Easter Sarah Rae, Rosenthal Emily W, Morton-Eggleston Emma, Nour Nawal, Tuomala Ruth, Zera Chloe A
Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Biology, and the Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Obstet Gynecol. 2017 Nov;130(5):946-952. doi: 10.1097/AOG.0000000000002252.
To investigate the association among public health insurance, preconception care, and pregnancy outcomes in pregnant women with pregestational diabetes.
This is a retrospective cohort of pregnant women with pregestational type 1 or type 2 diabetes from 2006 to 2011 in Massachusetts-a state with universal insurance coverage since 2006. Women delivering after 24 weeks of gestation and receiving endocrinology and obstetric care in a multidisciplinary clinic were included. Rates of preconception consultation, our primary outcome of interest, were then compared between publicly and privately insured women. We used univariate analysis followed by logistic regression to compare receipt of preconception consultation and other secondary diabetes care measures and pregnancy outcomes according to insurance status.
Fifty-four percent (n=106) of 197 women had public insurance. Publicly insured women were younger (median age 30.4 compared with 35.3 years, P<.01) with lower rates of college education (12.3% compared with 45.1%, P<.01). Women with public insurance were less likely to receive a preconception consult (5.7% compared with 31.9%, P<.01), had lower rates of hemoglobin A1C less than 6% at the onset of pregnancy (37.2% compared with 58.4%, P=.01), and experienced higher rates of pregnancies affected by congenital anomalies (10.4% compared with 2.2%, P=.02) compared with those with private insurance. In adjusted analyses controlling for educational attainment, maternal age, and body mass index, women with public insurance were less likely to receive a preconception consult (adjusted odds ratio [OR] 0.21, 95% CI 0.08-0.58), although the odds of achieving the target hemoglobin A1C (adjusted OR 0.45, 95% CI 0.20-1.02) and congenital anomaly (adjusted OR 2.23, 95% CI 0.37-13.41) were similar after adjustment.
Despite continuous access to health insurance, publicly insured women were less likely than privately insured women to receive a preconception consult-an evidence-based intervention known to improve pregnancy outcomes. Improving use of preconception care among publicly insured women with diabetes is critical to reducing disparities in outcomes.
探讨公共医疗保险、孕前保健与妊娠糖尿病孕妇妊娠结局之间的关联。
这是一项对2006年至2011年马萨诸塞州患有1型或2型孕前糖尿病孕妇的回顾性队列研究——自2006年起该州实行全民医保覆盖。纳入妊娠24周后分娩且在多学科诊所接受内分泌和产科护理的妇女。然后比较公共保险和私人保险妇女之间孕前咨询率（我们感兴趣的主要结局）。我们采用单因素分析，随后进行逻辑回归，以根据保险状况比较孕前咨询及其他继发性糖尿病护理措施的接受情况和妊娠结局。
197名妇女中有54%（n = 106）拥有公共保险。拥有公共保险的妇女更年轻（中位年龄30.4岁，而私人保险妇女为35.3岁，P <.01），大学教育率更低（12.3% 相比于45.1%，P <.01）。拥有公共保险的妇女接受孕前咨询的可能性更小（5.7% 相比于31.9%，P <.01），妊娠开始时血红蛋白A1C低于6%的比例更低（37.2% 相比于58.4%，P =.01），与私人保险妇女相比，受先天性异常影响的妊娠率更高（10.4% 相比于2.2%，P =.02）。在控制了教育程度、产妇年龄和体重指数的调整分析中，拥有公共保险的妇女接受孕前咨询的可能性更小（调整后的优势比[OR]为0.21，95%可信区间为0.08 - 0.58），尽管调整后达到目标血红蛋白A1C的几率（调整后的OR为0.45，95%可信区间为0.20 - 1.02）和先天性异常的几率（调整后的OR为2.23，95%可信区间为0.37 - 13.41）相似。
尽管能持续获得医疗保险，但拥有公共保险的妇女比拥有私人保险的妇女接受孕前咨询的可能性更小——孕前咨询是一种已知可改善妊娠结局的循证干预措施。提高患有糖尿病的公共保险妇女对孕前保健的利用对于减少结局差异至关重要。
