Maternal Characteristics Associated with Having Gestational Diabetes Mellitus Among the 2002 Birth C

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Maternal Characteristics Associated with Having
Gestational Diabetes Mellitus Among the 2002
Birth Cohort of California WomenAnura
Ratnasiri, MSRenato Littaua DVM, MPVMMichael
Curtis, PhDShabbir Ahmad, DVM, MS, PhD
Epidemiology and Evaluation SectionMaternal,
Child and Adolescent Health/Office of Family
Planning BranchCalifornia Department of Health
Services12th Annual Maternal and Child Health
Epidemiology ConferenceAtlanta, Georgia

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Background

• Gestational Diabetes Mellitus (GDM) complicates
  between 4 and 14 of pregnancies in the nation1.
• Recurrence risk is about 30 in subsequent
  pregnancies2.
• Women with a history of GDM have a 20-50 chance
  of developing type II diabetes 5-10 years after
  the index pregnancy, with a lifetime risk near
  803.
• 1 Engelgau MM, et al. The epidemiology of
  diabetes and pregnancy in the U.S., 1988.
  Diabetes Care 1810291033, 1995.
• 2 Nicholson, W Epidemiology and Risk Factors for
  Gestational Diabetes Mellitus (2006). CDC Webcast
  September 06, 2006.
• 3 Owens et al., Preconception Care and Women with
  or at Risk for Diabetes Implication for
  Community Intervention (2006). Maternal Child
  Health J (2006) 10S137-S141

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Background

• GDM is treatable especially if detected early in
  pregnancy4
• Maternal complications associated with GDM
  include increased risk for pre-term labor,
  pregnancy-induced hypertension and caesarian
  section deliveries.
• Fetal and neonatal complications associated with
  GDM include increased risk for miscarriages,
  stillbirths, and macrosomia.
• Offspring of women with GDM are at increased risk
  of obesity, glucose intolerance and diabetes as
  children or adults.
• 4Langer O, , et. al. Intensified versus
  conventional management of gestational diabetes.
  Am J Obstet Gynecol 17010361047, 1994

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Research Questions

• What is the trend in the prevalence of GDM in
  California?
• What are the rates of GDM across racial/ethnic
  and age groups among California women?
• What maternal socio-demographic characteristics
  are associated with developing GDM?

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Methods

• Data Sources
• California hospital discharge data (HDD) files
  from 1997 to 2004.
• 2002 HDD files were linked with the 2002 Birth
  Cohort File.
• Sample
• Inclusion Criteria
• California resident women with a delivery outcome
  as recorded in the HDD (ICD9-CM v27.x). This
  includes both live births and fetal deaths.
• Women with a diagnosis of GDM (ICD9-CM 648.8) as
  recorded in the HDD labor and delivery records.
• Exclusion Criteria
• Women with a diagnosis of Type I or Type II
  diabetes (ICD9-CM codes of 250.x, 648.0x, v58.67)
  as recorded in the HDD labor and delivery record.
• Analysis
• Prevalence (number of women with GDM / number of
  women with a birth) x 100
• Backward stepwise logistic regression was used to
  obtain adjusted odds ratios of the maternal
  characteristics associated with having GDM.

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Percent of Resident California Women with a
Diagnosis of GDM 1997-2004
Data Source Hospital Discharge Data,
1997-2004 Numerator number of women with a
diagnosis of GDM (ICD9-CM code 648.8) Denominator
number of hospitalized women with a birth
outcome, excluding women with pre-existing
diabetes (ICD9-CM
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2002 Cohort of Birthing Women in California

• 2002 linked HDD and Birth Cohort Population
• 509,196 resident hospitalized women with a birth
• 3,730 women with pre-existing diabetes (Type I or
  II) were excluded.
• 290 women with a diagnosis of pre-existing
  diabetes (Type I or II) and GDM were excluded.
• 2002 linked HDD and Birth Cohort Study Sample
• 505,176 resident hospitalized women with a birth
  and no pre-existing diabetes
• 503,063 live births, 2,113 fetal deaths
• 25,257 (5.0) women were identified with a
  diagnosis of GDM

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Percent of Women with a Diagnosis of GDMby
Race/Ethnicity 2002
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Percent of Women with a Diagnosis of GDMby
Maternal Age 2002
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Percent of Women with a Diagnosis of GDMby
Education 2002
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Percent of Women with a Diagnosis of GDM by Other
Maternal Characteristics 2002
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Variables Included in the Multivariate Logistic
Regression Model

• Using bivariate analyses, all of the following
  variables were found to be statistically
  associated with a women having GDM
• Age
• Race/Ethnicity
• Education
• Delivery Payer (private v. public)
• Maternal Birthplace (U.S. v. foreign born)
• Plurality (singleton v. multiple birth)
• Parity (two or more live births)

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Bivariate Unadjusted Odds Ratios and Multivariate
Logistic Regression Adjusted Odds Ratios

• Independent Variable Unadjusted OR Adjusted OR
• Age
• lt19 (ref.) 1.0 1.0
• 20-24 2.2 (2.0-2.4) 2.4 (2.2-2.6)
• 25-29 4.5 (4.1-5.0) 5.2 (4.7-5.7)
• 30-34 6.8 (6.2-7.4) 8.5 (7.7-9.4)
• 35-39 10.1 (9.2-11.0) 13.4 (12.1-14.7)
• 40 13.5 (12.2-14.9) 18.3 (16.5-20.3)
• Race/Ethnicity
• White (ref) 1.0 1.0
• American Indian 1.8 (1.5-2.2) 2.4 (2.0-2.9)
• Asian/Pacific Islander 2.3 (2.3-2.4) 2.1
  (2.0-2.2)
• Hispanic 1.5 (1.5-1.6) 1.7 (1.7-1.8)
• African American 1.1 (1.1-1.2) 1.4 (1.3-1.5)

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Bivariate Unadjusted Odds Ratios and Multivariate
Logistic Regression Adjusted Odds Ratios

• Independent Variables Unadjusted OR Adjusted OR
• Education
• ltHigh School 0.89 (0.87-0.93) 1.44
  (1.38-1.50)
• High School 1.03 (1.00-1.08) 1.52 (1.45-1.59)
• Some College 1.04 (1.00-1.08) 1.40
  (1.34-1.46)
• College or more 1.00
• Private Delivery Payer 1.16 (1.13-1.19) NS
• Foreign born 1.76 (1.72-1.81) 1.14 (1.10-1.18)
• Plurality (multiple birth) 1.48
  (1.35-1.61) 1.34 (1.22-1.47)
• Parity (two or more live births) 1.44
  (1.40-1.48) 1.12 (1.09-1.57)

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Results of MLR Adjusted Odds Ratios with 95 CI
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Results

• Rate of GDM is steadily increasing in California
• GDM is associated with age, race/ethnicity,
  education, birthplace, parity and plurality of
  birth
• Delivery payer is not associated with having GDM
• GDM risk strongly increases with age
• Minority populations are at increased risk of
  developing GDM compared to White even after
  controlling for other characteristics.

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Public Health Implications

• Early detection and treatment of GDM is vital to
  efforts to improve maternal health and birth
  outcomes
• Importance of prenatal care
• The clinical component of the California Diabetes
  and Pregnancy Program focus its outreach to women
  with increased risk for GDM for both health
  education and care
• Improve GDM Surveillance
• GDM based on secondary data is underreported
• Gestational Diabetes Act of 2006 (Senate Bill
  3914)
• Introduced in September 2006, aims to expand
  research, education and treatment of GDM and
  obesity during pregnancy