Download PDF
Am J Perinatol 2022; 39(12): 1279-1287
DOI: 10.1055/a-1788-5600
SMFM Fellowship Series Article

Differences in Hemoglobin A1c during Pregnancy between Non-Hispanic Black versus White Women with Prepregnancy Diabetes

Kartik K. Venkatesh 
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
,
Naleef Fareed
2   Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
,
Miranda K. Kiefer
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
,
Courtney A. Ware
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
,
Elizabeth Buschur
3   Division of Endocrinology, Department of Medicine, The Ohio State University, Columbus, Ohio
,
Mark B. Landon
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
,
Stephen F. Thung
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
,
Maged M. Costantine 
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
,
Steven G. Gabbe
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
,
Joshua J. Joseph
4   Department of Bioinformatics, The Ohio State University, Columbus, Ohio
› Author Affiliations Funding K.K.V. was supported by the Care Innovation and Community Improvement Program at The Ohio State University.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Objective The objective of this was to determine whether the change in hemoglobin A1c (HbA1c) from early to late pregnancy differs between non-Hispanic Black and White women with prepregnancy diabetes.

Study Design A retrospective analysis was performed from an integrated prenatal and diabetes care program from 2012 to 2016. We compared HbA1c as a continuous measure and secondarily, HbA1c <6.5%, cross-sectionally, and longitudinally in early (approximately 10 weeks) and late (approximately 31 weeks) pregnancies. Linear and logistic regression were used and adjusted for age, body mass index, White diabetes class, medication use, diabetes type, gestational age at baseline HbA1c measurement, and baseline hemoglobin.

Results Among 296 non-Hispanic Black (35%) and White pregnant women (65%) with prepregnancy diabetes (39% type 1 and 61% type 2), Black women were more likely to experience increased community-level social determinants of health as measured by the Social Vulnerability Index (SVI) and were less likely to have type 1 diabetes and have more severe diabetes versus White women (p < 0.05). Black women had higher mean HbA1c (7.8 vs. 7.4%; beta: 0.75; 95% confidence interval [CI]: 0.30–1.19) and were less likely to have HbA1c < 6.5% at 10 weeks compared with White women (24 vs. 35%; adjusted odds ratio: 0.45; 95% CI: 0.24–0.81) but not after adjusting for SVI. At 31 weeks, both groups had similar mean HbA1c (both 6.5%) and were equally as likely to have HbA1c < 6.5% (57 vs. 54%). From early to late pregnancy, Black women had a higher percentage decrease in HbA1c (1.3 vs. 0.9%; beta = 0.63; 95% CI: 0.27–0.99) and were equally as likely to have an improvement or stable HbA1C < 6.5% from 10 to 31 weeks, with both groups having a similar mean HbA1c (6.5%) at 31 weeks.

Conclusion Despite experiencing greater community-level social determinants of health, Black women with pregestational diabetes had a larger reduction in HbA1c and were able to equally achieve the target of HbA1c < 6.5% by late pregnancy compared with White women as part of an integrated diabetes and prenatal care program.

Key Points

  • An integrated diabetes and pregnancy care program may decrease racial and ethnic disparities in glycemic control.

  • Black women had a larger reduction in HbA1c versus White women.

  • Black women were able to equally achieve the target of HbA1c < 6.5% by late pregnancy versus White women.

Keywords

diabetes - pregnancy - race - disparities - glycemic control - hemoglobin A1c

Authors' Contributions

K.K.V., N.F., J.J.J., and S.G.B. conceived of the study. Data collection and interpretation were conducted by M.K.K., C.A.W., E.B., M.C., M.B.L., and S.F.T. Data analysis was conducted by K.K.V., N.F., M.K.K., and J.J.J.


This manuscript will be presented as a poster presentation at the Society for Maternal-Fetal Medicine Annual Meeting, February, 2022.




