Diabetes during pregnancy increases the risk for adverse maternal and infant health
outcomes. Type 1 or type 2 diabetes diagnosed before pregnancy (preexisting diabetes)
increases infants’ risk for congenital anomalies, stillbirth, and being large for
gestational age (
1
). Diabetes that develops and is diagnosed during the second half of pregnancy (gestational
diabetes) increases infants’ risk for being large for gestational age (
1
) and might increase the risk for childhood obesity (
2
); for mothers, gestational diabetes increases the risk for future type 2 diabetes
(
3
). In the United States, prevalence of both preexisting and gestational diabetes increased
from 2000 to 2010 (
4
,
5
). Recent state-specific trends have not been reported; therefore, CDC analyzed 2012–2016
National Vital Statistics System (NVSS) birth data. In 2016, the crude national prevalence
of preexisting diabetes among women with live births was 0.9%, and prevalence of gestational
diabetes was 6.0%. Among 40 jurisdictions with continuously available data from 2012
through 2016, the age- and race/ethnicity-standardized prevalence of preexisting diabetes
was stable at 0.8% and increased slightly from 5.2% to 5.6% for gestational diabetes.
Preconception care and lifestyle interventions before, during, and after pregnancy
might provide opportunities to control, prevent, or mitigate health risks associated
with diabetes during pregnancy.
NVSS collects data for all live births in 50 states, New York City,* and District
of Columbia (DC).
†
The U.S. Standard Certificate of Live Birth (birth certificate) uniformly documents
birth-related information across jurisdictions and was revised in 2003 to include
distinct fields for preexisting and gestational diabetes; the National Center for
Health Statistics recommends information about these conditions be collected from
prenatal care records, labor and delivery forms, or delivery records.
§
The birth certificate also includes information on maternal characteristics, which
might be self-reported or collected from medical records.
¶
The revised birth certificate was implemented in 40 jurisdictions as of 2012** (representing
86.3% of live births to U.S. residents) and in all jurisdictions as of January 2016.
The national prevalences of preexisting and gestational diabetes were calculated for
U.S. resident mothers who had a live birth in 2016. Crude prevalences were calculated
overall and by selected maternal characteristics among women with complete information
for each particular characteristic
††
; chi-square tests were used to evaluate differences by characteristic. To examine
changes in prevalence of preexisting and gestational diabetes, jurisdiction-specific
prevalences were calculated for U.S. resident mothers with a live birth during 2012–2016
and who were residing in jurisdictions that adopted the revised birth certificate
by January 1 of the year in which they gave birth; women with missing data on diabetes
status (<1%) were excluded from this portion of the analysis. Jurisdiction-specific
prevalences were calculated for each year after directly standardizing to the distribution
of age and race/ethnicity of U.S. resident mothers with live births in 2012 because
these characteristics vary by jurisdiction and are nonmodifiable determinants of diabetes.
For 40 jurisdictions with data available from 2012 to 2016 (n = 17,050,514 women;
86% of U.S. resident women with live births during 2012–2016), differences in standardized
prevalences between 2012 and 2016 were calculated for each jurisdiction and for all
jurisdictions combined; differences were assumed to be independent and were evaluated
using the z-statistic. P-values <0.05 were considered statistically significant.
In 2016, the crude national prevalences of preexisting and gestational diabetes were
0.9% and 6.0%, respectively (Table 1); prevalence varied by all characteristics examined
(p<0.05). For example, by race/ethnicity, the prevalence of preexisting diabetes was
highest among American Indian/Alaska Native women (2.1%) and Native Hawaiian/Pacific
Islander women (1.8%), and the prevalence of gestational diabetes was highest among
non-Hispanic Asian women (11.1%). The prevalences of both preexisting and gestational
diabetes varied by prepregnancy body mass index (BMI): among underweight women, the
prevalences of preexisting diabetes and gestational diabetes were 0.3% and 2.9%, respectively;
whereas among women with class III obesity, the respective prevalences were 3.2% and
13.9%.
