|Year : 2020 | Volume
| Issue : 3 | Page : 99-104
Demographics, prevalence and outcomes of diabetes in pregnancy in NW Ontario
Ruben Hummelen1, Ribal Kattini2, Jenna Poirier2, Sharen Madden1, Holly Ockenden3, Joseph Dooley4, Len Kelly5
1 Division of Clinical Sciences, Northern Ontario School of Medicine, Sioux Lookout, Ontario, Canada
2 Research Intern Anishnaabe Bimaadiziwin Research Program, Sioux Lookout NOSM Local Education Group, Ontario, Canada
3 Research Coordinator, BORN Ontario, Ottawa, Ontario, Canada
4 Division of Clinical Sciences, Northern Ontario School of Medicine; Sioux Lookout Meno Ya Win Health Centre, Sioux Lookout, Ontario, Canada
5 Sioux Lookout Meno Ya Win Health Centre, Sioux Lookout, Ontario, Canada
|Date of Submission||29-Aug-2019|
|Date of Decision||11-Sep-2019|
|Date of Acceptance||31-Oct-2019|
|Date of Web Publication||24-Jun-2020|
MD, M Clin Sci, FCFP, FRRM Len Kelly
Sioux Lookout Meno Ya Win Health Centre, Sioux Lookout, Ontario
Source of Support: None, Conflict of Interest: None
Introduction: Diabetes in pregnancy confers increased risk. This study examines the prevalence and birth outcomes of diabetes in pregnancy at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) and other small Ontario hospitals.
Methods: This was a retrospective study of maternal profile: age, parity, comorbidities, mode of delivery, neonatal birth weight, APGARS and complications. Data were compared to other Ontario hospitals offering an equivalent level of obstetrical services.
Results: Type 2 diabetes mellitus in pregnancy is far more prevalent in mothers who deliver at SLMHC (relative risk [RR]: 20.9, 95% confidence interval [CI]: 16.0–27.2); the rates of gestational diabetes (GDM) are double (RR: 2.0, 95% CI: 1.7–2.3). SLMHC mothers with diabetes were on average 5 years younger and of greater parity with increased substance use. Neonates largely had equivalent outcomes except for increased macrosomia, neonatal hypoglycaemia and hyperbilirubinaemia in GDM pregnancies.
Conclusion: Patients with diabetes in pregnancy at SLMHC differ substantially from mothers delivering at Ontario hospitals with a comparable level of service. Programming and resources must meet the service needs of these patients.
Introduction: Le diabète durant la grossesse élève le risque. Cette étude s'est penchée sur la prévalence des issues liées à l'accouchement causées par le diabète durant la grossesse au centre de santé SLMHC (Sioux Lookout Meno Ya Win Health Centre) et dans d'autres petits hôpitaux ontariens.
Méthodologie: Il s'agissait d'une étude rétrospective du profil de la mère: âge, parité, comorbidités, méthode d'accouchement, poids du bébé à la naissance, score APGAR et complications. Les données ont été comparées à celles d'autres hôpitaux ontariens qui offrent un niveau équivalent de services obstétriques.
Résultats: Le diabète de type 2 durant la grossesse est beaucoup plus répandu chez les femmes qui accouchent au SLMHC (risque relatif [RR]: 20,9; intervalle de confiance [CI] à 95 %: 16,0–27,2); le taux de diabète gestationnel est deux fois plus élevé (RR: 2,0; IC à 95 %: 1,7–2,3). Les femmes diabétiques ayant accouché au SLMHC étaient en moyenne 5 ans plus jeunes, avaient eu plus de naissances et elles consommaient des drogues en plus grand nombre. L'état des nouveau-nés était grandement équivalent, à l'exception d'un plus grand nombre de macrosomies, d'hypoglycémies néonatales et d'hyperbilirubinémies dans les cas de diabète gestationnel.
Conclusion: Les patientes diabétiques durant la grossesse vues au SLMHC diffèrent substantiellement des femmes qui accouchent dans les hôpitaux ontariens offrant un niveau comparable de services. La programmation et les ressources doivent répondre aux besoins en matière de services de ces patientes.