Publication History

Received: 24 November 2021

Accepted: 22 February 2022

Accepted Manuscript online:
04 March 2022

Article published online:
25 May 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Coton SJ, Nazareth I, Petersen I. A cohort study of trends in the prevalence of pregestational diabetes in pregnancy recorded in UK general practice between 1995 and 2012. BMJ Open 2016; 6 (01) e009494
    CrossrefPubMedGoogle Scholar
  • 2 Correa A, Bardenheier B, Elixhauser A, Geiss LS, Gregg E. Trends in prevalence of diabetes among delivery hospitalizations, United States, 1993-2009. Matern Child Health J 2015; 19 (03) 635-642
    CrossrefPubMedGoogle Scholar
  • 3 Albrecht SS, Kuklina EV, Bansil P. et al. Diabetes trends among delivery hospitalizations in the U.S., 1994-2004. Diabetes Care 2010; 33 (04) 768-773
    CrossrefPubMedGoogle Scholar
  • 4 Bardenheier BH, Imperatore G, Devlin HM, Kim SY, Cho P, Geiss LS. Trends in pre-pregnancy diabetes among deliveries in 19 U.S. states, 2000-2010. Am J Prev Med 2015; 48 (02) 154-161
    CrossrefPubMedGoogle Scholar
  • 5 Zhang Q, Wang Y, Huang ES. Changes in racial/ethnic disparities in the prevalence of type 2 diabetes by obesity level among US adults. Ethn Health 2009; 14 (05) 439-457
    CrossrefPubMedGoogle Scholar
  • 6 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 (06) 1590-1596
    CrossrefPubMedGoogle Scholar
  • 7 Persson M, Norman M, Hanson U. Obstetric and perinatal outcomes in type 1 diabetic pregnancies: a large, population-based study. Diabetes Care 2009; 32 (11) 2005-2009
    CrossrefPubMedGoogle Scholar
  • 8 Gortazar L, Goday A, Flores-Le Roux JA. et al. Trends in prevalence of pre-existing diabetes and perinatal outcomes: a large, population-based study in Catalonia, Spain, 2006-2015. BMJ Open Diabetes Res Care 2020; 8 (01) e001254
    CrossrefPubMedGoogle Scholar
  • 9 Davidson AJF, Park AL, Berger H. et al. Risk of severe maternal morbidity or death in relation to elevated hemoglobin A1c preconception, and in early pregnancy: a population-based cohort study. PLoS Med 2020; 17 (05) e1003104
    CrossrefPubMedGoogle Scholar
  • 10 Creanga AA, Bateman BT, Kuklina EV, Callaghan WM. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010. Am J Obstet Gynecol 2014; 210 (05) 435.e1-435.e8
    CrossrefPubMedGoogle Scholar
  • 11 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 (02) 285-294
    CrossrefPubMedGoogle Scholar
  • 12 Starikov RS, Inman K, Chien EK. et al. Can hemoglobin A1c in early pregnancy predict adverse pregnancy outcomes in diabetic patients?. J Diabetes Complications 2014; 28 (02) 203-207
    CrossrefPubMedGoogle Scholar
  • 13 American Diabetes Association. 14. Management of diabetes in pregnancy: standards of medical care in diabetes-2020 . Diabetes Care 2020; 43 (Suppl. 01) S183-S192
    CrossrefPubMedGoogle Scholar
  • 14 Walker RJ, Strom Williams J, Egede LE. Influence of race, ethnicity and social determinants of health on diabetes outcomes. Am J Med Sci 2016; 351 (04) 366-373
    CrossrefPubMedGoogle Scholar
  • 15 Jardine J, Walker K, Gurol-Urganci I. et al; National Maternity and Perinatal Audit Project Team. Adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities in England: a national cohort study. Lancet 2021; 398 (10314): 1905-1912
    CrossrefPubMedGoogle Scholar
  • 16 Hill-Briggs F, Adler NE, Berkowitz SA. et al. Social determinants of health and diabetes: a scientific review. Diabetes Care 2020; 44 (01) 258-279
    CrossrefPubMedGoogle Scholar
  • 17 Ogunwole SM, Golden SH. Social determinants of health and structural inequities-root causes of diabetes disparities. Diabetes Care 2021; 44 (01) 11-13
    CrossrefPubMedGoogle Scholar
  • 18 Golden SH, Joseph JJ, Hill-Briggs F. Casting a health equity lens on endocrinology and diabetes. J Clin Endocrinol Metab 2021; 106 (04) e1909-e1916
    CrossrefPubMedGoogle Scholar
  • 19 Smalls BLRT, Ritchwood TD, Bishu KG, Egede LE. Racial/ethnic differences in glycemic control in older adults with type 2 diabetes: United States 2003-2014. Int J Environ Res Public Health 2020; 17 (03) 950
    CrossrefPubMedGoogle Scholar
  • 20 Kahkoska AR, Shay CM, Crandell J. et al. Association of race and ethnicity with glycemic control and hemoglobin A1c levels in youth with type 1 diabetes. JAMA Netw Open 2018; 1 (05) e181851
    CrossrefPubMedGoogle Scholar
  • 21 Rodríguez JE, Campbell KM. Racial and ethnic disparities in prevalence and care of patients with type 2 diabetes. Clin Diabetes 2017; 35 (01) 66-70
    CrossrefPubMedGoogle Scholar
  • 22 Venkatesh KK, Joseph J, Kiefer M. et al. Association between Social Vulnerability and Achieving Glycemic Control among Pregnant Women with Pregestational Diabetes Obstertrics and Gynecology. In press.
    Google Scholar
  • 23 Finneran MM, Kiefer MK, Ware CA. et al. The use of longitudinal hemoglobin A1c values to predict adverse obstetric and neonatal outcomes in pregnancies complicated by pregestational diabetes. Am J Obstet Gynecol MFM 2020; 2 (01) 100069
