Health service use and health system costs associated with diabetes during pregnancy in Australia.

BACKGROUND AND AIMS: In the context of the rising rate of diabetes in pregnancy in Australia, this study aims to examine the health service and resource use associated with diabetes during pregnancy. METHODS AND RESULTS: This project utilised a linked administrative dataset containing health and cost data for all mothers who gave birth in Queensland, Australia between 2012 and 2015 (n = 186,789, plus their babies, n = 189,909). The association between maternal characteristics and diabetes status were compared with chi-square analyses. Multiple logistic regression produced the odds ratio of having different outcomes for women who had diabetes compared to women who did not. A two-sample t-test compared the mean number of health services accessed. Generalised linear regression produced the mean costs associated with health service use. Mothers who had diabetes during pregnancy were more likely to have their labour induced at <38 weeks gestation (OR:1.39, 95% CI:1.29-1.50); have a cesarean section (OR: 1.26, 95% CI:1.22-1.31); have a preterm birth (OR:1.24, 95%: 1.18-1.32); have their baby admitted to a Special Care Nursery (OR: 2.34, 95% CI:2.26-2.43) and a Neonatal Intensive Care Unit (OR:1.25, 95%CI: 1.14-1.37). On average, mothers with diabetes access health services on more occasions during pregnancy (54.4) compared to mothers without (50.5). Total government expenditure on mothers with diabetes over the first 1000 days of the perinatal journey was significantly higher than in mothers without diabetes ($12,757 and $11,332). CONCLUSION: Overall, mothers that have diabetes in pregnancy require greater health care and resource use than mothers without diabetes in pregnancy.

Outcomes, care utilization, and expenditures in adolescent pregnancy complicated by diabetes.

BACKGROUND AND OBJECTIVE: Adolescence and pregestational diabetes separately increase risks of adverse pregnancy outcomes, but little is known about their combined effect. To analyze pregnancy outcomes, healthcare utilization, and expenditures in adolescent pregnancies with and without pregestational diabetes using a national claims database. METHODS: Retrospective study using Truven Health MarketScan Commercial Claims and Encounters Database, 2011 to 2015. Females 12 to 19 years old, continuously enrolled for at least 12 months before a livebirth until 2 months after, were included. Pregestational diabetes, diabetes complications (ketoacidosis, retinopathy, neuropathy, nephropathy), comorbidities, and pregnancy outcomes (preeclampsia, preterm delivery, high birthweight, cesarean delivery) were identified using claims data algorithms. Healthcare utilization and payer expenditure were tabulated per enrollee. Multivariate logistic regressions assessed pregnancy outcomes; multivariate OLS regression assessed payer expenditures. RESULTS: About 33 502 adolescents were included. Adolescents without diabetes had pregnancy outcomes consistent with national estimates. Adolescents with uncomplicated diabetes had increased odds of preeclampsia adjusted odds ratios 2.41 (95% confidence interval 1.93-3.02), preterm delivery 1.50 (1.21-1.87), high birthweight 1.84 (1.50-2.27), and cesarean delivery 1.81 (1.52-2.15). Diabetes with ketoacidosis and/or end-organ damage had higher odds of preeclampsia 5.62 (2.77-11.41), preterm delivery 5.81 (3.00-11.25), high birthweight 2.38 (1.08-5.24), and cesarean delivery 3.43 (1.78-6.64). Adolescents with diabetes utilized significantly more outpatient and inpatient care during pregnancy. Payer expenditures increased by 45.3% (34.8-55.9%) among adolescents with diabetes and by 82.6% (49.1-116.0%) among adolescents with diabetes complicated by ketoacidosis and/or end-organ damage. CONCLUSION: Compared with normal adolescent pregnancies, pregestational diabetes significantly increases risks of adverse pregnancy outcomes and significantly escalates healthcare utilization and cost.

Trends in the incidence of diabetes, its clinical sequelae, and associated costs in pregnancy.