TABLE 1
Unadjusted prevalences of preexisting diabetes and gestational diabetes among women
with a live birth, by selected maternal characteristics — United States, 2016
Characteristic*
No.†
% Preexisting diabetes
% Gestational diabetes
Total
3,942,094
0.9
6.0
Age group (yrs)
<20
211,827
0.4
1.9
20–24
803,153
0.5
3.3
25–29
1,148,057
0.7
5.1
30–34
1,110,010
1.0
7.0
35–39
546,995
1.4
9.6
≥40
122,052
2.1
12.8
Race and Hispanic origin
§
White, non-Hispanic
2,054,437
0.7
5.3
Black, non-Hispanic
558,044
1.2
4.8
Asian, non-Hispanic
254,326
0.9
11.1
Hispanic
917,822
1.0
6.6
American Indian/Alaska Native
31,375
2.1
9.2
Native Hawaiian/Pacific Islander
9,337
1.8
8.4
More than one race
80,836
0.9
5.8
Nativity
U.S.-born
3,024,356
0.8
5.2
Not U.S.-born
909,638
0.9
8.4
Education
Less than high school
537,990
1.1
6.2
High school graduate
978,917
0.9
5.5
Some college
1,128,682
1.0
6.2
College graduate
784,655
0.6
5.9
More than college
460,768
0.6
6.0
Payment source for delivery
Medicaid
1,668,864
1.0
5.9
Private
1,936,143
0.8
6.2
Other¶
313,437
0.7
5.1
Trimester entry into prenatal care
First
2,955,378
0.9
6.2
Second
639,593
0.8
5.6
Third or none
235,409
0.7
4.6
Parity
Nulliparous
1,498,458
0.8
5.2
Primiparous
1,263,445
0.8
5.9
Multiparous
1,165,053
1.0
7.1
Prepregnancy body mass index**
Underweight
134,392
0.3
2.9
Normal weight
1,699,751
0.4
3.6
Overweight
997,977
0.8
6.1
Obesity Class I
548,092
1.3
8.8
Obesity Class II
266,105
2.0
11.2
Obesity Class III
187,689
3.2
13.9
* Statistically significant (p<0.05) differences in the distribution of preexisting
diabetes, gestational diabetes (or no diabetic conditions) were observed by all maternal
characteristics.
† The number of women within a characteristic group (e.g., age group) might not sum
to the total number of women because of missing information.
§ Race and Hispanic origin are reported separately on the birth certificate. Women
reporting Hispanic origin were categorized as Hispanic regardless of their race. Categories
represent single-race reporting (i.e., mothers reported only one race); mothers reporting
more than one race were categorized as “More than one race.”
¶ Includes insurance provided by TRICARE or the Indian Health Service.
** Prepregnancy body mass index (BMI; kg/m2) classified as underweight (BMI <18.5),
normal weight (BMI 18.5–24.9), overweight (BMI 25.0–29.9), obesity class I (BMI 30.0–34.9),
obesity class II (35.0–39.9), and obesity class III (BMI ≥40.0).
After standardizing for age and race/ethnicity, the 2016 prevalence of preexisting
diabetes ranged from 0.5% in California to 1.7% in West Virginia (Table 2) (Figure);
prevalence of gestational diabetes ranged from 3.4% in DC to 9.2% in South Dakota
(Table 2) (Figure). From 2012 to 2016, among the 40 jurisdictions with continuously
available data, the standardized prevalence of preexisting diabetes was stable at
0.8% (Table 2). Statistically significant increases in the prevalence of preexisting
diabetes were observed in eight jurisdictions (range = 0.1% [California] to 0.3% [Georgia]);
a significant decrease was observed only for Oklahoma (0.4%). From 2012 to 2016, the
standardized prevalence of gestational diabetes increased from 5.2% to 5.6%. Statistically
significant increases in the prevalence of gestational diabetes were observed in 22
jurisdictions (range = 0.3% [Illinois] to 3.2% [South Dakota]); significant decreases
were observed in six jurisdictions (range = 0.4% [Massachusetts] to 1.9% [New Hampshire]).