    CrossrefPubMedGoogle Scholar
  • 24 Finneran MM, Ware CA, Kiefer MK. et al. The accuracy and cost-effectiveness of selective fetal echocardiography for the diagnosis of congenital heart disease in patients with pregestational diabetes stratified by hemoglobin A1c. Am J Perinatol 2019; 36 (12) 1216-1222
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Bio-Rad laboratories I. Variant II Turbo HbA1c Kit—2.0. U. S.. 2021 Accessed October 10, 2021, at: https://www.accessdata.fda.gov/cdrh_docs/reviews/K090699.pdf
    PubMed
  • 26 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 201: pregestational diabetes mellitus. Obstert Gynecol 2018; 132 (06) e228-e48
    CrossrefPubMedGoogle Scholar
  • 27 Ingram DD, Parker JD, Schenker N. et al. United States Census 2000 population with bridged race categories. Vital Health Stat 2 2003; 2 (135) 1-55
    PubMedGoogle Scholar
  • 28 Keppel K, Bilheimer L, Gurley L. Improving population health and reducing health care disparities. Health Aff (Millwood) 2007; 26 (05) 1281-1292
    CrossrefPubMedGoogle Scholar
  • 29 Institute of Medicine CoUaE-iRaEDiHCSB.. Stith AY, Nelson AR. eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academic Press; 2003
    Google Scholar
  • 30 Centers for Disease Control and Prevention/ Agency for Toxic Substances and Disease Registry/ Geospatial Research A, and Services Program.. CDC/ATSDR Social Vulnerability Index 2021 Accessed October 10, 2021, at: https://www.atsdr.cdc.gov/placeandhealth/svi/data_documentation_download.html
    PubMed
  • 31 Ahmad J, Rafat D. HbA1c and iron deficiency: a review. Diabetes Metab Syndr 2013; 7 (02) 118-122
    CrossrefPubMedGoogle Scholar
  • 32 Bennett SN, Tita A, Owen J, Biggio JR, Harper LM. Assessing White's classification of pregestational diabetes in a contemporary diabetic population. Obstet Gynecol 2015; 125 (05) 1217-1223
    CrossrefPubMedGoogle Scholar
  • 33 Kirk JK, Bell RA, Bertoni AG. et al. Ethnic disparities: control of glycemia, blood pressure, and LDL cholesterol among US adults with type 2 diabetes. Ann Pharmacother 2005; 39 (09) 1489-1501
    CrossrefPubMedGoogle Scholar
  • 34 Easter SR, Rosenthal EW, Morton-Eggleston E, Nour N, Tuomala R, Zera CA. Disparities in care for publicly insured women with pregestational diabetes. Obstet Gynecol 2017; 130 (05) 946-952
    CrossrefPubMedGoogle Scholar
  • 35 Palatnik A, Harrison RK, Walker RJ, Thakkar MY, Egede LE. Maternal racial and ethnic disparities in glycemic threshold for pharmacotherapy initiation for gestational diabetes. J Matern Fetal Neonatal Med 2022; 35 (01) 58-65
    CrossrefPubMedGoogle Scholar
  • 36 Shah VN, Snell-Bergeon JK, Demmitt JK. et al. Relationship between time-in-range, HbA1c, and the glucose management indicator in pregnancies complicated by type 1 diabetes. Diabetes Technol Ther 2021; 23 (12) 783-790
    CrossrefPubMedGoogle Scholar
  • 37 Singh P, Jonnalagadda P, Morgan E, Fareed N. Outpatient portal use in prenatal care: differential use by race, risk, and area social determinants of health. J Am Med Inform Assoc 2021; 29 (02) 364-371
    CrossrefPubMedGoogle Scholar
  • 38 Leziak K, Birch E, Jackson J, Strohbach A, Niznik C, Yee LM. Identifying mobile health technology experiences and preferences of low-income pregnant women with diabetes. J Diabetes Sci Technol 2021; 15 (05) 1018-1026
    CrossrefPubMedGoogle Scholar
  • 39 Kirk JK, D'Agostino Jr RB, Bell RA. et al. Disparities in HbA1c levels between African-American and non-Hispanic white adults with diabetes: a meta-analysis. Diabetes Care 2006; 29 (09) 2130-2136
    CrossrefPubMedGoogle Scholar
  • 40 Gary TL, McGuire M, McCauley J, Brancati FL. Racial comparisons of health care and glycemic control for African American and white diabetic adults in an urban managed care organization. Dis Manag 2004; 7 (01) 25-34
    CrossrefPubMedGoogle Scholar
  • 41 Heisler M, Faul JD, Hayward RA, Langa KM, Blaum C, Weir D. Mechanisms for racial and ethnic disparities in glycemic control in middle-aged and older Americans in the health and retirement study. Arch Intern Med 2007; 167 (17) 1853-1860
    CrossrefPubMedGoogle Scholar
  • 42 Shah NS, Wang MC, Freaney PM. et al. Trends in gestational diabetes at first live birth by race and ethnicity in the US, 2011-2019. JAMA 2021; 326 (07) 660-669
    Google Scholar
  • 43 Kirk JK, Passmore LV, Bell RA. et al. Disparities in A1C levels between Hispanic and non-Hispanic white adults with diabetes: a meta-analysis. Diabetes Care 2008; 31 (02) 240-246
    CrossrefPubMedGoogle Scholar
  • 44 Toschi E, Michals A, Adam A. et al. Usefulness of CGM-derived metric, the glucose management indicator, to assess glycemic control in non-white individuals with diabetes. Diabetes Care 2021; 44 (12) 2787-2789
    CrossrefPubMedGoogle Scholar