Mots-clés: Diabète, Premières Nations, grossesse
Keywords: Diabetes, First Nations, pregnancy
|How to cite this article:|
Hummelen R, Kattini R, Poirier J, Madden S, Ockenden H, Dooley J, Kelly L. Demographics, prevalence and outcomes of diabetes in pregnancy in NW Ontario. Can J Rural Med 2020;25:99-104
|How to cite this URL:|
Hummelen R, Kattini R, Poirier J, Madden S, Ockenden H, Dooley J, Kelly L. Demographics, prevalence and outcomes of diabetes in pregnancy in NW Ontario. Can J Rural Med [serial online] 2020 [cited 2021 Aug 6];25:99-104. Available from: https://www.cjrm.ca/text.asp?2020/25/3/99/287619
| Introduction|| |
Diabetes in pregnancy increases maternal and neonatal adverse events., The high prevalence of type 2 diabetes mellitus (T2DM) in manyFirst Nations populations includes women in their reproductive years, conferring increased risk in pregnancy. Rural obstetrical programmes servingFirst Nations in Canada operate in this environment of diabetes-related challenges and their programme needs may be unique.
The adverse event risk begins at conception for women with pre-existing T2DM. Hyperglycaemia at conception and during organogenesis increases the risk for stillbirth and congenital anomalies., Gestational diabetes (GDM) developing later in pregnancy affects foetal growth, with resultant increases in macrosomia, shoulder dystocia and caesarean section.,, GDM diagnosed in the first trimester is assumed to be newly recognised 'overt', or pre-existing diabetes and these pregnancies share the risk profile associated with T2DM.,
Rural hospitals servingFirst Nations populations may encounter higher rates of diabetes in pregnancy compared to other obstetrical programmes. This study examined the demographics, prevalence and outcomes of diabetes in pregnancy for women who delivered at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) in comparison to other Ontario hospitals with a similar level of obstetrical services.
| Methods|| |
SLMHC has a catchment population of 29,000 living in the town of Sioux Lookout and 26 remote fly-in communities. Obstetrical services are provided by family physicians at the integrated pregnancy programme (IPP) with an average of 400 annual deliveries. Tertiary level care is available in Thunder Bay, Ontario, or Winnipeg, Manitoba, each over 300 km away, as accessed by air transportation.
This retrospective study compares the maternal and neonatal populations at SLMHC and other Ontario obstetrical programmes, providing a similar level of service, from April 1, 2012, to March 31, 2017. Live birth data from the Better Outcomes Registry and Network (BORN) Ontario was accessed for SLMHC and other maternity level 1B Ontario hospitals. This designation by the Provincial Council for Maternal and Child Health identifies low-risk obstetrical programmes with a minimum standard of C-section availability and family physicians or midwife provision of intrapartum and neonatal care. These 30 comparable provincial hospital programmes averaged 416 deliveries annually; three were rural (Ontario rurality index ≥75).
Maternal data for patients with GDM or T2DM included age, parity, pre-pregnancy weight, comorbidities and mode of delivery. Neonatal variables included gestational age, birth weight, APGAR scores and complications. The study was reviewed and approved by the BORN Indigenous consultant and the local Sioux LookoutFirst Nations Health Authority and received ethics approval from the SLMHC Research Review and Ethics Committee.
| Results|| |
There were 2,084 live births at SLMHC during the 5-year study period. Diabetic status was available for 2,073 patients. Most patients (1,833; 88%) were non-diabetic; GDM was present in 164 (7.9%) and T2DM in 76 (3.7%) patients. Other maternity level 1B hospitals had 69,149 deliveries, 96% of whom were non-diabetic, 4% GDM and 0.24% T2DM.
Women with both classes of diabetes who delivered at SLMHC were on average 5 years younger and of greater parity than at other maternity level 1B hospitals. Increased neonatal macrosomia, hypoglycaemia and hyperbilirubinaemia were identified solely in SLMHC patients with GDM.