TABLE 2
Standardized* prevalence of preexisting and gestational diabetes among women with
a live birth, by jurisdiction, year, and percentage point change — United States,
2012–2016
Jurisdiction
Percentage of women with preexisting diabetes
Percentage of women with gestational diabetes
2012
2013
2014
2015
2016
Percentage-point difference, 2012 to 2016 (95% CI)†
2012
2013
2014
2015
2016
Percentage-point difference, 2012 to 2016 (95%CI)†
Alabama
—§
—§
1.1
1.1
1.1
—§
—§
—§
4.6
4.8
5.3
—§
Alaska
—§
0.6
1.0
1.0
0.9
—§
—§
7.2
6.9
6.7
8.3
—§
Arizona
—§
—§
0.8
0.8
0.8
—§
—§
—§
5.7
6.9
6.9
—§
Arkansas
—§
—§
1.0
1.0
1.0
—§
—§
—§
5.2
5.4
5.6
—§
California
0.4
0.4
0.4
0.4
0.5
0.1 (0.0 to 0.1)†
4.2
4.4
4.7
4.6
4.6
0.4 (0.4 to 0.5)†
Colorado
0.7
0.8
0.7
0.6
0.7
0.0 (-0.1 to 0.1)
4.2
4.4
4.2
4.2
4.3
0.1 (-0.1 to 0.4)
Connecticut
—§
—§
—§
—§
0.8
—§
—§
—§
—§
—§
5.7
—§
Delaware
1.0
0.9
0.8
0.8
0.9
-0.2 (-0.4 to 0.1)
7.5
6.9
7.9
7.2
7.2
-0.3 (-1.0 to 0.5)
District of Columbia
0.6
0.8
0.8
0.5
0.8
0.1 (-0.2 to 0.4)
2.9
3.0
2.8
2.5
3.4
0.5 (-0.3 to 1.3)
Florida
0.8
0.8
0.7
0.7
0.8
-0.1 (-0.1 to 0.0)
5.0
4.6
4.4
4.3
4.4
-0.5 (-0.7 to -0.4)†
Georgia
0.7
0.8
0.9
1.0
0.9
0.3 (0.2 to 0.4)†
4.0
4.1
3.8
3.8
4.7
0.7 (0.5 to 0.8)†
Hawaii
—§
—§
0.6
0.5
0.5
—§
—§
—§
3.3
4.5
3.8
—§
Idaho
0.7
0.7
0.7
0.7
1.0
0.3 (-0.0 to 0.6)
5.7
6.3
5.6
6.6
5.8
0.1 (-0.7 to 0.9)
Illinois
0.8
0.8
0.7
0.8
0.9
0.1 (0.0 to 0.1)
5.9
6.2
6.0
6.3
6.3
0.3 (0.2 to 0.5)
Indiana
1.1
1.0
1.0
1.0
1.0
-0.0 (-0.2 to 0.1)
6.7
6.2
6.1
6.2
6.9
0.1 (-0.2 to 0.4)
Iowa
1.0
1.0
1.2
1.2
1.3
0.2 (0.0 to 0.4)†
7.2
8.0
7.8
8.3
8.4
1.1 (0.6 to 1.6)†
Kansas
0.8
0.9
0.9
0.8
0.8
-0.0 (-0.2 to 0.1)
5.8
5.7
6.0
6.0
6.4
0.5 (0.2 to 0.9)†
Kentucky
1.1
1.0
1.1
1.1
1.1
0.1 (-0.1 to 0.2)
6.2
5.9
6.1
6.0
6.4
0.2 (-0.2 to.6)
Louisiana
0.8
0.9
0.9
1.0
1.0
0.2 (0.1 to 0.3)†
5.0
6.1
6.0
5.9
5.9
0.9 (0.5 to 1.2)†
Maine
—§
—§
1.0
1.0
0.9
—§
—§
—§
6.5
6.0
6.2
—§
Maryland
0.8
0.8
0.8
0.8
0.8
0.0 (-0.1 to 0.1)
4.8
5.0
5.6
5.9
5.9
1.1 (0.8 to 1.3)†
Massachusetts
0.7
0.8
0.7
0.8
0.8
0.1 (-0.0 to 0.2)
5.2
4.8
4.8
5.2
4.8
-0.4 (-0.6 to -0.1)†
Michigan
0.9
0.8
0.8
0.8
0.9
0.1 (-0.0 to 0.2)
6.2
5.4
5.5
5.4
5.5
-0.7 (-1.0 to -0.5)†
Minnesota
1.1
0.9
1.0
1.0
0.9
-0.1 (-0.3 to 0.0)
7.0
7.1
6.7
6.7
7.1
0.1 (-0.2 to 0.5)
Mississippi
—§
0.8
1.0
0.8
0.8
—§
—§
4.9
4.5
4.3
4.3
—§
Missouri
0.8
0.8
0.8
1.0
0.8
0.0 (-0.1 to 0.2)
6.0
5.8