BACKGROUND: Increasing diabetes prevalence affects a substantial number of pregnant women in the United States. Our aims were to evaluate health outcomes, medical costs, risks and types of complications associated with diabetes in pregnancy for mothers and newborns. METHODS: In this retrospective claims analysis, patients were identified from the Truven Health MarketScan(®) database (2004-2011 inclusive). Participants were aged 18-45 years, with ascertainable diabetes status [Yes/No], date of birth event >2005 and continuous health plan enrolment ≥21 months before and 3 months after the birth. RESULTS: In total, 839 792 pregnancies were identified, and 66 041 (7.86%) were associated with diabetes mellitus [type 1 (T1DM), 0.13%; type 2 (T2DM), 1.21%; gestational (GDM), 6.29%; and GDM progressing to T2DM (patients without prior diabetes who had a T2DM diagnosis after the birth event), 0.23%]. Relative risk (RR) of stillbirth (2.51), miscarriage (1.28) and Caesarean section (C-section) (1.77) was significantly greater with T2DM versus non-diabetes. Risk of C-section was also significantly greater for other diabetes types [RR 1.92 (T1DM); 1.37 (GDM); 1.63 (GDM progressing to T2DM)]. Risk of overall major congenital (RR ≥ 1.17), major congenital circulatory (RR ≥ 1.19) or major congenital heart (RR ≥ 1.18) complications was greater in newborns of mothers with diabetes versus without. Mothers with T2DM had significantly higher risk (RR ≥ 1.36) of anaemia, depression, hypertension, infection, migraine, or cardiac, obstetrical or respiratory complications than non-diabetes patients. Mean medical costs were higher with all diabetes types, particularly T1DM ($27 531), than non-diabetes ($14 355). CONCLUSIONS: Complications and costs of healthcare were greater with diabetes, highlighting the need to optimize diabetes management in pregnancy.

Comparison of maternal morbidity and medical costs during pregnancy and delivery between patients with gestational diabetes and patients with pre-existing diabetes.

AIMS: To evaluate the effects of gestational diabetes and pre-existing diabetes on maternal morbidity and medical costs, using data from the Korea National Health Insurance Claims Database of the Health Insurance Review and Assessment Service. METHODS: Delivery cases in 2010, 2011 and 2012 (459 842, 442 225 and 380 431 deliveries) were extracted from the Health Insurance Review and Assessment Service database. The complications and medical costs were compared among the following three pregnancy groups: normal, gestational diabetes and pre-existing diabetes. RESULTS: Although, the rates of pre-existing diabetes did not fluctuate (2.5, 2.4 and 2.7%) throughout the study, the rate of gestational diabetes steadily increased (4.6, 6.2 and 8.0%). Furthermore, the rates of pre-existing diabetes and gestational diabetes increased in conjunction with maternal age, pre-existing hypertension and cases of multiple pregnancy. The risk of pregnancy-induced hypertension, urinary tract infections, premature delivery, liver disease and chronic renal disease were greater in the gestational diabetes and pre-existing diabetes groups than in the normal group. The risk of venous thromboembolism, antepartum haemorrhage, shoulder dystocia and placenta disorder were greater in the pre-existing diabetes group, but not the gestational diabetes group, compared with the normal group. The medical costs associated with delivery, the costs during pregnancy and the number of in-hospital days for the subjects in the pre-existing diabetes group were the highest among the three groups. CONCLUSIONS: The study showed that the rates of pre-existing diabetes and gestational diabetes increased with maternal age at pregnancy and were associated with increases in medical costs and pregnancy-related complications.

Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States.

OBJECTIVE: Preconception care for women with diabetes can reduce the occurrence of adverse birth outcomes. We aimed to estimate the preconception care (PCC)-preventable health and cost burden of adverse birth outcomes associated with diagnosed and undiagnosed pregestational diabetes mellitus (PGDM) in the United States. STUDY DESIGN: Among women of reproductive age (15-44 years), we estimated age- and race/ethnicity-specific prevalence of diagnosed and undiagnosed diabetes. We applied age and race/ethnicity-specific pregnancy rates, estimates of the risk reduction from PCC for 3 adverse birth outcomes (preterm birth, major birth defects, and perinatal mortality), and lifetime medical and lost productivity costs for children with those outcomes. Using a probabilistic model, we estimated the reduction in adverse birth outcomes and costs associated with universal PCC compared with no PCC among women with PGDM. We did not assess maternal outcomes and associated costs. RESULTS: We estimated 2.2% of US births are to women with PGDM. Among women with diagnosed diabetes, universal PCC might avert 8397 (90% prediction interval [PI], 5252-11,449) preterm deliveries, 3725 (90% PI, 3259-4126) birth defects, and 1872 (90% PI, 1239-2415) perinatal deaths annually. Associated discounted lifetime costs averted for the affected cohort of children could be as high as $4.3 billion (90% PI, 3.4-5.1 billion) (2012 US dollars). PCC among women with undiagnosed diabetes could yield an additional $1.2 billion (90% PI, 951 million-1.4 billion) in averted cost. CONCLUSION: Results suggest a substantial health and cost burden associated with PGDM that could be prevented by universal PCC, which might offset the cost of providing such care.

