen with diabetes is a challenge, but the benefits shouldinclude better joint working and communication betweenprimary and secondary care services, empowerment ofwomen, improved preparation for pregnancy and, mostimportantly, improved pregnancy outcomes.

Mary Pierce, MD, MRCGP, General Practitioner andClinical Epidemiologist, Department of Epidemiologyand Public Health, University College, London, UKJo Modder, MRCOG, Obstetric Lead, ConfidentialEnquiry into Maternal and Child Health, andConsultant Obstetrician, University College LondonHospitals NHS Trust, UK

References1. Diabetes Care and Research in Europe: The Saint Vincent

Declaration. Diabetic Med 1990; 7: 360.2. Casson IF, Clarke CA, Howard CV, et al. Outcomes of preg-

nancy in insulin dependent diabetic women: results of a fiveyear population cohort study. BMJ 1997; 315: 275–278.

3. Hawthorne G, Robson S, Ryall EA, et al. Prospective popula-tion based survey of outcome of pregnancy in diabeticwomen: results of the Northern Diabetic Pregnancy Audit,1994. BMJ 1997; 315: 279–281.

4. Penney GC, Mair G, Pearson DW; Scottish Diabetes inPregnancy Group. Outcomes of pregnancy in women withtype 1 diabetes in Scotland: a national population-basedstudy. BJOG 2003; 110: 315–318.

5. Hadden DR, Alexander A, McCance DR, et al, NorthernIreland Diabetes Group, Ulster Obstetrical Society. Obstetricand diabetic care for pregnancy in diabetic women: 10 yearsoutcome analysis, 1985–1995. Diabetic Med 2001; 18: 546–553.

6. Department of Health. National Service Framework for Diabetes(England) Standards. London: The Stationery Office, 2001.

7. Department of Health. National Service Framework for Diabetes:Delivery Strategy. London: The Stationery Office, 2003.

8. Confidential Enquiry into Maternal and Child Health. Pregnancyin women with type 1 and type 2 diabetes in 2002–2003, England,Wales and Northern Ireland. London: RCOG Press; 2005.

9. Mary CM, Macintosh MC, Fleming KM, et al. Perinatal mor-tality and congenital anomalies in the babies of women withtype 1 and type 2 diabetes in England, Wales and NorthernIreland. BMJ; in press.

10. The Diabetes Control and Complications Trial ResearchGroup. Pregnancy outcomes in the Diabetes ComplicationsTrial. Am J Obstet Gynecol 1996; 174: 1343–1353.

11. Diabetes UK care recommendations. Folic acid supplementation inpregnancy. June 2005 [http://www.diabetes.org.uk/infocen-tre/carerec/folic.htm]

12. Confidential Enquiry into Maternal and Child Health. Maternityservices in 2002 for women with type 1 and type 2 diabetes,England, Wales and Northern Ireland. London: RCOG Press,2004.

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