High Risk Pregnancy – Mitigating Risks for Type 1 Diabetes + Black Maternal Health Outcomes

This content originally appeared on Beyond Type 1. Republished with permission.

By Kayla Hui, MPH

In 2020, Ariel Lawrence, a diabetes advocate and creator of Just A Little Suga–a storytelling platform that centers people of color with diabetes–found out that she was pregnant. Although Lawrence was excited, she couldn’t help but feel anxious. As a Black woman living with type 1 diabetes, Lawrence worried about how the intersection of having diabetes and being a Black woman would impact her and her baby.

According to Christopher Nau, MD, a doctor of maternal fetal medicine based in Cleveland, Ohio, timely access to diabetes and maternal health care is crucial, especially for Black women who—due to multiple factors including systemic racism and implicit bias— are three times more likely to die from childbirth compared to white women in the U.S.

“Once I found out that I was pregnant, I was experiencing a lot of anxiety. And although I was working with the care team to make sure that my management was tighter and my blood sugars were in range, the reality was that there were moments where it wasn’t in range, there were high blood sugars, and sometimes, there were high blood sugars for extended periods of time,” Lawrence tells Beyond Type 1.

Lawrence’s blood sugar level concerns lingered since getting diagnosed with type 1 when she was in the tenth grade. “In college, there was a nurse who had said to me, type 1 diabetes and pregnancy don’t mix,” Lawrence recalls. “At that point in my diabetes journey, I remember struggling to get my A1c below a 7.2. So for the longest, there was this question of can I actually do what I need to sustain a healthy pregnancy while living with diabetes?”

According to research, Black women are four times more likely to receive zero to five prenatal care visits when compared with white women. In addition to receiving statistically lower levels of care, “Black women are less likely to get into care early in the first trimester, which is important specifically for someone who has diabetes,” Nau says.

One of the contributing factors to poor health outcomes for pregnant Black people is systemic racism. Compared to pregnant white people, pregnant Black people are more likely to experience unfair treatment and discrimination within the healthcare system, such as being spoken to disrespectfully by healthcare personnel, being ignored after expressing fears/concerns, and experiencing poor bedside manner.

In addition to systemic racism, implicit bias–attitudes and stereotypes of other groups that manifest in overt and intentional discrimination–hampers maternal health for Black pregnant people. Implicit bias can impact a medical professional’s judgement to provide treatment and care in a timely manner. It can also hinder patient and provider communication.

When racial biases are expressed in a condescending manner, it can decrease the likelihood that patients will feel valued or heard and providers will recommend treatment options for patients.

Research shows that implicit bias is directly correlated with lower quality of care. A 2012 study found that cesarean deliveries–deliveries that can lead to more negative health outcomes for the pregnant individual and baby, including maternal mortality–were more common among Black and Latina women than white women.

From 2007 to 2016, there were 40.8 pregnancy-related deaths for Black women per 100,000 live births, triple the mortality rate compared to white women, who had 12.7 pregnancy-related deaths per 100,000 live births.

“I’m concerned as a Black woman with my own health, and whether or not I’ll live to share the experience of my birth because there have been so many women who unfortunately have passed away,” Lawrence says.

When Black pregnant people with diabetes do not receive timely maternal and diabetes care, Nau says that their blood sugar levels can rise, increasing the risk of miscarriage and birth defects increases. “The risk can be as high as 20 to 25 percent in someone who’s very poorly controlled,” Nau explains.

As a result, fetuses can have birth defects, such as cardiac malformations. Poorly controlled diabetes may also result in increased risk for stillbirth, respiratory distress, and jaundice, Nau explains. He adds that babies are at risk of hypoglycemia, also known as low blood sugar, initially after delivery.

When pregnant people have consistently elevated blood glucose levels, it can also increase the chances of having a c-section. When a baby is delivered by a c-section, pregnant people may take longer to recover post childbirth.

Strength of a Medical and Health Support System

Aware of the maternal health outcomes for Black women, Lawrence hired a doula, which helped ease her anxiety surrounding pregnancy. “I was aware that when it came to Black maternal health outcomes, Black women are more likely to experience a C-section and have complications as a result,” Lawrence says. “To help minimize my anxiety, I decided to find a doula.” For Lawrence, having a doula meant having an advocate and support system.

According to DONA International, doulas offer physical, emotional, and partner support throughout the pregnancy, birth, and early postpartum period. Research shows that women who use a birth doula are less likely to have a c-section, use pain medication, need pitocin, and more likely to rate their childbirth experience positively.

