Introduction 

Understanding and management of diabetes in pregnancy has evolved significantly in recent years. Nevertheless, challenges persist, and there is limited evidence of consistent or sustained improvement in outcomes in certain areas. One of these is the management of type 2 diabetes in pregnancy. 

A systematic meta-analysis showed that despite lower HbA1c, women with type 2 diabetes mellitus have similar, if not worse, fetal outcomes than those with type 1 diabetes.¹ Type 1 diabetes is associated with higher congenital anomaly risk, while type 2 diabetes is associated with worse overall maternal and perinatal outcomes. This remains a challenging area in many different parts of the world and in clinics across Australia and Aotearoa New Zealand.

This article examines challenges in the management of type 2 diabetes during pregnancy, including cultural considerations and socioeconomic barriers, and explores strategies for improved care. These can be used in individual clinical encounters and policy development.

Oversimplification, Stigma, and Engagement

This complex condition is frequently oversimplified, with diabetes in pregnancy framed as a consequence of maternal overweight status or “poor” lifestyle choices, reinforcing stigmatising narratives and the assumption that education and lifestyle modification alone are sufficient to resolve the condition. This leads to “lack of engagement from the woman” and frustration for the clinician.

People living with type 2 diabetes face much greater challenges in the management of their condition. It is far more complex, and socioeconomic factors play a significant role in the severity of the condition as well as its management

Healthcare Disparities and Social Determinants of Health

The glaring factor in the management of diabetes in pregnancy is healthcare disparities. Healthcare disparities can be defined as a “difference between population groups in the way they access, experience, and receive healthcare.”⁷ 

The World Health Organization, Centers for Disease Control, and many other public health groups have recently focused efforts to understand social determinants of health (SDoH) which can contribute to healthcare disparities.^8,9 

Lifelong and Intergenerational Impacts

Though short-term outcomes are measured in most studies of diabetes in pregnancy, it is the lifelong impacts of this condition that are of greater significance. 

Epigenetic changes occurring in utero may increase susceptibility to earlier development of obesity and diabetes in later life. A possible mechanism for the increased long-term disease risk in the offspring of mothers with diabetes in pregnancy could be metabolic and developmental changes in muscle and fat tissues, including adipocyte hypertrophy.³

Furthermore, animal studies show structural changes in the brain of offspring exposed to maternal diabetes, which could potentially be prevented by treatment of maternal diabetes.² 

Worldwide, by 2050, projections show that one in eight adults, approximately 853 million, will be living with diabetes, an increase of 46%. Pregnancy may represent a rare period of sustained healthcare engagement, particularly for structurally disadvantaged populations, offering an opportunity to improve health literacy and disrupt intergenerational diabetes risk. However, system-level constraints within diabetes care services often limit the capacity to realise this potential. 

Key Social Factors Affecting Diabetes

Decades of research have demonstrated that diabetes affects racial and ethnic minority and low-income adult populations disproportionately, with relatively intractable patterns seen in these populations’ higher risk of diabetes and rates of diabetes complications and mortality.⁴

With a healthcare shift toward greater emphasis on population health outcomes and value-based care, SDoH have risen to the forefront as essential intervention targets to achieve health equity. 

Income and Poverty

Individuals living in neighborhoods with higher poverty and less educational attainment have higher rates of pregnancy and neonatal complications with diabetes.⁶ 

Financial strain around the time of pregnancy has been well documented and disproportionately affects Black and Hispanic individuals in the US. Data is not available for Australia and Aotearoa New Zealand but there may be similarities. 

According to a 2023 study of US national survey data, the poverty rate among Black pregnant subjects before birth was 47.3% and in the month after birth was 54.6%. Among Hispanic pregnant subjects, the poverty rate before birth was 36.3% and in the month after birth was 49.7%.⁵ 

There are myriad factors contributing to baseline poverty rates and increase in poverty after birth. Financial strain may be due to limited sick or parental leave, high rental and housing, childcare, and transportation costs when going to clinics. 