5.9
6.2
6.8
0.8 (0.4 to 1.1)†
Montana
0.7
0.5
1.0
0.9
0.9
0.2 (-0.3 to 0.7)
2.8
4.0
4.6
5.2
4.7
1.8 (0.9 to 2.8)†
Nebraska
0.9
1.0
1.0
1.0
1.0
0.1 (-0.1 to 0.3)
5.8
6.4
5.7
6.0
6.5
0.7 (0.3 to 1.2)†
Nevada
0.9
0.8
0.9
0.9
1.0
0.1 (-0.1 to 0.2)
5.1
5.6
5.5
5.4
5.9
0.8 (0.4 to 1.1)†
New Hampshire
0.7
0.8
0.8
0.7
0.7
-0.0 (-0.3 to 0.3)
7.3
6.6
6.9
5.2
5.5
-1.9 (-3.0 to -0.7)†
New Jersey
—§
—§
—§
—§
0.8
—§
—§
—§
—§
—§
5.9
—§
New Mexico
0.8
0.9
0.9
0.9
0.8
-0.0 (-0.3 to 0.2)
3.4
3.5
4.3
4.4
4.7
1.4 (0.9 to 1.9)†
New York
0.7
0.7
0.8
0.7
0.8
0.2 (0.1 to 0.3)†
5.2
5.3
5.7
6.0
6.3
1.1 (1.0 to 1.3)†
New York City¶
0.5
0.5
0.5
0.5
0.5
0.0 (-0.0 to 0.1)
3.9
3.7
4.3
5.2
5.9
2.0 (1.8 to 2.2)†
North Carolina
0.8
0.8
0.8
0.9
1.0
0.2 (0.1 to 0.3)†
5.9
5.8
5.6
5.5
5.8
-0.0 (-0.2 to 0.2)
North Dakota
0.8
0.7
0.7
1.2
0.8
-0.0 (-0.4 to 0.4)
5.2
5.6
5.3
6.5
6.2
1.0 (-0.0 to 2.1)
Ohio
1.0
1.0
1.0
1.0
1.1
0.1 (-0.0 to 0.2)
7.6
7.8
7.67
8.0
8.2
0.6 (0.3 to 0.9)†
Oklahoma
1.2
0.8
0.9
0.9
0.9
-0.4 (-0.5 to -0.2)†
4.3
4.5
4.7
4.8
5.1
0.9 (0.5 to 1.2)†
Oregon
1.0
0.9
1.0
0.8
1.0
0.1 (-0.1 to 0.2)
7.5
8.0
8.1
8.0
8.1
0.6 (0.1 to 1.0)†
Pennsylvania
0.8
0.8
0.8
0.8
0.8
-0.0 (-0.1 to 0.0)
5.5
5.4
5.6
5.5
5.5
0.1 (-0.2 to 0.3)
Rhode Island
—§
—§
—§
0.7
0.8
—§
—§
—§
—§
6.7
6.1
—§
South Carolina
1.0
1.1
0.9
0.9
1.0
0.0 (-0.1 to 0.2)
5.9
6.5
7.3
7.0
7.1
1.1 (0.8 to 1.5)†
South Dakota
0.7
0.8
0.8
0.7
0.7
0.1 (-0.3 to 0.4)
6.1
7.1
8.5
8.4
9.2
3.2 (2.1 to 4.3)†
Tennessee
1.0
1.1
1.3
1.2
1.2
0.2 (0.1 to 0.3)†
7.0
6.7
6.1
6.2
6.1
-0.9 (-1.2 to -0.6)†
Texas
0.7
0.7
0.7
0.7
0.6
-0.0 (-0.1 to 0.0)
4.2
4.0
4.5
4.5
4.6
0.4 (0.3 to 0.5)†
Utah
0.7
0.7
0.7
0.9
0.7
0.0 (-0.1 to 0.2)
4.8
5.0
5.6
6.4
6.4
1.6 (1.1 to 2.1)†
Vermont
0.6
0.8
1.1
1.2
1.0
0.3 (-0.3 to 1.0)
4.4
6.3
4.2
4.0
4.3
-0.1 (-1.5 to 1.2)
Virginia
—§
0.6
0.5
0.7
0.7
—§
—§
4.2
4.8
5.1
5.3
—§
Washington
0.8
0.8
0.8
0.9
0.9
0.1 (0.1 to 0.2)†
6.7
6.7
7.0
7.6
7.8
1.0 (0.8 to 1.3)†
West Virginia
—§
—§
2.0
1.5
1.7
—§
—§
—§
6.7
7.1
7.2
—§
Wisconsin
1.1
1.2
1.0
1.0
1.1
0.1 (-0.1 to 0.2)
7.0
7.1
7.0
6.9
6.6
-0.4 (-0.7 to -0.1)†
Wyoming
0.9
0.9
0.8
1.0
0.6
-0.3 (-1.0 to 0.3)
3.3
3.3
3.7
4.6
3.8
0.5 (-0.4 to 1.3)
40 jurisdictions with data during 2012–2016**
0.8
0.8
0.8
0.8
0.8
0.1 (0.0 to 0.1)†
5.2
5.2
5.4
5.5
5.6
0.4 (0.4 to 0.5)†
Abbreviation: CI = confidence interval.
* Standardized to the age and race/ethnicity distribution of U.S. resident mothers
