Likewise, the 1.46-fold risk of primary CD among the women who were treated with insulin (108/338 women or 46.8%) compared to the women without insulin treatment (22/47 women or 32.0%) observed in our study was similar to the relative risk of primary CD of 1.48 among insulin-treated pregnant women with GDM (24.7%) compared to those without insulin therapy (16.7%) found in the study of Ehrenberg et al. [8]. Here, INS is linked to gestational diabetes.