Women with disabilities at significantly higher risk for adverse maternal outcomes

ByMaria Marabito

Pregnant women with a physical, intellectual or sensory disability had a significantly higher risk for adverse outcomes compared with pregnant women without a disability, according to findings published in JAMA Network Open.

Researchers said these adverse outcomes included mild or severe preeclampsia, gestational diabetes, placenta previa, hemorrhage, premature rupture of membranes, maternal death, thromboembolism, cardiovascular events and infection.

“Additional research is needed to understand the reasons for this increased risk and to develop needed interventions to reduce it,” Jessica L. Gleason, PhD, a research fellow of perinatal and pediatric epidemiology at the Eunice Kennedy Shriver National Institute of Child Health and Human Development, said in a press release.

The researchers retrospectively analyzed the medical charts of 2,074 pregnant women with a documented disability and 221,311 pregnant women who did not. The women delivered at hospitals in the U.S. between January 2002 and January 2008. The mean age of the women was 27.6 years. Also, 49.4% were white, 22.5% were Black, 17.5% were Hispanic and 4.1% were Asian or Pacific Islander.

Prevalence of disability

Overall, 0.9% of women included in the study had a disability. Among them, 83.5% had a physical disability, 12.1% had a sensory disability and 4.4% had an intellectual disability, according to Gleason and colleagues. Women with a disability were more likely to be non-Hispanic white, use public insurance or self-pay, have a higher BMI before pregnancy and have a history of chronic disease.

Risk for adverse events

The researchers reported that women with a disability had a significantly higher risk for almost all adverse maternal outcomes compared with women without a disability. The composite risk for any pregnancy complication was increased 27% among those with physical disabilities (adjusted RR = 1.27; 95% CI, 1.16-1.38), 53% for women with sensory disabilities (aRR = 1.53; 95% CI, 1.26-1.86), and 49% for women with intellectual disabilities (aRR = 1.49; 95% CI, 1.06-2.1).

Women with any disability had a 48% greater risk for mild preeclampsia (aRR = 1.48; 95% CI, 1.2-1.81), nearly double the risk for severe preeclampsia or eclampsia (aRR = 2.15; 95% CI, 1.8-2.56), and a 27% greater risk for postpartum hemorrhage (aRR = 1.27; 95% CI, 1.08-1.49).

Women with sensory disabilities had 6.22 times (95% CI, 3.74-10.37) greater risk for infection; women with physical disabilities had 3.9 times (95% CI, 2.65-5.73) greater risk for a cardiovascular event; and women with intellectual disabilities had 1.76 times (95% CI, 1.42-2.19) greater risk for severe preeclampsia or eclampsia, according to the researchers.

Having a disability with also associated with a higher risk for any severe maternal morbidity event (aRR = 1.59; 95% CI, 1.43-1.76) with the highest risk observed in women with a sensory disability (aRR = 2.39; 95% CI, 1.89-3). In addition, having a disability was associated with a higher risk for obstetric intervention, including receiving oxytocin during labor (aRR = 1.08; 95% CI, 1.01-1.16) and operative vaginal delivery (aRR = 1.33; 95% CI, 1.27-1.39). The researchers also found an increased risk for cesarean delivery among women with disabilities (aRR = 1.34; 95% CI, 1.26-1.43). This finding is generalizable today since current cesarean delivery rates are the same now as they were at the midpoint of the dataset, Gleason said.

Moreover, women with any disability had a higher risk for postpartum fever (aRR = 1.32; 95% CI, 1.03-1.67), maternal thromboembolism (aRR = 6.08; 95% CI, 4.03-9.16), cardiovascular events (aRR = 4.02; 95% CI, 2.87-5.63) and infection (aRR = 2.69; 95% CI, 1.97-3.67). The results further showed that women with a disability had a higher mortality risk compared with women without a disability (aRR = 11.19; 95% CI, 2.4-52.19).

“Our findings may be a direct reflection of the challenges women with all types of disabilities face when accessing and receiving care, which is likely compounded by poorer preconception health,” Gleason and colleagues wrote.

Improving care for all patients with disabilities could be as simple as making the office space or exam table more accessible, Gleason told Healio Primary Care.

“Improving pregnancy and birth outcomes among women with disabilities really starts with primary care and ensuring that both their general health and reproductive health needs are met in a stigma free environment,” she said.

Study highlights gaps in research, clinical care

In a related commentary, Hilary K. Brown, MSc, PhD, an assistant professor of epidemiology at the University of Toronto Scarborough, discussed the lack of research on women with disabilities, even though “women with disabilities experience preconception social, health, and health care disparities, such as poverty, chronic illness and barriers to health care, that are known risk factors for adverse maternal outcomes.”

In addition to more research, Brown also called for more education efforts among health care professionals, who have previously reported a lack of training and insufficient resources related to disability and pregnancy.

The findings from the study “reflect the urgency of the need for further consideration of disability in obstetric research and clinical practice,” she wrote.