Continuous glucose monitoring vs. self-monitoring in pregnant individuals with type 1 diabetes: an economic analysis.

BACKGROUND: In the United States, approximately 1% of pregnancies are complicated by pregestational diabetes. Individuals with type 1 diabetes have an increased risk of adverse maternal and neonatal outcomes. While continuous glucose monitoring has demonstrated benefits for patients with type 1 diabetes, its cost is higher than traditional intermittent fingerstick monitoring, particularly if used only during pregnancy. OBJECTIVE: To develop an economic analysis model to compare in silico the cost of continuous glucose monitoring and self-monitoring of blood glucose in a cohort of pregnant individuals with type 1 diabetes mellitus. STUDY DESIGN: We developed an economic analysis model to compare two glucose monitoring strategies in pregnant individuals with type 1 diabetes: continuous glucose monitoring and self-monitoring. The model considered hypertensive disorders of pregnancy, large for gestational age, cesarean delivery, neonatal intensive care unit (NICU) admission, and neonatal hypoglycemia. The primary outcome was the total cost per strategy in 2022 USD from a health system perspective, with self-monitoring as the reference group. Probabilities, relative risks, and costs were extracted from the literature, and the costs were adjusted to 2022 US dollars. Sensitivity analyses were conducted by varying parameters based on the probability, relative risk, and cost distributions. The robustness of the results was tested through 1000 Monte Carlo simulations. RESULTS: In the base-case analysis, the cost of pregnancy using continuous glucose monitoring was $26,837 compared to $29,039 for self-monitoring, resulting in a cost reduction of $2,202 per individual. The parameters with the greatest effect on the incremental cost included the relative risk of NICU admission, cost of NICU admission, continuous glucose monitoring costs, and usual care costs. Monte Carlo simulations indicated that continuous glucose monitoring was the optimal strategy 98.7% of the time. One-way sensitivity analysis showed that continuous glucose monitoring was more economical if the relative risk of NICU admission with continuous glucose monitoring vs. self-monitoring was below 1.15. CONCLUSION: Compared to self-monitoring, continuous glucose monitoring is an economical strategy for pregnant individuals with type 1 diabetes mellitus.

Costs of NHS maternity care for women with multiple pregnancy compared with high-risk and low-risk singleton pregnancy.

OBJECTIVE: To compare antenatal and obstetric costs for multiple pregnancy versus singleton pregnancy risk groups and to identify factors driving cost differentials. DESIGN: Observational study over 15 months (2001-02). SETTING: Four district hospitals in southeast England. POPULATION: Consecutive women with multiple pregnancy and singleton women with risk factors for fetal congenital heart disease (CHD) (pregestational diabetes, epilepsy, or family history of CHD) or Down syndrome, and a sample of low-risk singleton women. METHODS: Clinical care was audited from the second trimester anomaly scan until postnatal discharge, and the resource items were costed. Multiple regression analysis determined predictors of costs. MAIN OUTCOME MEASURES: NHS mean costs of antenatal and obstetric care for different types of pregnancy. RESULTS: A total of 959 pregnancies were studied. Three percent of 243 women with multiple pregnancy reached 40 weeks of gestation compared with 54-55% of 163 low-risk and 322 Down syndrome risk women and 36% of 231 cardiac risk women. Antenatal costs for cardiac risk (1,153 pounds sterling) and multiple pregnancy (1,048 pounds sterling) were nearly double the costs for other two groups (P < 0.001). As 63% of multiple births were delivered by caesarean section, the obstetric cost for multiple pregnancy (3,393 pounds sterling) was 1,000 pounds sterling greater overall. Pregestational diabetes was the most influential factor driving singleton costs, resulting in similar total costs for multiple pregnancy women (4,442 pounds sterling) and for women with diabetes (4,877 pounds sterling). CONCLUSIONS: Our analyses confirm that multiple pregnancies are substantially more costly than most singleton pregnancies. Identifying women with diabetes as equally costly is pertinent because of the findings of the Confidential Enquiry into Maternal and Child Health that standards of maternal care for diabetics often are inadequate.