Substance exposure (smoking, alcohol and opioids) was substantially more common in the NW Ontario obstetrical population. Labour inductions and delivery before 39 weeks were more common at SLMHC for both classes of diabetes, with equivalent overall C-section rates. Planned C-sections were less common at SLMHC (relative risk [RR]: 0.5, 95% confidence interval [CI]: 0.3–0.9) maternal and neonatal characteristics and birth outcomes are listed for GDM [Table 1] and T2DM [Table 2].
|Table 1: Characteristics of gestational diabetes mellitus patients at Sioux Lookout Meno Ya Win Health Centre and other Ontario Maternity 1B hospitals, April 1, 2012-March 31, 2017|
Click here to view
|Table 2: Characteristics of type 2 diabetes mellitus patients in pregnancy at Sioux Lookout Meno Ya Win Health Centre and other Ontario Maternity 1B hospitals, April 2012-March 2017|
Click here to view
| Discussion|| |
The prevalence of pre-existing T2DM and GDM is much higher at SLMHC compared to other Ontario hospitals with a comparable level of obstetrical services. Associated adverse outcomes were more common: unplanned C-sections, neonatal hypoglycaemia and macrosomia. Total C-section and neonatal resuscitation rates were equivalent.
The substantial difference in the rates of pre-existing T2DM (RR: 20.9, 95% CI: 16.0–27.2) speaks to the high diabetes prevalence in NW Ontario. It may also reflect the transfer of care of pregnant patients with T2DM to specialists and/or larger facilities in other areas of the province, as the provincial prevalence of T2DM in pregnancy is double (0.4%) in other Ontario maternity 1B hospitals (0.2%).
At SLMHC, both classes of diabetic patients delivered at a mean of 38 weeks and experienced more inductions of labour. This contrasted with comparable hospitals where only T2DM patients were induced and delivered before 39 weeks. This highlights the clinical decision-making around time of delivery for patients with diabetes, with earlier deliveries occurring at SLMHC. It is not clear if other perceived risks also played a role in these decisions.
Inductions for both classes of diabetes were more common at SLMHC: GDM (RR: 1.3, 95% CI: 1.1–1.6) and T2DM (RR: 1.8, 95% CI: 1.3–2.4). All cohorts had equivalent overall C-section rates, but a different pattern of care is evident for patients at SLMHC when analysing data for T2DM patients. Unfortunately, we cannot distinguish if a planned section was elective or a repeat, but the combination of more inductions and fewer planned C-sections in T2DM patients at SLMHC may indicate a physician and/or patient preference favouring a vaginal delivery. These findings are consistent with the higher trial of labour and vaginal birth after delivery previously documented at SLMHC. While C-section rates for T2DM patients in each cohort are equivalent, it is sobering to see that operative deliveries occur in almost one-half of the deliveries of women with pre-existing T2DM.
All neonates had similar APGAR and resuscitation rates. GDM neonates at SLMHC had increased rates of macrosomia and hypoglycaemia. This may indicate suboptimal glycaemic control during pregnancy; we note a lower rate of insulin use in these patients. At first glance, neonates of T2DM patients at SLMHC seem to have better outcomes, but the small number of patients (76) limits the ability to draw more informed conclusions.
Congenital anomalies and stillbirths are acknowledged adverse events associated with pre-existing T2DM, and neither are included in our data set; BORN supresses rare event data (<6) in respect of patient confidentiality.
Substance exposure, an order of magnitude higher at SLMHC, is comparable to otherFirst Nations obstetrical populations in Quebec, Manitoba and Alberta.,, The presence of a similar maternal risk profile across geographically distinctFirst Nations demonstrates the common inherited effects of colonisation and systemic discrimination and their ongoing contribution to health inequities.,,,
Youth, parity, diabetes and substance use contribute to the profile of mothers delivering at SLMHC, which is quite distinct from Ontario hospitals with a comparable level of obstetrical services. Programming needs to address this, and culturally relevant initiatives are developing. The scope of hospital-based IPP includes addiction medicine in prenatal care. SLMHC participates in a 20-week pregnancy support workers' programme and the Sioux LookoutFirst Nations Health Authority hosts Full Scope Indigenous Doula training., Beyond these efforts, the unique context and demographics of the SLMHC obstetrical population highlight the need for broad social and medical programming, including issues not typically associated with maternity care: food security, poverty and culturally appropriate care.,,,, Not all small hospital obstetrical programmes need be created equal.
Data not reliably available from BORN included congenital anomalies and oral hypoglycaemic use in pregnancy; only live births were included.
| Conclusion|| |
The SLMHC obstetrical population has higher rates of both gestational and pre-existing diabetes than other Ontario hospitals with a comparable level of service. Diabetic mothers at SLMHC are younger and of greater parity with increased substance use. Programming is required which recognises and accommodates the unique service needs of this population.
Financial support and sponsorship: This study was supported by the Northern Ontario Academic Medicine Association AHSC AFP Innovation Fund award.
