Syed et al. BMC Public Health 2011, 11(Suppl 3):S2 http://www.biomedcentral.com/1471-2458/11/S3/S2 caused by autoimmune destruction and resulting in an absence of insulin; while type 2 diabetes occurs due to insulin resistance and beta cell dysfunction and is likely to be the result of interactions between genetic, environ- mental and immunological factors including diet, physi- cal activity and obesity [3]. Women diagnosed with diabetes prior to pregnancy (pre-existing diabetes) will experience an increase in insulin demands during pregnancy [4]. Diabetes can have significant impacts on maternal, fetal and neonatal outcomes. The presence of diabetes can increase the risk of stillbirth by five times, and the risk of neonatal death by three times [5]. Studies have shown perinatal mortality rates are two to three times higher amongst babies of diabetic women as opposed to the gen- eral population. Also higher rates of congenital anomalies in babies of women with diabetes have been reported compared to the general population [6,7]. Since the intro- duction of insulin as a treatment for diabetes, mortality and morbidity rates have improved; still, they remain sig- nificantly higher than those of the general population. Longer term glycaemic control in women with diabetes is critical to satisfactory pregnancy outcome. In order to decrease the rate of stillbirths among maternal diabetics, a variety of interventions have been adopted. The keystone of these interventions has been early detection of diabetes with monitoring of blood glu- cose levels and where needed interventions to ‘normal- ize’ these so that complications can be reduced. The objective of this review is to assess the impact of the detection and control of maternal diabetes on stillbirths using data from randomized studies, if available, or from observational studies. Methods Literature search In order to collect evidence for the effect of detection and control of diabetes during pregnancy on stillbirths or perinatal mortality as outcomes, we conducted a sys- tematic search of all the literature published till July 2010. The databases searched were PubMed, Cochrane Database of Systematic Reviews and WHO Regional Databases. Besides, hand search of bibliographies of rele- vant reviews was performed. Experts in the field were contacted for further data or for unpublished trials. The following search strategy was utilized for PubMed: (“Diabetes Mellitus”[Mesh] OR “Diabetes Mellitus, Type 2”[Mesh] OR “Diabetes Mellitus, Type 1”[Mesh] OR “Glucose Intolerance”[Mesh] OR “Diabetes, Gestatio- nal”[Mesh] OR “diabetes*” OR “gestational diabetes” OR “glucose intolerance”) AND ("Pregnancy"[Mesh] OR “Pregnancy Trimester, Third"[Mesh] OR “Pregnancy Tri- mester, Second"[Mesh] OR “Pregnancy Trimester, First”[Mesh] OR “Pregnancy Trimesters”[Mesh] OR Page 2 of 12 “pregnan*” OR “mother*” OR “maternal” OR “Mothers”[- Mesh]) AND (“Fetal Mortality”[Mesh] OR “Stillbirth”[- Mesh] OR “Perinatal Mortality”[Mesh] OR “Fetal Death”[Mesh] OR “Embryo Loss”[Mesh] OR “Fetal Viabi- lity”[Mesh] OR stillbirth* OR “fetal death*” OR “Fetal loss” OR “perinatal mortality” OR miscarriage* OR abor- tion* OR “baby’s death” OR “death of baby” OR “infant death” OR “death of fetus” OR “intrauterine death*”) For the purpose of our review, stillbirth was defined as the expulsion of a dead fetus from the body of the mother after 28 weeks of gestation. Perinatal mortality was defined as stillbirths plus the deaths within the first seven days of birth. Inclusion/exclusion criteria Inclusion criteria All studies linking screening, control and detection of diabetes during pregnancy with stillbirth (or perinatal mortality) were included The studies selected were from both developed and developing countries. All studies were included irrespective of language. For non-English articles, we primarily relied on the abstracts but did not translate the entire article into English. All studies were included in the meta-analyses irre- spective of the methodological quality of the study. Studies were included in our review if they reported on interventions for diabetic pregnancies and had data on stillbirth or perinatal mortality as outcomes. Exclusion criteria Studies were excluded if they did not report on rele- vant outcomes i.e. stillbirth or perinatal mortality. Studies were excluded if they did not focus on the selected interventions (screening/monitoring/ pharmacotherapy). The studies were grouped according to the following interventions: (1) impact of early detection (1st trime- ster) strategies versus late detection (24th to 28th week of gestation i.e. regular screening ) of gestational diabetes mellitus (GDM) in pregnancy; (2) outpatient versus hospital based monitoring and management; (3) intensified management (dietary advice, increased fre- quency of monitoring, increased clinic visits or phar- macotherapy) versus conventional management strategies for diabetes in pregnancy; (4) Optimal versus suboptimal glucose control; (5) pre-conception care versus no/conventional care (6) effectiveness of contin- uous infused insulin versus multiple dose insulin; (7) comparisons between different types of insulin; (8) oral hypoglycemic agents and metformin use in diabetic pregnancies versus insulin treatment or no treatment; (9) Pregestational and gestational DM versus normal pregnancy.