A Prepregnancy Care Program for Women With Diabetes: Effective and Cost Saving.

CONTEXT: Only a minority of women with diabetes attend prepregnancy care service and the economic effects of providing this service are unclear. OBJECTIVE: The objective of the study was to design, put into practice, and evaluate a regional prepregnancy care program for women with types 1 and 2 diabetes. DESIGN: This was a prospective cohort and cost-analysis study. SETTING: The study was conducted at antenatal centers along the Irish Atlantic Seaboard. PARTICIPANTS: Four hundred fourteen women with type 1 or 2 diabetes participated in the study. INTERVENTIONS: The intervention for the study was a newly developed prepregnancy care program. MAIN OUTCOME MEASURES: The program was assessed for its effect on the risk of adverse pregnancy outcomes. The difference between program delivery cost and the excess cost of treating adverse outcomes in nonattendees was evaluated. RESULTS: In total, 149 (36%) attended: this increased from 19% to 50% after increased recruitment measures in 2010. Attendees were more likely to take preconception folic acid (97.3% vs 57.7%, P < .001) and less likely to smoke (8.7% vs 16.6%, P = .03) or take potentially teratogenic medications at conception (0.7 vs 6.0, P = .008). Attendees had lower glycated hemoglobin levels throughout pregnancy (first trimester glycated hemoglobin 6.8% vs 7.7%, P < .001; third trimester glycated hemoglobin 6.1% vs 6.5%, P = .001), and their offspring had lower rates of serious adverse outcomes (2.4% vs 10.5%, P = .007). The adjusted difference in complication costs between those who received prepregnancy care vs usual antenatal care only is €2578.00. The average cost of prepregnancy care delivery is €449.00 per pregnancy. CONCLUSIONS: This regional prepregnancy care program is clinically effective. The cost of program delivery is less than the excess cost of managing adverse pregnancy outcomes.

Financial implications of implementing standards of care for diabetes and pregnancy.

This article examines the financial implications of implementing standards of care for pregnancy among women with diabetes, including both the costs of enhanced treatment and the savings of avoided adverse outcomes. Numerous studies have demonstrated the harmful effects of poor blood glucose control for both mother and fetus. Standards set forth by the American Diabetes Association aim to reduce maternal complications and fetal adverse outcomes, such as congenital malformations. Because the precise configuration of resources required to meet these standards was not outlined in the American Diabetes Association statement, a panel of physicians (all specialists in pregnancy care for women with diabetes) was convened to develop a model program. Implementing such a program during the preconception and prenatal periods will represent an intensification of resource use in the outpatient setting. However, through these preventive measures, medical care costs for maternal and fetal complications can be avoided.

Medicare admission criteria for diabetes mellitus in Florida.

Medicare criteria for admission of patients to hospitals are the responsibility of Peer Review Organizations in each state. In 1986, in Florida, an attempt was made to introduce stricter than previously accepted admission criteria for diabetes mellitus. The new criteria were found to be unacceptable to many physicians and potentially dangerous. This article describes how a group of endocrinologists and diabetologists were able to impact on the Florida Peer Review Organization and change the criteria to allow for more acceptable standards without jeopardizing the review process.

An economic analysis of interventions for diabetes.

The objective of this article is to stratify interventions for diabetes according to their economic impact. We conducted a review of the literature to select articles that performed a cost-benefit analysis for 17 widely practiced interventions for diabetes. A scale for categorizing interventions according to their economic impact was defined. The 17 interventions were classified as follows: 1) clearly cost-saving, 2) clearly cost-effective, 3) possibly cost-effective, 4) non-cost-effective, or 5) unclear. Clearly cost-saving interventions included eye care and pre-conception care. Clearly cost-effective interventions included nephropathy prevention in type 1 diabetes and improved glycemic control. Possibly cost-effective interventions included nephropathy prevention in type 2 diabetes and self-management training. Non-cost-effective interventions were not identified. Interventions with unclear economic impact included case management, medical nutrition therapy, self-monitoring of blood glucose, foot care, blood pressure control, blood lipid control, smoking cessation, exercise, weight loss, HbA1c measurement, influenza vaccination, and pneumococcus vaccination. Widely practiced interventions for patients with diabetes can be clearly cost-saving and clearly cost-effective. These practices are attractive from both a medical and an economic perspective.

