Persistent Neonatal Risks in Maternal Type 1 Diabetes: A Call for Improved Maternal Care

Pregnancies complicated by type 1 diabetes remain among the most challenging in perinatal medicine. In the study 'Neonatal outcomes among neonates of women with and without type 1 diabetes in Sweden from 2010 to 2022' by Goldberg and colleagues, published in Acta Paediatrica [1], the authors analyzed more than 1.4 million singleton births in Sweden from 2010 to 2022, providing a sobering update on neonatal outcomes in mothers with type 1 diabetes. Their findings demonstrate that, despite advances in technology and obstetric care, infants born to women with type 1 diabetes continue to face substantially higher risks of stillbirth, congenital malformations, preterm birth, large-for-gestational-age status, hypoglycemia, and neonatal mortality compared to those born to mothers without type 1 diabetes. The strength of this nationwide cohort lies in its scale and data quality, drawing from the Swedish Medical Birth Register, which provides near-complete, detailed coverage of births after gestational week 22 and a relatively high prevalence of type 1 diabetes (0.5%). By adjusting for maternal age, body mass index (BMI), parity, smoking or snuff use, country of birth, and year of delivery, the investigators confirmed that the adverse neonatal outcomes associated with maternal type 1 diabetes were not explained solely by maternal background factors but remained independently linked to the disease itself. Strikingly, nearly 42% of neonates of type 1 diabetes mothers were large for gestational age, and almost 40% developed hypoglycemia, with adjusted odds ratios of 22.0 (95% confidence interval 20.9–23.1) and 45.9 (95% confidence interval 43.6–48.2), respectively. Moreover, neonates of mothers with type 1 diabetes had more than double the risk of stillbirth and a four times higher risk of death in the neonatal period. Compared with a register-based study that included births in Sweden from the 1990s and early 2000s [2], the risk of stillbirth declined, possibly reflecting improvements in glycemic monitoring, obstetric surveillance, and increased labor induction rates. Yet, paradoxically, the rates of preterm birth and large-for-gestational-age infants increased, highlighting that progress has been uneven, possibly linked to increasing BMI in the pregnant population. Several mechanisms are likely at play in diabetic pregnancies. Maternal hyperglycemia and fetal hyperinsulinism accelerate fetal growth and predispose to metabolic instability after birth [3]. Maternal BMI adds an additional burden, amplifying the risk of congenital malformations and macrosomia in a dose–response pattern [4]. Importantly, Goldberg et al. observed the highest risk of malformations in the underweight group (13.6% with type 1 diabetes vs. 3.2% without), who are often undertreated with insulin, underscoring previous findings that hyperglycemia itself can jeopardize fetal development [5, 6]. From a clinical perspective, the findings reinforce the ongoing gap between policy aspirations and reality. The St. Vincent Declaration, signed more than three decades ago, pledged that pregnancies complicated by diabetes should achieve outcomes comparable to those without diabetes [7]. This study reveals that, despite Sweden's free and accessible healthcare, advanced diabetes technology, and digital readiness, the goal remains unmet. The implication is clear: achieving equal perinatal outcomes requires intensified efforts. Several strategies deserve emphasis. First, optimizing glycemic control before conception and throughout pregnancy is paramount, with evidence that the level of HbA1c is critical, although even near-normal HbA1c levels may not eliminate excess risk [5, 6]. Second, maternal BMI requires greater attention; targeted preconception counseling and support for healthy weight may reduce both malformation risk and macrosomia [4]. Glucagon-like peptide receptor agonists emerge as promising adjunct medications to insulin for improving clinical outcomes in type 1 diabetes, including overweight and obesity [8], but their effects on pregnancy outcomes remain to be established [9]. Third, newer technologies, such as continuous glucose monitoring and automated insulin delivery, although promising, require rigorous evaluation for their impact on perinatal outcomes at the population level [10]. Ultimately, addressing regional and individual disparities in women's health and personalizing care remain essential to achieving equitable outcomes. The contribution of Goldberg and colleagues is significant. Their analysis not only quantifies current risks but also identifies directions for future research and policy. Future studies should evaluate how emerging diabetes treatments and technologies influence maternal and neonatal health, how care models can better support women before and during pregnancy, and how multidisciplinary strategies can reduce the persistent gaps highlighted in this study. In conclusion, neonates born to mothers with type 1 diabetes continue to face a disproportionate burden of morbidity and mortality. The findings of this large national cohort remind us that while progress has been made, much remains to be done. Readers of Acta Paediatrica will find this study a compelling call to action, demanding renewed commitment to research, clinical innovation, and health policy aimed at achieving the long-overdue goal of equal outcomes for all pregnancies. Sophia Brismar Wendel: conceptualization, writing – original draft, methodology, writing – review and editing, resources. The author declares no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.