Although Australia and Aotearoa New Zealand provide relatively generous paid parental leave entitlements, recent migrants and individuals with limited or interrupted workforce participation may face significant challenges. 

Limited income reduces access to healthy foods. CGM is not funded in many regions, and this creates a disparity between those who can afford it and those who cannot. 

Even where welfare systems exist, as in Australia and Aotearoa New Zealand, claiming welfare support continues to be difficult for eligible participants, and welfare payments inadequate.¹⁴ Experiences of discrimination, surveillance, and culturally unsafe care further erode trust in health services, leading to delayed engagement with prevention, reduced uptake of services, and poorer long-term diabetes management.^6,14 In pregnancy, this distrust may be intensified by heightened monitoring and judgement, reinforcing disengagement during a critical period for intergenerational health intervention.  

Structural Racism

Hundreds of articles report consistent associations between structural racism, geographical inequity, and poor physical and mental health in people with diabetes. 

The way that structural inequity affects the pathways between upstream and downstream SDoH are complex and operate in multilayered ways. Moreover, the impacts of structural inequity accumulate over time and can affect generational trajectories of health. For example, structural inequity can lead to differences in upstream resources, such as money, power, knowledge, prestige, and beneficial social connections, which have enduring associations with downstream factors, such as socioeconomic status and resultant diabetes. 

Additionally, institutional and cultural racism can affect diabetes through stigma, stereotypes, prejudice, and discrimination, perpetuating inequitable physical and mental health outcomes. 

Risk of diabetes in Aotearoa New Zealand and Australia is shaped not only by individual behaviours, but by the enduring impacts of colonisation and the resulting distrust in health and social systems among Indigenous and marginalised communities. Colonisation has disrupted traditional food systems, land ownership, cultural practices, and social structures for Māori and Aboriginal and Torres Strait Islander peoples, while embedding structural racism within healthcare, welfare, and policy institutions.^4,12,14 

Education and Health Literacy

Lower education can make it harder to understand nutrition labels and treatment plans, recognise early symptoms, and self-manage insulin or medications. Health literacy strongly predicts diabetes self-management success. 

Being aware that these groups may encounter significant barriers when attempting to access healthcare may assist healthcare providers and policy makers to improve their approaches to delivering diabetes education.¹⁶ 

Specifically, numeracy skills play a role in outcomes. A paper from 2008 identified that poor numeracy skills were common in patients with diabetes. Low diabetes-related numeracy skills were associated with worse perceived self-efficacy, fewer self-management behaviors, and possibly poorer glycemic control.¹⁸ 

Food Environment and Food Insecurity

Obesogenic environments and the widespread availability of ultra-processed foods play a significant role in the development and progression of diabetes. 

Food environments characterised by high availability, affordability, and marketing of energy-dense, nutrient-poor ultra-processed foods contribute to excess caloric intake, weight gain, insulin resistance, and metabolic dysfunction. 

These environments disproportionately affect populations experiencing socioeconomic disadvantage, where access to healthy, affordable foods and supportive spaces for physical activity is limited. As a result, diabetes risk is shaped not only by individual behaviours but by structural and commercial determinants of health, highlighting the need for policy-level interventions that address food systems, regulation, and environmental drivers. 

A review of current literature suggests an association between the built environment and type 2 diabetes, likely driven by two key pathways – physical activity and the food environment.¹⁹ 

Food insecurity is a significant social determinant. Evidence shows that adults with diabetes who experience food insecurity have worse diet quality, reduced self-efficacy, and lower medication adherence, amplifying health disparities.²⁰ 

Culture, Ethnicity, and Migration

Certain ethnic groups face higher diabetes risk due to genetic and epigenetic factors that may mean that they are extremely insulin resistant, even at lower BMIs. 