Cost-benefit analysis of preconception care for women with established diabetes mellitus.

OBJECTIVE: To determine whether the additional costs of preconception care are balanced by the savings from averted complications. Several studies have demonstrated the efficacy of preconception care in reducing congenital anomalies in infants born of mothers with pre-existing diabetes mellitus. RESEARCH DESIGN AND METHODS: This study used literature review, consensus development among an expert panel of physicians, and surveys of medical care personnel to obtain information about the costs and consequences of preconception plus prenatal care compared with prenatal care only for women with established diabetes. Preconception care involves close interaction between the patient and an interdisciplinary health-care team as well as intensified evaluation, follow-up, testing, and monitoring. The outcome measures assessed in this study are the medical costs of preconception care versus prenatal care only and the benefit-cost ratio. RESULTS: The costs of preconception plus prenatal care are $17,519/delivery, whereas the costs of prenatal care only are $13,843/delivery. Taking into account maternal and neonatal adverse outcomes, the net savings of preconception care are $1720/enrollee over prenatal care only and the benefit-cost ratio is 1.86. The preconception care program remained cost saving across a wide range of assumptions regarding incidence of adverse outcomes and program cost components. CONCLUSIONS: Despite significantly higher per delivery costs for participants in a hypothetical preconception care program, intensive medical care before conception resulted in cost savings compared with prenatal care only. Third-party payers can expect to realize cost savings by reimbursing preconception care in this high-risk population.

Efficacy of home glucose monitoring in diabetic pregnancy.

A randomized, prospective study was performed to evaluate the efficacy of daily home glucose monitoring on the outcome of pregnancies in women with insulin-dependent diabetes mellitus. Home glucose monitoring was compared with a weekly venipuncture protocol. No differences were observed between groups in clinical features (age, parity, White's classification) or representative delivery outcomes (method of delivery, weeks' gestation, or weight at birth). No statistically significant differences were observed between the groups in several aspects of perinatal morbidity. However, home glucose monitoring was associated with fewer readmissions for diabetic control (p = 0.05), fewer days in the hospital (p less than 0.01), and decreased total patient expense (p less than 0.05).

Screening for gestational diabetes: an analysis of health benefits and costs.

The current recommendation to screen all pregnant mothers for diabetes at 28 weeks of gestation is examined using known epidemiological evidence in a cost-benefit analysis. The available data indicate that the potential decrease in the perinatal mortality rate would be the most cost-efficient potential health outcome of a gestational diabetes screening policy. A decrease in macrosomia and cesarean sections would be additional potential benefits, but at a cost so great that it is not an important factor in making a decision to screen for gestational diabetes. Since it is unlikely that a study can be done that would ethically demonstrate the effectiveness of universal screening in decreasing the perinatal mortality rate, further research should perhaps focus on decreasing the cost of screening, as the available data do not clearly demonstrate a favorable cost-benefit ratio in universal screening for gestational diabetes.

Diabetes and pregnancy. Preconception care, pregnancy outcomes, resource utilization and costs.

OBJECTIVE: To describe and compare pregnancy outcomes, resource utilization and costs among women with diabetes who receive and do not receive preconception care. STUDY DESIGN: A multicenter, prospective, observational study of women with type 1 diabetes who received preconception care (PC), became pregnant and delivered (PC women) and women with type 1 diabetes who received prenatal care (PC) only and delivered (PN women). RESULTS: As compared to PN women (n = 74), PC women (n = 24) were seen earlier in gestation and had significantly lower glycosylated hemoglobin levels. The combined number of outpatient visits for PC women was not greater than for PN women. PC women were hospitalized significantly less during pregnancy and tended to have shorter inpatient stays. The mean length of stay after delivery was significantly shorter for PC women. Intensity of care tended to be lower and length of stay shorter for infants of mothers who received PC care. The net cost saving associated with PC care was approximately $34,000 per patient. CONCLUSION: PC achieves its major intended health benefits and is associated with reduced resource utilization and substantially reduced costs. For both health and economic reasons, clinical practice and public policy should embrace PC.

Diabetes in pregnancy: efficacy and cost of hospitalization as compared with ambulatory management--a prospective controlled study.