delivering in 2012.
† Statistically significant (p<0.05) difference from 2012 to 2016.
§ A dash indicates revised birth certificates were not available by January 1 of that
year for that jurisdiction.
¶ Natality data from New York City are reported separately and are not included in
New York state estimates.
** Among the 40 jurisdictions with data during 2012–2016, the sample sizes were 3,391,723
(2012); 3,378,197 (2013); 3,435,616 (2014); 3,434,815 (2015); and 3,410,163 (2016).
FIGURE
Standardized* prevalence of preexisting (panel A) and gestational (panel B) diabetes
among women who had a live birth — United States, 2016
Abbreviations: DC = District of Columbia; NYC = New York City.
* Standardized to age and race/ethnicity distribution of U.S. resident mothers delivering
in 2012.
The figure shows two maps of the United States, one depicting the prevalence of preexisting
diabetes and the other depicting the prevalence of gestational diabetes among women
who had a live birth, by state in 2016.
Discussion
In 2016, the crude national prevalences of preexisting and gestational diabetes were
0.9% and 6.0%, respectively.
§§
From 2012 to 2016 among 40 jurisdictions with continuously available data, the age-
and race/ethnicity-standardized prevalence of preexisting diabetes remained stable
(<0.1 percentage point change), and the prevalence of gestational diabetes increased
by 0.4 percentage point. Changes in preexisting and gestational diabetes reported
here extend findings from two studies using hospital discharge data from 19 states;
these studies found the age-adjusted prevalence of preexisting diabetes increased
from 0.7% to 0.9% from 2000 to 2010, and the prevalence of gestational diabetes increased
from 3.7% to 5.8% (
4
,
5
). Observed increases in the prevalence of preexisting and gestational diabetes might
reflect, in part, recent increases in the prevalence of prepregnancy obesity.
¶¶
Estimates of preexisting diabetes may be leveling off compared to what has been seen
in recent years. The high prevalence of gestational diabetes in Asian women is consistent
with previous literature (
5
). Preconception care and lifestyle interventions before, during, and after pregnancy
might provide opportunities to control, prevent, or mitigate health risks associated
with diabetes during pregnancy.