In the PANDORA study, ethnic-specific rates of postpartum type 2 diabetes and prediabetes were reported for women with diabetes in pregnancy (DIP), gestational diabetes (GDM), or normoglycaemia in pregnancy over a short follow-up of 2.5 years. The study concluded that First Nations women experience a high incidence of postpartum type 2 diabetes after GDM/DIP, highlighting the need for culturally responsive policies at an individual and systems level, to prevent diabetes and its complications.¹⁰ 

A Danish study that included more than 20,000 women with GDM who were followed over a mean of 7.3 years concluded that women from Pakistan and Sri Lanka had three to four times higher incidence rate compared with Danish women. 

Not only are the rates of type 2 diabetes higher, but so are the complications. Diabetes in pregnancy clinics now see women with renal disease and severe vasculopathy. These complications also exhibit stark ethnic differences between Māori and non-Māori patients.¹² 

Cultural food practices may conflict with standard dietary advice. Food can be seen as an expression of love and bonding, and sweet foods and fruits may be considered culturally to be more appropriate during pregnancy. Satisfying cravings is seen as a means of caring for the pregnant person and may be at odds with nutritional advice given for “healthy eating”. 

Why This Matters

Diabetes is not just a lifestyle disease. Social factors shape: 

• Risk of developing diabetes 

• Ability to manage it 

• Long-term outcomes 

Addressing diabetes effectively requires medical care plus social support. Our clinical care will be ineffective unless there is a wraparound service that addresses the core issues. 

What can we change in our practice?

Apart from being willing to explore social economic factors for the people we see and attempting to refer or direct them to resources, some other practical changes are:  

Language

Language used in diabetes care plays a critical role in shaping patient engagement, self-efficacy, and health outcomes.^19,21 Stigmatising, judgmental, or deficit-focused language – such as framing diabetes as a result of personal failure or “non-compliance” – can reinforce blame, increase diabetes-related distress, and erode trust in healthcare providers, particularly among populations already experiencing structural disadvantage.^20,22  

In contrast, person-first, strengths-based, and non-judgmental language has been shown to support engagement, improve self-management behaviours, and foster more collaborative therapeutic relationships.^19,21 The use of respectful and culturally safe language is especially important in pregnancy and chronic disease contexts, where surveillance and moral judgement are often intensified. From a policy and systems perspective, embedding guidance on appropriate language into clinical standards, professional education, and service delivery frameworks represents a low-cost but impactful strategy to reduce stigma, improve care experiences, and promote equity in diabetes outcomes.^19,21 

Value Lived Experience

Valuing lived experience in the management of diabetes in pregnancy is essential to improving engagement, trust, and equity in care. Lived experience brings critical insight into the social, cultural, and structural barriers that shape diabetes management during pregnancy and supports a shift from compliance-based models toward partnership and shared decision-making. This can be done in clinics with care grounded in listening and curiosity rather than advice that is poorly aligned with patients’ lived realities. When writing guidelines and policies, ensuring that the whanau voice is included is crucial. 

Provide culturally appropriate care

Providing culturally appropriate medical care for Māori and Aboriginal and Torres Strait Islander peoples is central to fulfilling obligations under Te Tiriti o Waitangi and achieving the aims of Closing the Gap.^23-24 In Aotearoa New Zealand, culturally appropriate care reflects the principles of partnership, protection, and equity, requiring health systems to work alongside Māori, uphold tino rangatiratanga, and actively address inequities in health outcomes.^23,24 In Australia, Closing the Gap commitments similarly emphasise culturally safe, community-led healthcare as essential to improving access, trust, and outcomes for Aboriginal and Torres Strait Islander peoples.^25,26 Across both contexts, culturally appropriate care involves recognising the ongoing impacts of colonisation, valuing Indigenous knowledge systems, engaging whānau and family, and ensuring communication and care environments are culturally safe. Failure to do so risks perpetuating mistrust and inequity, whereas embedding these principles within policy, service design, and clinical practice supports more effective, respectful, and equitable care for diabetes management in pregnancy.^23-26