BACKGROUND: Pregnant diabetic women are often subjected to frequent and prolonged hospitalizations to assure tight glycemic control, but in recent years attempts have been made at ambulatory control. The financial and social advantages of ambulatory management are obvious, but no report to date has prospectively compared its efficacy with that of hospitalization. OBJECTIVES: To evaluate the efficacy and cost of ambulatory care as compared to repeated hospitalizations for management of diabetes in pregnancy. METHODS: We conducted an 8 year prospective controlled study that included 681 diabetic women, experiencing 801 singleton pregnancies, with commencement of therapy prior to 34 gestational weeks. During 1986-1989, 394 pregnancies (60 pregestational diabetes mellitus and 334 gestational diabetes mellitus) were managed by hospitalization, and for the period 1990-1993, 407 pregnancies (61 PGDM and 346 GDM) were managed ambulatorily. Glycemic control, maternal complications, perinatal mortality, neonatal morbidity and hospital cost were analyzed. RESULTS: There was no difference in metabolic control and pregnancy outcome in women with PGDM between the hospitalized and the ambulatory groups. Patients with GDM who were managed ambulatorily had significantly lower mean capillary glucose levels, later delivery and higher gestational age at induction of labor as compared to their hospitalized counterparts. In this group there were also lower rates of neonatal hyperbilirubinemia, phototherapy and intensive care unit admissions and stay. The saved hospital cost (in Israeli prices) in the ambulatory group was $6,000 and $15,000 per GDM and PGDM pregnancy, respectively. CONCLUSIONS: Ambulatory care is as effective as hospitalization among PGDM patients and more effective among GDM patients with regard to glycemic control and neonatal morbidity. This is not only more convenient for the pregnant diabetic patient, but significantly reduces treatment costs.

Diabetes and perinatal loss. A continuing problem.

OBJECTIVE: To determine the fetal outcome in diabetic pregnant patients managed exclusively by the obstetrician at King Faisal Military Hospital in the south-west region of Saudi Arabia, and to compare this with the non-diabetic control group in the same hospital. METHODS: Case-control study of 83 diabetic and non-diabetic pregnant patients who delivered at King Faisal Military Hospital over a 2 year period. RESULTS: The perinatal mortality rate in diabetic patients was 6.02% while that in the non-diabetic control group was 1.2%. However, the difference was not statistically significant, p>0.05. There was a difference in the mean birth weight between the cases and controls; p = 0.001 and the cesarean section rate was 5 times higher in the cases than in controls [corrected]. This was statistically significant; OR=5.22 (1.90-16.48). CONCLUSION: Diabetes in pregnancy is still a major cause of perinatal loss in our community. The increase in cesarean section in diabetic pregnant patients also indicates a drain in the financial resources. It is recommended that emphasis should be placed on health education in order to reduce the cost of child birth as this condition may be prevented.

The challenge of multidisciplinary research: improving diabetic pregnancy together.

Improving diabetic pregnancy outcome is a goal shared by many involved specialists. Despite proper glucose control, the incidence of maternal and perinatal complications is very high, including a high risk for pre-eclampsia, congenital malformations, perinatal mortality and macrosomia. To improve outcome, not only collaborating in the doctor's office is required but also participation in critical evaluation of our treatment strategies by means of randomised clinical trials.

Modeling the independent effects of gestational diabetes mellitus on maternity care and costs.

OBJECTIVE: To explore the independent effects of gestational diabetes mellitus (GDM) on maternity care and costs. RESEARCH DESIGN AND METHODS: Estimates for maternity care resource activity and costs for 4,372 women, of whom 354 (8.1%) were diagnosed with GDM, were generated from data from the Atlantic Diabetes in Pregnancy (ATLANTIC DIP) database. Multivariate regression analysis was applied to explore the effects of GDM on 1) mode of delivery, 2) neonatal unit admission, and 3) maternity care cost, while controlling for a range of other demographic and clinical variables. RESULTS: Women with a diagnosis of GDM had significantly higher levels of emergency caesarean section (odds ratio [OR] 1.75 [95% CI 1.08-2.81]), their infants had significantly higher levels of neonatal unit admission (3.14 [2.27-4.34]), and costs of care were 34% greater (25-43) than in women without GDM. Other variables that significantly increased costs were weight, age, primiparity, and premature delivery. CONCLUSIONS: GDM plays an independent role in explaining variations in rates of emergency caesarean section, neonatal unit admission, and costs of care, placing a substantial economic burden on maternity care services. Interventions that prevent the onset of GDM have the potential to yield substantial economic and clinical benefits.