Risks faced by some pregnant Medicaid enrollees highlight need for adequate postnatal care

Key takeaways:

• Opioid use disorder may be far more prevalent among pregnant Medicaid enrollees.
• Earlier enrollment in Medicare corresponded with lower risk for severe maternal morbidity among those with opioid use disorder.

The rates of opioid use disorder among pregnant people enrolled in Medicaid may be twice as high as prior estimates, according to a recent cross-sectional analysis published in JAMA Network Open.

Pregnant persons with opioid use disorder also faced a higher risk for severe adverse health outcomes, with that risk increasing among those who enrolled in Medicaid in their final trimester or after delivery, researchers noted.

“Unfortunately, we were not surprised by the findings,” Samantha G. Auty, PhD, a research assistant professor at Boston University, told Healio.

According to the researchers, Medicaid is the primary source of coverage through which pregnant and postpartum people with opioid use disorder can access services that lower the risk for adverse maternal health outcomes.

Despite this, little is known about the opioid use disorder adverse maternal health outcomes burden among pregnant Medicaid enrollees and how adverse maternal health outcomes affect this population, according to Auty.

Meanwhile, data limitations have made it difficult to assess inpatient and outpatient service use among Medicaid enrollees “until relatively recently,” Auty added. “With the new [Transformed Medicaid Statistical Information System Analytic Files (T-MSIS)] data, we can measure both outpatient and inpatient service use over time — increasing our ability to detect both opioid use disorder and adverse maternal health outcomes.”

In the cross-sectional study, researchers used T-MSIS data to identify 96,309 Medicaid-enrolled pregnant people diagnosed with opioid use disorder in 47 states who had 108,975 deliveries between March 1, 2016, and Nov. 16, 2018.

Researchers calculated national and state-by-state rates of opioid use disorder and severe maternal morbidity, which referred to a composite measurement of 20 different severe maternal health outcomes.

They reported a mean rate of opioid use disorder among pregnant Medicaid enrollees of 324.8 per 10,000 live births across states, 75% above prior estimates of 146 per 10,000 live births.

The analysis showed a mean unadjusted rate of severe maternal morbidity, excluding blood transfusions, of 292.1 per 10,000 live births among those with opioid use disorder.

The most common severe maternal morbidity conditions included adult respiratory distress syndrome (23.2%) sepsis (14.1%), ventilation (13.8%) pulmonary edema or acute heart failure (13.4%) and eclampsia (12.9%).

According to Auty, one surprising finding included the significant variation in severe maternal morbidity rates by state, ranging from 101 per 10,000 live births in South Dakota to 682.2 per 10,000 live births in California.

“But we don't explore mechanisms [that] are driving that variation in this study,” she said.

The rate of severe maternal morbidity did not meaningfully change when the researchers adjusted for enrollee characteristics and comorbidities (305.6 per 10,000 live births).

Duration of Medicaid enrollment also influenced severe maternal morbidity rates, which researchers reported as 335.7 per 10,000 live births among those enrolled before pregnancy and 423.8 per 10,000 live births among those enrolled at delivery.

Auty and colleagues identified several study limitations, which included limited generalizability to states not included in the analysis and possible underestimation of severe maternal morbidity and opioid use disorder rates among people who had their care covered by payers other than Medicaid.

The data “underscore the importance of providing medications for opioid use disorder for those who have opioid use disorder and are pregnant or of reproductive age,” Auty told Healio. “We know these medications reduce the risk of adverse maternal health outcomes, so continuing to focus on scaling up access to these services is important.”

Prenatal and postnatal care are “also imperative to ensure comprehensive support for maternal and infant health,” she added.

“The evidence in this paper could be used to support work that focuses on health system or individual level factors that influence the risk of adverse outcomes in this group.”