Acta Diabetologica

, Volume 55, Issue 3, pp 243–251 | Cite as

Maternal educational level and the risk of persistent post-partum glucose metabolism disorders in women with gestational diabetes mellitus

  • Inês Gante
  • Ana Carina Ferreira
  • Gonçalo Pestana
  • Daniela Pires
  • Njila Amaral
  • Jorge Dores
  • Maria do Céu Almeida
  • José Luis Sandoval
Original Article



Gestational diabetes mellitus (GDM) occurs in 5–15% of pregnancies, and lower maternal educational attainment has been associated with higher risk of GDM. We aimed to determine if maternal education level is associated with persistent post-partum glucose metabolism disorders in women with GDM.


Retrospective cohort study of women with GDM followed in 25 Portuguese health institutions between 2008 and 2012. Educational attainment was categorised into four levels. Prevalence of post-partum glucose metabolism disorders (type 2 diabetes mellitus, increased fasting plasma glucose or impaired glucose tolerance) was compared and adjusted odds ratios calculated controlling for confounders using logistic regression.


We included 4490 women diagnosed with GDM. Educational level ranged as follows: 6.8% (n = 307) were at level 1 (≤ 6th grade), 34.6% (n = 1554) at level 2 (6–9th grade), 30.4% (n = 1364) at level 3 (10–12th grade) and 28.2% (n = 1265) at level 4 (≥ university degree). At 6 weeks post-partum re-evaluation, 10.9% (n = 491) had persistent glucose metabolism disorders. Educational levels 1 and 2 had a higher probability of persistent post-partum glucose metabolism disorders when compared to level 4 (OR = 2.37 [1.69;3.32], p < 0.001 and OR = 1.39 [1.09;1.76], p = 0.008, for level 1 and 2, respectively), an association that persisted in multivariable logistic regression adjusting for confounders (level 1 OR = 2.25 [1.53;3.33], p < 0.001; level 2 OR = 1.43 [1.09;1.89], p = 0.01).


Persistent post-partum glucose metabolism disorders are frequent in women with GDM and associated with lower maternal educational level. Interventions aimed at this risk group may contribute towards a decrease in prevalence of post-partum glucose metabolism disorders.


Diabetes Gestational Education Women Post-partum 



We thank the multidisciplinary teams of obstetricians and diabetologists of Portuguese health institutions who collected patient data for the National Registry of Gestational Diabetes. In addition, we would like to acknowledge the alumni and faculty of the Harvard Medical School—Portugal Clinical Scholars Research Training Programme for useful scientific discussions. DP was partially supported by Fundação para a Ciência e Tecnologia under the Program for doctoral training in clinical research for medical interns (SFRH/SINT/95317/2013).


This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

All procedures in this study were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

For this type of study using retrospective and anonymised data, participants’ written consent was not required.

Supplementary material

592_2017_1090_MOESM1_ESM.xlsx (332 kb)
Supplementary material 1 (XLSX 331 kb)
592_2017_1090_MOESM2_ESM.docx (29 kb)
Supplementary material 2 (DOCX 29 kb)
592_2017_1090_MOESM3_ESM.pdf (15 kb)
Supplementary material 3 (PDF 15 kb)
592_2017_1090_MOESM4_ESM.pdf (12 kb)
Supplementary material 4 (PDF 11 kb)


