Written by Cynthia Herrick, MD, FACP, assistant professor in the Division of Endocrinology, Metabolism and Lipid Research at Washington University School of Medicine
Paving the path to reproductive equity requires raising awareness of the long term consequences of conditions first diagnosed in pregnancy. Pregnancy complications like gestational diabetes and pre-eclampsia serve as early warning signs for a woman’s future disease risk; however, our fragmented healthcare system often makes it difficult to effectively monitor and prevent disease in these women.
Women who have gestational diabetes (high blood sugar first diagnosed during pregnancy) have a substantial future risk of developing type 2 diabetes. Moreover, while gestational diabetes affects 5-9% of pregnancies in the U.S., it disproportionately affects racial and ethnic minority populations and women of lower socioeconomic status. Furthermore, while most women with gestational diabetes have normal blood sugars after delivery, up to half of women with gestational diabetes may progress to type 2 diabetes, usually in the first 5-10 years after the complicated pregnancy. Black and Hispanic women having the highest risk for progression.
Recognizing risk is the first step in establishing effective diabetes screening and prevention programs. Both the American College of Obstetricians and Gynecologists and the American Diabetes Association recommend that women get screened for diabetes 4-12 weeks after a pregnancy complicated by gestational diabetes, and they should continue to get screened for diabetes every 1-3 years for the rest of their life. This is because type 2 diabetes is preventable. Lifestyle changes that result in 5-10% weight loss and increase aerobic exercise to 150 minutes per week or the use of a medication called metformin can reduce the risk for developing type 2 diabetes by 50 % at 3 years and by 35-40% at 10 years among women with a history of gestational diabetes.
Unfortunately, many women do not get the screening they need. Only about half of women with private insurance get a recommended screening test in the first postpartum year. Follow-up is additionally complicated for women on Medicaid during pregnancy, particularly in states like Missouri, where women now qualify for Medicaid during pregnancy up to 305% of the federal poverty level (FPL) but lose comprehensive Medicaid coverage 60 days postpartum unless they make less than 21% of the FPL. By linking Medicaid administrative claims and electronic health records, our research group recently described follow-up care among women on Medicaid during pregnancy receiving care in Federally Qualified Health Centers. Among 1,078 women with gestational diabetes who delivered in Missouri from 2010-2015, 10% had recommended screening for diabetes by 12 weeks postpartum and 19% received a recommended screening test by one year postpartum. Overall, 30% of women ultimately received a recommended screening test after delivery and before the next pregnancy or the end of data.
Ongoing diabetes screening and prevention strategies are critical, particularly for women who are at risk of losing their health insurance after pregnancy. Programs that begin during pregnancy and continue into the postpartum period, when fewer resources have traditionally been available, may help bridge this gap. Incorporating community health workers and mobile technology in patient support and education may be part of the local solution. At the state level, adaptation of existing family planning waiver programs to cover diabetes screening and prevention services after 60 days postpartum could help women get needed care. However, Medicaid expansion to eliminate gaps in health coverage is ultimately necessary for advancing not only reproductive equity, but health equity, over the life course for Missouri mothers and their children.