December 8, 2022
We are pleased to have the opportunity to express our views about the Women’s Preventive Services Initiative (WPSI) recommendations for diabetes screening after pregnancy.
The National Center for Health Research (NCHR) is a nonprofit think tank that conducts, analyzes, and scrutinizes research on a range of health issues, with particular focus on which prevention strategies and treatments are most effective for which patients and consumers. We do not accept funding from companies that make products that are the subject of our work, so we have no conflicts of interest.
We appreciate WPSI encouraging continued diligence during the postpartum period in patients who were diagnosed with diabetes mellitus during pregnancy. Because a diagnosis of gestational diabetes increases a patient’s chances of getting type 2 diabetes, it is critical to ensure these patients are closely followed.
To reflect the high risk of type 2 diabetes in these patients, the WPSI now recommends universal screening rather than risk-based screening for all patients diagnosed with diabetes during pregnancy. Initially, patients should be screened for diabetes in the first four to six weeks and up to one year postpartum. Thereafter, WPSI recommends a screening test at least every 3 years for a minimum of 10 years after pregnancy for women who did not have a screening test in the first year postpartum or those with a negative initial postpartum screening test.
Women who had a negative screening test in the early postpartum period should have a repeat test beyond six months postpartum for confirmation. This is especially true if the hemoglobin A1C test is used because it is less accurate in the early weeks and months after pregnancy. Women who had a positive screening test in the early postpartum period should have a repeat test at least six months postpartum to confirm the diagnosis of diabetes, regardless of the type of initial test.
We encourage additional research into barriers to obtaining this important diabetes screening after pregnancy. Research suggests that women are not getting the screening they need, and it is important to determine why. For example, in one study of more than 12,000 women with diabetes during pregnancy, 70% had neither glucose testing nor a primary care visit at one year and 33% had neither at three years1. Only about six percent underwent any glucose test within the first eight weeks postpartum. Of those, only 60% received the recommended oral glucose tolerance test1. All women in the study had continuous insurance. Another study found that even when about 95% of women had an ambulatory care visit during the first six months postpartum, less than five percent completed the recommended oral glucose tolerance test2. Other studies have found similarly poor adherence to postpartum diabetes screening recommendations.
We are especially concerned that researchers have found racial variation in postpartum screening rates3. Although Black women are most likely to progress to type 2 diabetes after a pregnancy affected by gestational diabetes, they have a very low rate of diabetes screening after pregnancy3. Given such poor follow-up, it is critical to conduct research to explore what social and structural barriers stop patients from getting this vital screening. Such research will help develop interventions to overcome these obstacles. Studies should examine barriers from both the patient and provider perspectives and address unique problems faced by different ethnic groups.
Additionally, we recommend further research into the long-term sequelae of diabetes during pregnancy, including such problems as metabolic syndrome2, cardiovascular disease4 and kidney disease5. For example, one study that followed more than 1,000 women over about 25 years found that patients with a history of diabetes during pregnancy had a 60% greater likelihood of developing cardiovascular disease and an increased likelihood of having a heart attack or myocardial infarction (MI)4. The health impact on these patients may develop over decades and span various medical disciplines. This suggests that adequate follow-up will likely require input from a variety of specialists in addition to the Ob/Gyn and primary care physician. Additional research into long-term complications may result in the development of recommendations that address possible health outcomes that may occur throughout a patient’s lifetime.
- Bernstein JA, Quinn E, Ameli O, et al. Follow-up after gestational diabetes: a fixable gap in women’s preventive healthcare. BMJ Open Diab Res Care. 2017;5(1):e000445. doi:10.1136/bmjdrc-2017-000445
- Thayer SM, Lo JO, Caughey AB. Gestational Diabetes. Obstetrics and Gynecology Clinics of North America. 2020;47(3):383-396. doi:10.1016/j.ogc.2020.04.002
- Balaji B, Ranjit Mohan A, Rajendra P, Mohan D, Ram U, Viswanathan M. Gestational Diabetes Mellitus Postpartum Follow-Up Testing: Challenges and Solutions. Canadian Journal of Diabetes. 2019;43(8):641-646. doi:10.1016/j.jcjd.2019.04.011
- Tobias DK, Stuart JJ, Li S, et al. Association of History of Gestational Diabetes With Long-term Cardiovascular Disease Risk in a Large Prospective Cohort of US Women. JAMA Intern Med. 2017;177(12):1735. doi:10.1001/jamainternmed.2017.2790
- Barrett PM, McCarthy FP, Evans M, et al. Does gestational diabetes increase the risk of maternal kidney disease? A Swedish national cohort study. Mortazavi F, ed. PLoS ONE. 2022;17(3):e0264992. doi:10.1371/journal.pone.0264992