  1. 1.
    Kampmann U, Madsen LR, Skajaa GO, Iversen DS, Moeller N, Ovesen P (2015) Gestational diabetes: a clinical update. World J Diabetes 6(8):1065–1072. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Metzger BE, Lowe LP, Dyer AR, Trimble ER, Chaovarindr U, Coustan DR et al (2008) Hyperglycemia and adverse pregnancy outcomes. N Engl J Med 358(19):1991–2002. CrossRefPubMedGoogle Scholar
  3. 3.
    Di Cianni G, Miccoli R, Volpe L, Lencioni C, Del Prato S (2003) Intermediate metabolism in normal pregnancy and in gestational diabetes. Diabetes Metab Res Rev 19(4):259–270. CrossRefPubMedGoogle Scholar
  4. 4.
    Gorgal R, Goncalves E, Barros M, Namora G, Magalhaes A, Rodrigues T et al (2012) Gestational diabetes mellitus: a risk factor for non-elective cesarean section. J Obstet Gynaecol Res 38(1):154–159. CrossRefPubMedGoogle Scholar
  5. 5.
    Mitanchez D, Yzydorczyk C, Simeoni U (2015) What neonatal complications should the pediatrician be aware of in case of maternal gestational diabetes? World J Diabetes 6(5):734–743. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Simeoni U, Barker DJ (2009) Offspring of diabetic pregnancy: long-term outcomes. Semin Fetal Neonatal Med 14(2):119–124. CrossRefPubMedGoogle Scholar
  7. 7.
    Yogev C, Hod C, Oats M et al (2010) Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study: preeclampsia. Am J Obstet Gynecol 202(3):255 e1–255 e7. CrossRefGoogle Scholar
  8. 8.
    Kim C, Newton KM, Knopp RH (2002) Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 25(10):1862–1868CrossRefPubMedGoogle Scholar
  9. 9.
    Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (2003) Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 26(Suppl 1):S5–S20.
  10. 10.
    Grundy SM, Benjamin IJ, Burke GL, Chait A, Eckel RH, Howard BV et al (1999) Diabetes and cardiovascular disease: a statement for healthcare professionals from the American Heart Association. Circulation 100(10):1134–1146CrossRefPubMedGoogle Scholar
  11. 11.
    Nathan DM, Davidson MB, DeFronzo RA, Heine RJ, Henry RR, Pratley R et al (2007) Impaired fasting glucose and impaired glucose tolerance: implications for care. Diabetes Care 30(3):753–759. CrossRefPubMedGoogle Scholar
  12. 12.
    Lee AJ, Hiscock RJ, Wein P, Walker SP, Permezel M (2007) Gestational diabetes mellitus: clinical predictors and long-term risk of developing type 2 diabetes: a retrospective cohort study using survival analysis. Diabetes Care 30(4):878–883. CrossRefPubMedGoogle Scholar
  13. 13.
    Magliano DJ, Barr EL, Zimmet PZ, Cameron AJ, Dunstan DW, Colagiuri S et al (2008) Glucose indices, health behaviors, and incidence of diabetes in Australia: the Australian Diabetes, Obesity and Lifestyle Study. Diabetes Care 31(2):267–272. CrossRefPubMedGoogle Scholar
  14. 14.
    Bouthoorn SH, Silva LM, Murray SE, Steegers EA, Jaddoe VW, Moll H et al (2015) Low-educated women have an increased risk of gestational diabetes mellitus: the Generation R Study. Acta Diabetol 52(3):445–452. CrossRefPubMedGoogle Scholar
  15. 15.
    Carpenter MW, Coustan DR (1982) Criteria for screening tests for gestational diabetes. Am J Obstet Gynecol 144(7):768–773CrossRefPubMedGoogle Scholar
  16. 16.
    World Health Organization (2014) Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy: a World Health Organization Guideline. Diabetes Res Clin Pract 103(3):341–363.
  17. 17.
    Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA, Damm P et al (2010) International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 33(3):676–682. CrossRefPubMedGoogle Scholar
  18. 18.
    Rasmussen KM, Yaktine AL (eds) (2009) Weight gain during pregnancy—reexamining the guidelines. Washington (DC): National Academies Press (US)Google Scholar