Conflicts of interest: There are no conflicts of interest.
| References|| |
Coustan D, Lowe L, Metzger B, Dyer A. The HAPO Study: Paving the way for new diagnostic criteria for GDM. Am J Obstet Gynecol 2010;202:654.e1-654.
HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, Dyer AR, Trimble ER, Chaovarindr U, et al
. Hyperglycemia and adverse pregnancy outcomes. N
Engl J Med 2008;358:1991-2002.
Feig DS, Hwee J, Shah BR, Booth GL, Bierman AS, Lipscombe LL. Trends in incidence of diabetes in pregnancy and serious perinatal outcomes: A large, population-based study in Ontario, Canada, 1996-2010. Diabetes Care 2014;37:1590-6.
Tennant PW, Glinianaia SV, Bilous RW, Rankin J, Bell R. Pre-existing diabetes, maternal glycated haemoglobin, and the risks of fetal and infant death: A population-based study. Diabetologia 2014;57:285-94.
Liu SL, Shah BR, Naqshbandi M, Tran V, Harris SB. Increased rates of adverse outcomes for gestational diabetes and pre-pregnancy diabetes in on-reserveFirst Nations Women in Ontario, Canada. Diabet Med 2012;29:e180-3.
Dyck R, Klomp H, Tan LK, Turnell RW, Boctor MA. A comparison of rates, risk factors, and outcomes of gestational diabetes between aboriginal and non-aboriginal women in the Saskatoon health district. Diabetes Care 2002;25:487-93.
Berger H, Gagnon R, Sermer M, Basso M, Bos H, Brown RN, et al
. Diabetes in pregnancy. J Obstet Gynaecol Can 2016;38:667-790.
Sweeting AN, Ross GP, Hyett J, Molyneaux L, Constantino M, Harding AJ, et al
. Gestational diabetes mellitus in early pregnancy: evidence for poor pregnancy outcomes despite treatment. Diabetes Care 2016;39:75-81.
American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of medical care in diabetes-2019. Diabetes Care 2019;42:S13-S28.
Walker R, Cromarty H, Kelly L, St Pierre-Hansen N. Achieving cultural safety in aboriginal health services: Implementation of a cross-cultural safety model in a hospital setting. Diversity Health Care 2009:6:11-22.
Institute for Clinical Evaluative Sciences. Results/Diabetes measures across Ontario. Available from: https://www.ices.on.ca
. [Last accessed on 2019 Aug 20].
Sokoloski EH. Canadian first nations women's beliefs about pregnancy and prenatal care. Can J Nurs Res 1995;27:89-100.
Dooley J, Jumah N, Okenden H, Madden S, Bollinger M, Sprague C, et al
. Caesarean sections and vaginal birth after caesarean section rates in a first nations community-based obstetrical program in Northwest Ontario. J Obstet Gynaecol Can 2020. pii: S1701-2163 (19) 30768-6.
Oster RT, King M, Morrish DW, Mayan MJ, Toth EL. Diabetes in pregnancy amongFirst Nations women in Alberta, Canada: A retrospective analysis. BMC Pregnancy Childbirth 2014;14:136.
Aljohani N, Rempel BM, Ludwig S, Morris M, McQuillen K, Cheang M, et al
. Gestational diabetes in Manitoba during a twenty-year period. Clin Invest Med 2008;31:E131-7.
Crowshoe L, Dannenbaum D, Green M, Henderson R, Naqshbandi Hayward M, Toth E. et al
. Diabetes Canada clinical practice guidelines expert committee. Diabetes Canada 2018 clinical practice guidelines for the prevention and management of diabetes in canada” type 2 diabetes and indigenous peoples. Can J Diabetes. 2018;42 Suppl 1:S1-325.
Smylie J, Phillips-Beck W. Truth, respect and recognition: Addressing barriers to Indigenous maternity care. CMAJ 2019;191:E207-E208.
Dooley J, Ryan G, Gerber Finn L, Bollinger M, Matumoto C, Hopman W, Kelly L. Maternal opioid use disorder and neonatal abstinence syndrome in NW Ontario: A seven-year retrospective analysis and description of rural program development. CJRM 2018;23:39-44.
Anderson M. Indigenous health research and reconciliation. CMAJ 2019;191:E930-1.
[Table 1], [Table 2]