Improved pregnancy outcomes in women with type 1 and type 2 diabetes but substantial clinic-to-clinic variations: a prospective nationwide study

Helen R Murphy, Ruth Bell, Cher Cartwright, Paula Curnow, Michael Maresh, Margery Morgan, Catherine Sylvester, Bob Young, Nick Lewis-Barned, Helen R Murphy, Ruth Bell, Cher Cartwright, Paula Curnow, Michael Maresh, Margery Morgan, Catherine Sylvester, Bob Young, Nick Lewis-Barned

Abstract

Aims/hypothesis: The aim of this prospective nationwide study was to examine antenatal pregnancy care and pregnancy outcomes in women with type 1 and type 2 diabetes, and to describe changes since 2002/2003.

Methods: This national population-based cohort included 3036 pregnant women with diabetes from 155 maternity clinics in England and Wales who delivered during 2015. The main outcome measures were maternal glycaemic control, preterm delivery (before 37 weeks), infant large for gestational age (LGA), and rates of congenital anomaly, stillbirth and neonatal death.

Results: Of 3036 women, 1563 (51%) had type 1, 1386 (46%) had type 2 and 87 (3%) had other types of diabetes. The percentage of women achieving HbA1c < 6.5% (48 mmol/mol) in early pregnancy varied greatly between clinics (median [interquartile range] 14.3% [7.7-22.2] for type 1, 37.0% [27.3-46.2] for type 2). The number of infants born preterm (21.7% vs 39.7%) and LGA (23.9% vs 46.4%) were lower for women with type 2 compared with type 1 diabetes (both p < 0.001). The prevalence rates for congenital anomaly (46.2/1000 births for type 1, 34.6/1000 births for type 2) and neonatal death (8.1/1000 births for type 1, 11.4/1000 births for type 2) were unchanged since 2002/2003. Stillbirth rates are almost 2.5 times lower than in 2002/2003 (10.7 vs 25.8/1000 births for type 1, p = 0.0012; 10.5 vs 29.2/1000 births for type 2, p = 0.0091).

Conclusions/interpretation: Stillbirth rates among women with type 1 and type 2 diabetes have decreased since 2002/2003. Rates of preterm delivery and LGA infants are lower in women with type 2 compared with type 1 diabetes. In women with type 1 diabetes, suboptimal glucose control and high rates of perinatal morbidity persist with substantial variations between clinics.

Data availability: Further details of the data collection methodology, individual clinic data and the full audit reports for healthcare professionals and service users are available from http://content.digital.nhs.uk/npid .

Keywords: Antenatal; Congenital anomaly; Diabetes; Glucose; Large for gestational age; Neonatal; Pre-pregnancy care; Pregnancy; Preterm; Stillbirth.

Conflict of interest statement

Data availability

Further details of the data collection methodology, individual clinic data and the full audit reports for healthcare professionals and service users are available from http://content.digital.nhs.uk/npid.

Funding

The NPID audit is commissioned by the Healthcare Quality Improvement Partnership as part of the National Clinical Audit programme funded by NHS England and the Welsh government. The 2015 audit was prepared in collaboration with NHS Digital and supported by Diabetes UK and Public Health England.

Duality of interest

HRM sits on a scientific advisory board for Medtronic (insulin pump manufacturer). The authors declare that there is no duality of interest associated with this manuscript.

Contribution statement

HRM, RB, MMa, MMo, NLB, BY made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data. CC, PC and CS analysed the data. HRM drafted the manuscript. All authors critically reviewed the manuscript for important intellectual content and gave final approval for publication. HRM is the guarantor of this work.

Figures

Fig. 1
Fig. 1
Variation between clinics in the percentage of women taking 5 mg folic acid and achieving target HbA1c levels <6.5% (48 mmol/mol) in early pregnancy. Percentage of women with type 1 diabetes: (a) achieving target HbA1c levels in early pregnancy and (b) taking 5 mg folic acid and at individual clinics. Percentage of women with type 2 diabetes: (c) achieving target HbA1c levels in early pregnancy and (d) taking 5 mg folic acid at individual clinics. The clinics are ranked from smallest number to greatest number of women achieving the targets left to right. Solid line, median; dashed lines, IQR
Fig. 2
Fig. 2
Relationships for achievement of glycaemic control targets (HbA1c < 6.5% [48 mmol/mol]) with (a) preterm delivery before 37 weeks’ gestation and (b) rates of LGA in infants (customised birthweight >90th percentile). Black bars, type 1 diabetes; grey bars, type 2 diabetes
Fig. 3
Fig. 3
Stillbirth rate during the NPID audit 2015 compared with CEMACH 2002/2003 for women with type 1 and type 2 diabetes. Data presented are stillbirth rates per 1000 births with 95% CI. Dashed line, stillbirth rate for the general maternity population for 2015 (based on data from the Office for National Statistics [12])

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