  19. 19.
    Dores JM, Magalhães A, Carvalheiro M (2017) Relatório de Consenso sobre a Diabetes e Gravidez. Portuguese General-Directorate of Health. 2011.
  20. 20.
    Ferrara A, Peng T, Kim C (2009) Trends in postpartum diabetes screening and subsequent diabetes and impaired fasting glucose among women with histories of gestational diabetes mellitus: a report from the Translating Research Into Action for Diabetes (TRIAD) Study. Diabetes Care 32(2):269–274. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Bennett WL, Ennen CS, Carrese JA, Hill-Briggs F, Levine DM, Nicholson WK et al (2011) Barriers to and facilitators of postpartum follow-up care in women with recent gestational diabetes mellitus: a qualitative study. J Womens Health (Larchmt) 20(2):239–245. CrossRefGoogle Scholar
  22. 22.
    Pastore I, Chiefari E, Vero R, Brunetti A (2017) Postpartum glucose intolerance: an updated overview. Endocrine. Google Scholar
  23. 23.
    White IR, Royston P, Wood AM (2011) Multiple imputation using chained equations: issues and guidance for practice. Stat Med 30(4):377–399. CrossRefPubMedGoogle Scholar
  24. 24.
    Coustan DR, Carpenter MW, O’Sullivan PS, Carr SR (1993) Gestational diabetes: predictors of subsequent disordered glucose metabolism. Am J Obstet Gynecol 168(4):1139–1144 (discussion 44–5) CrossRefPubMedGoogle Scholar
  25. 25.
    Kjos SL, Buchanan TA, Greenspoon JS, Montoro M, Bernstein GS, Mestman JH (1990) Gestational diabetes mellitus: the prevalence of glucose intolerance and diabetes mellitus in the first two months post partum. Am J Obstet Gynecol 163(1 Pt 1):93–98CrossRefPubMedGoogle Scholar
  26. 26.
    Schaefer-Graf UM, Buchanan TA, Xiang AH, Peters RK, Kjos SL (2002) Clinical predictors for a high risk for the development of diabetes mellitus in the early puerperium in women with recent gestational diabetes mellitus. Am J Obstet Gynecol 186(4):751–756CrossRefPubMedGoogle Scholar
  27. 27.
    Nielsen LR, Ekbom P, Damm P, Glumer C, Frandsen MM, Jensen DM et al (2004) HbA1c levels are significantly lower in early and late pregnancy. Diabetes Care 27(5):1200–1201CrossRefPubMedGoogle Scholar
  28. 28.
    Wild S, Roglic G, Green A, Sicree R, King H (2004) Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 27(5):1047–1053CrossRefPubMedGoogle Scholar
  29. 29.
    Karve A, Hayward RA (2010) Prevalence, diagnosis, and treatment of impaired fasting glucose and impaired glucose tolerance in nondiabetic U.S. adults. Diabetes Care 33(11):2355–2359. CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    American Diabetes Association (2015) 5. Prevention or delay of type 2 diabetes. Diabetes Care 38(Suppl 1):S31–S32.

Copyright information

© Springer-Verlag Italia S.r.l., part of Springer Nature 2017

Authors and Affiliations

  1. 1.Department of ObstetricsMaternidade Bissaya Barreto - Centro Hospitalar e Universitário de CoimbraCoimbraPortugal
  2. 2.Department of NephrologyHospital Curry Cabral - Centro Hospitalar Lisboa CentralLisbonPortugal
  3. 3.Department of CardiologyCentro Hospitalar de São JoãoPortoPortugal
  4. 4.Department of Infectious DiseasesCentro Hospitalar de Lisboa Norte and Faculdade de Medicina de LisboaLisbonPortugal
  5. 5.Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
  6. 6.Department of Obstetrics and GynecologyHospital Beatriz AngeloLouresPortugal
  7. 7.Department of EndocrinologyCentro Hospitalar do PortoPortoPortugal
  8. 8.Unit of Population Epidemiology, Department of Community Medicine, Primary Care, and Emergency MedicineGeneva University HospitalsGenevaSwitzerland

Personalised recommendations