Preconception care refers to health care before pregnancy that optimizes a woman’s
health and pregnancy-related outcomes, should a pregnancy occur.*** Preconception
care provides an opportunity to reinforce the importance of diabetes management among
reproductive-aged women with type 1 or type 2 diabetes and might reduce adverse pregnancy
outcomes by improving glycemic control before critical developmental stages of the
fetus early in pregnancy (
6
). Because prepregnancy overweight and obesity are strongly associated with developing
gestational diabetes, preconception care offers an opportunity to provide all women
with recommended BMI screening and to refer women with obesity to intensive multicomponent
behavioral interventions.
†††
Gestational diabetes strongly predicts the development of future type 2 diabetes (
3
). Women with gestational diabetes are recommended to receive testing for type 2 diabetes
4–12 weeks postpartum and, if diabetes is detected, referred for follow-up care; lifelong
monitoring is recommended for women with normal results.
§§§
Although national estimates of postpartum diabetes testing are unavailable, some studies
report suboptimal testing rates (
7
), suggesting missed opportunities to provide health care for women with diabetes
and those at risk for developing diabetes.
Structured lifestyle change programs that promote a healthy diet and increase physical
activity, such as CDC-recognized programs coordinated through the National Diabetes
Prevention Program, reduce the risk for type 2 diabetes in nonpregnant populations
at high risk.
¶¶¶
During the first half of pregnancy, lifestyle interventions might reduce the risk
for developing gestational diabetes; however, additional research is needed to understand
the most successful intervention designs (
8
). Among women who had gestational diabetes but did not develop type 2 diabetes after
pregnancy, postpartum lifestyle interventions have been found to reduce postpartum
weight retention and improve markers of insulin resistance (
9
). Importantly, postpartum mothers face unique barriers to engaging in lifestyle interventions,
including childcare responsibilities and time constraints (
9
).
The findings in this report are subject to at least five limitations. First, prevalences
of preexisting and gestational diabetes might be underestimated because of underreporting
or incomplete birth certificate information, the degree of which might vary by jurisdiction,
or because this study was limited to live births; studies indicate sensitivity of
identifying preexisting diabetes from birth certificates ranges from 47%–52%, whereas
sensitivity for identifying gestational diabetes ranges from 46%–83% (
10
). Second, recommendations for gestational diabetes screening changed in 2014, and
diagnostic criteria might vary by individual practice; consequently, differences in
prevalence over time or by jurisdiction might reflect variations in screening or diagnostic
practices. Third, analyses examining changes over time were limited to 40 jurisdictions
with available data and, as a result, do not represent the entire U.S. population
of women giving birth. Fourth, differences in standardized prevalences between the
two times do not necessarily imply a steady rate of change during the entire period,
which might not reflect actual variation observed. Finally, some statistically significant
findings might be driven by large sample sizes and might not reflect a meaningful
change.
In 2016, the national prevalences of preexisting and of gestational diabetes were
0.9% and 6.0%, respectively, and prevalences of both conditions increased slightly
from 2012 to 2016; notably, standardized prevalences and changes over time varied
by jurisdiction. Preconception care and lifestyle interventions before, during, and
after pregnancy might prevent, control, or mitigate risks associated with diabetes
during pregnancy.
Summary
What is already known about this topic?
Diabetes diagnosed before (preexisting diabetes) and during (gestational diabetes)
pregnancy increases the risk for adverse infant and maternal health outcomes. Recent
prevalence and trend estimates for these conditions have not been reported.
What is added by this report?
In 2016, the national prevalences of preexisting and gestational diabetes were 0.9%
and 6.0%, respectively. Among 40 jurisdictions, the age- and race/ethnicity-standardized
preexisting diabetes prevalence was stable at 0.8%, and the gestational diabetes prevalence
increased from 5.2% to 5.6%.
What are the implications for public health practice?
Changes in preexisting and gestational diabetes suggest strategies before, during,
and after pregnancy are needed to prevent, control, or mitigate risks associated with
these conditions.