During the birthing process, Lawrence’s doula liaised and communicated between Lawrence and medical professionals to ensure that Lawrence knew what the doctors were doing.

Coupled with a doula, Lawrence also leaned on her therapist for support. “I was afraid that something bad might happen. So, I had a therapist supporting me through that,” Lawrence says.

Improving Maternal Health Outcomes for Black Pregnant People With Diabetes

Alissa Erogbogbo, MD, medical director of operations at Hospitalist Group, says that there are opportunities to improve maternal health outcomes for Black pregnant people with diabetes through legislation. She says that an ideal bill would include postpartum follow up. “Whether it’s a nurse that they follow up with, a phone call to make sure they [pregnant people] are checking their blood sugars, there’s a lot of opportunity to really decrease the maternal mortality rate,” Erobogbo says.

In the U.S, the Medicaid program provides coverage for almost half of all births. Unfortunately, coverage only lasts 60 days postpartum. States have the option to extend Medicaid postpartum coverage for 12 months by applying for a section 1115 waiver. In April 2021, Illinois became the first state to extend Medicaid coverage for up to one full year after pregnancy. Joining Illinois’s postpartum Medicaid expansion are Missouri and Georgia.

However, there is still a long way to go, according to Erogbogbo. A handful of states including Colorado, Texas, Wisconsin, and Florida have enacted legislation to seek federal approval of their 1115 waiver, but the majority of states have taken no direction.

“Most states need to follow that bandwagon. Continuity of care helps you understand how your health is progressing, what preventative measures that you can take,” Erogbogbo tells Beyond Type 1.

While postpartum coverage is available in some states, Medicaid program expansion is far from sufficient. To build on current maternal health efforts, Congresswoman Alma Adams, Senator Cory Booker, and members of the Black Maternal Health Caucus introduced the Black Maternal Health Momnibus Act of 2021, a bill that would not only expand postpartum coverage for up to 24 months postpartum under the Special Supplemental Nutrition Program for Woman, Infants, and Children, but improve maternal health among racial and ethnic groups by addressing the social determinants of health.

If the Momnibus Act is passed, it would implement several actions such as providing funding to community-based organizations that are working to improve the maternal health space, diversifying the perinatal workforce to ensure that pregnant people are receiving culturally sensitive maternity care, improving data collection to better understand the causes of maternal health outcomes, and promoting innovative payment models to incentivize high-quality maternal health care and non-clinical perinatal support.

The bill was first introduced to the house on February 8, 2021 and was referred to the subcommittee on Crime, Terrorism, and Homeland Security on April 23, 2021. Since the bill’s inception, it has been endorsed by over 240 organizations.

The aforementioned policies are not an end-all solution, but serve as a start to addressing disparate health outcomes for Black pregnant people on the policy level. People can also advocate to improve Black maternal and health conditions by:

Resources

Source: diabetesdaily.com

Pregnancy, Delivery, and Postpartum Care During the COVID-19 Pandemic

Almost any pregnancy is full of excitement but can be stressful at times. Add in having diabetes and living through a global pandemic, and it can be quite anxiety-provoking. This article summarizes how recent policy changes due to COVID-19 may be affecting women with diabetes who are currently pregnant or have recently given birth.

A High-Risk Pregnancy

For women with diabetes, pregnancy is automatically classed as a high-risk affair. Although a healthy pregnancy is very possible with any type of diabetes, a lot of emphasis is placed on optimizing glycemic management, and women are closely followed with extra appointments and ultrasound scans throughout the pregnancy, and in particular, during the third trimester.

Telemedicine and In-Person Appointments

For those who are going through pregnancy during the COVID-19 pandemic, certain appointments may be possible to achieve via telemedicine. For example, if you’re working with an endocrinologist to manage your blood sugar levels, odds are, that can be achieved largely through telemedicine (or email). However, certain other checks (like ultrasounds), or if a woman is experiencing concerns or complications, there is no substitute for an in-person healthcare provider or even a hospital visit.

Ask your provider(s) which in-person appointments they expect you to keep and why. Also, keep in mind that there will likely be additional precautions, like waiting in your vehicle, instead of the waiting room, for example.

To curtail the spread of the novel coronavirus, most doctors’ offices and hospitals have now implemented strict policies concerning the number of visitors who are allowed at appointments. Most will find that for all (or almost all) appointments, women will be asked to come to their appointment without any additional visitors.

Of course, these new policies, while important, also can bring up considerable emotional issues. Pregnancy is supposed to be an exciting time, most often shared with loved ones, like your partner and family. Milestone appointments, attended alone, may feel bittersweet.

