Why are so many mothers missing diabetes follow-up after childbirth?

By Vijay Kumar MalesuReviewed by Susha Cheriyedath, M.Sc.May 11 2026

A large NYC cohort reveals that most women with postpartum-onset diabetes miss recommended A1C monitoring, exposing gaps in follow-up care shaped by race, insurance, and caregiving burden.

Study: Social determinants of health and recommended A1C monitoring among women with postpartum-onset diabetes: results from a retrospective cohort. Image Credit: Pixel-Shot / Shutterstock

In a recent study published in the journal BMJ Open Diabetes Research & Care, researchers examined how social determinants of health influence recommended Hemoglobin A1C (HbA1c, also called A1C) monitoring among women diagnosed with postpartum-onset diabetes.

Postpartum Diabetes Monitoring Background

Diabetes is increasingly affecting women of reproductive age worldwide. Gestational diabetes (GDM) often leads to type 2 diabetes mellitus later in life. Regular testing of A1C levels is important for monitoring long-term blood sugar control and guiding diabetes management, which may help reduce the risk of cardiovascular disease, kidney injury, and nerve disorders. But social determinants of health, such as race, access to insurance, education, and caregiving responsibilities, may influence whether women get recommended post-delivery diabetes monitoring after hospital discharge. Further research is needed to improve access to postpartum diabetes care.

APPLE Cohort Study Design

Researchers conducted a retrospective population-based cohort study using data from the A1C in Pregnancy and Postpartum Linkage for Equity (APPLE) cohort in New York City. The study linked birth certificate records, hospital discharge data, and mandatory New York City A1C Registry data collected between 2009 and 2019. The analysis included women who gave birth from 2009 to 2016 and then were diagnosed with diabetes. Women with pre-pregnancy diabetes were excluded to ensure the focus remained on diabetes diagnosed after childbirth.

The main analysis included 5,590 women who had at least one A1C test after diagnosis. Researchers defined postpartum diabetes as having two or more A1C readings of 6.5% or higher after delivery. They could not distinguish between type 1 and type 2 diabetes using registry A1C values, even though they expected most cases to represent type 2 diabetes. Recommended diabetes monitoring followed American Diabetes Association guidelines, which advise A1C testing at least every six months.

The researchers examined a variety of social determinants of health. This included factors such as: race and ethnicity; nativity; type of insurance; participation in the Women, Infants and Children (WIC) Program; level of education; and the number of children. They also checked factors such as body mass index (BMI), age at diagnosis, and history of GDM. Cox proportional hazards models were used to evaluate the timing of the first follow-up A1C test, while Poisson regression models examined the rate of biannual monitoring over three years. Researchers adjusted statistical models for both social and clinical characteristics to better understand independent associations with diabetes monitoring patterns.

A1C Monitoring Gaps and Disparities

The study revealed major gaps in postpartum diabetes monitoring. In the three-year biannual monitoring analysis, which included 2,638 women with sufficient follow-up data, only 13.0% completed all recommended biannual A1C tests during the three-year follow-up period, indicating that most women were not receiving routine diabetes care at the frequency recommended by clinical guidelines. About one-fifth of participants completed 5 of the 6 recommended tests, and the median time to the first follow-up A1C test was 5.2 months after diagnosis among women who had at least 1 post-diagnosis test.

The cohort reflected the diversity of New York City, with the median age of women at diagnosis between 30 and 39 years, and many self-identified as other Hispanic (31.4%) or non-Hispanic Black (30.8%). More than 75% were insured on Medicaid at the time of delivery, and over 80% entered pregnancy overweight or with obesity. Over half had also experienced a previous history of GDM, indicating a strong link between pregnancy-related metabolic disorders and later diabetes development.

Non-Hispanic Black women experienced slower and less frequent diabetes monitoring than non-Hispanic White women. After adjusting for social and clinical factors, non-Hispanic Black women had a 10% lower likelihood of receiving an earlier first follow-up A1C test and an 8% lower rate of recommended biannual testing over time. Black Hispanic women showed similar patterns, although some results did not reach statistical significance.

Healthcare Access and Medicaid Findings

Researchers discussed a number of different potential causes for these differences between races. Historical and structural inequities such as residential segregation, limited access to healthcare facilities, and provider bias may contribute to less frequent monitoring of diabetes among Black women. Delayed or inconsistent follow-up may increase the risk of poorer diabetes control and downstream complications.

Women insured through Medicaid had better monitoring outcomes than women with private or other government insurance. Medicaid recipients had a 14% higher likelihood of receiving an earlier first A1C follow-up test and a higher overall rate of recommended monitoring. These findings were encouraging because they suggest that Medicaid-related outreach programs and expanded postpartum coverage may improve healthcare engagement.

Women who had more children had lower rates of diabetes monitoring and experienced longer delays before receiving their first A1C test compared with women without previous children. Researchers recommended that healthcare systems develop strategies to expand mothers' access to healthcare, including child care services, providing flexible appointment times, establishing medical appointment reminder systems, and creating paid leave policies.

The authors noted several limitations, including that the findings were specific to New York City and may not apply to other settings, and that they were generalizable mainly to women already connected to A1C testing. Some women may also have moved away, received testing outside New York City, or met registry criteria for diabetes without receiving a formal diagnosis.

Postpartum Diabetes Care Policy Implications

The study demonstrates that many women with postpartum-onset diabetes are not monitored regularly and may face an increased risk of poorer long-term outcomes. Social determinants of health were strongly associated with access to follow-up care, with non-Hispanic Black women and mothers with larger families facing greater barriers to timely testing. In contrast, Medicaid coverage seemed to enhance engagement in diabetes monitoring, suggesting that health-supportive policies can have an impactful effect.

These findings highlight the need for stronger postpartum care systems, better transitions to primary care, and structural interventions that reduce caregiving, financial, and healthcare access barriers for reproductive-aged women living with diabetes.

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