To help increase support during these times, ask your healthcare providers what their specific policies are and inquire whether it is possible to have your support person or people attend with you virtually. For instance, you may find that your practice will allow your partner to phone in via videochat to virtually experience a milestone ultrasound, and will give them an opportunity to ask any questions that they might have. While not the same as under normal circumstances, this can offer women more emotional support during these exciting (and challenging) times.

Labor and Delivery

One fear that many women are expressing these days (and rightfully so!) is one of having to labor and deliver their babies without a support person. While formal “birth plans” are notorious for falling apart (at least somewhat, as no birth is predictable), this is perhaps the first time in our recent history that women have to worry about not being able to have their emotional support system in place for the big event.

It appears that most hospitals are balancing the need for limiting viral spread with the importance of emotional support for patients during this critical time. Most likely, your hospital will allow one support person to attend your labor and delivery (although this may not be the case everywhere, especially in COVID-19 disease epicenters). However, be prepared that they may not be able to accompany you during the postpartum hospital stay. Ask your hospital ahead of time what the policy is (also for vaginal delivery vs. c-section) so you can be prepared. Also, you may find that (if deemed appropriate) your discharge from the hospital may happen sooner than what is typical.

Diabetes online community member, Shannon M. (who has type 1 diabetes) described to us her challenging experience with delivering her baby boy amid the COVID-19 outbreak:

“I planned on being induced at 39 weeks but was induced the day I hit 38 weeks due to the doctors personal concern about the virus. The hospital was also thinking of starting to allow no help in the delivery room and they wanted to make sure I had someone there with me, as well as to get in and out of the hospital before the virus spread got even worse. My biggest concern the entire time ended up being for the virus rather than health of the baby in general.

While I was in labor, they decided I needed an emergency c-section and took me into another room. I was concerned about going into so many different rooms because that increased my chances of getting the virus rather than being afraid of the c-section itself.

After everything, my baby was taken to NICU for low blood sugars. As I had expected this, I wasn’t too worried, but again, worried about his extended stay in the hospital because of the virus. This also meant I had to visit him daily in the hospital, which concerned me, trying to not get the virus myself and transfer it to him or the rest of my family.

They only let me recover one day in the hospital from the c-section, when it’s usually three days. The social worker admitted to me the cases were getting bad in our hospital and just wanted everyone who didn’t absolutely have to be there, out. Everyone had to wear masks and gloves throughout the hospital. One of my nurses continued to not wear her mask around me and it made me very paranoid.

My baby is still in the NICU. It has now been 13 days and I still have anxiety visiting him. I don’t leave his room to eat or use the restroom unless I absolutely have to. It’s been a horrible experience and cannot wait to get him home. I also live in Essex county NJ, which is the second-worst infected county in the second-most infected state, as we are 20 minutes from NYC.”

Postpartum Care

In addition to possibly leaving the hospital earlier than expected, women are likely going to experience more isolation than they normally would. Importantly, this can affect the rates of postpartum depression, which is of great concern.

Taking time every day for essential self-care and human connection is important for all new moms and is perhaps even more critical during these tough times. Having a support system in place, even if you’re only able to communicate remotely, can help women feel more supported.

Photo credit: smpratt90 (Pixabay)

While many women will probably attend their 6-week postpartum check-up (especially for birth control, like an IUD), this may not be the case for those who don’t have any upcoming procedures, questions or concerns (I actually cancelled my own 6-week postpartum check-up that was supposed to take place mid-March). Be sure to bring up any physical or mental health concerns to your doctor right away. Don’t forget that many issues can be addressed via telemedicine (e.g., mental health appointments), so you can safely stay at home with your baby.

Also, don’t forget to check in with your pediatrician’s office about what their policies are. Most likely, only one parent will be able to attend the child’s well-visit appointments. Some appointments may even be postponed, depending on the specific circumstances.

Jennifer A., who delivered her son at the end of March, describes:

“My son has only had one appointment over a phone chat. It was OK. I prefer to keep him safe but I also want to make sure my son is healthy and growing right and that is hard to tell over a phone.”

Conclusions

Going through pregnancy, labor and delivery, and the postpartum period, while also managing diabetes, is difficult enough but can feel overwhelming during a global virus pandemic. Understanding that the inconvenient policies are there to help protect you and your baby, and getting the mental health and emotional support you need during and after pregnancy is key to keeping the big picture in mind and being able to enjoy this very special time.

Are you currently pregnant or have recently had a baby during this crisis? We’d love to hear about your thoughts and experiences.

Source: diabetesdaily.com

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