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CME / ABIM MOC / CE

Are Pregnant Women With Disabilities at Higher Risk for Adverse Maternal Outcomes?

  • Authors: News Author: Kate Johnson; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 1/28/2022
  • Valid for credit through: 1/28/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for obstetricians/gynecologists, /primary care/family medicine practitioners, public health officials, nurses, neurologists, rheumatologists and other members of the healthcare team for pregnant women with disabilities.

The goal of this activity is to describe risks for a range of obstetric interventions and adverse maternal outcomes, including severe maternal morbidities (SMM) and mortality, among women with and without disabilities, according to findings from the Consortium on Safe Labor (CSL), a retrospective US cohort, including comprehensive medical chart review for deliveries between January 2002 and January 2008.

Upon completion of this activity, participants will:

  • Describe risks for various obstetric interventions and adverse maternal outcomes, including SMM and mortality, among women with and without disabilities, according to findings from the CSL cohort
  • Determine clinical and public health implications of risks for various obstetric interventions and adverse maternal outcomes, including SMM and mortality, among women with and without disabilities, according to findings from the CSL cohort
  • Outline implications for the healthcare team


Disclosures

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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.

Disclosures for additional planners can be found here.


News Author

  • Kate Johnson

    Freelance writer, Medscape

    Disclosures

    Disclosure: Kate Johnson has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Own stock, stock options, or bonds from the following ineligible company(ies): AbbVie (former)

Editor/CME Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.


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This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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    For Nurses

  • Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0 contact hours are in the area of pharmacology.

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CME / ABIM MOC / CE

Are Pregnant Women With Disabilities at Higher Risk for Adverse Maternal Outcomes?

Authors: News Author: Kate Johnson; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 1/28/2022

Valid for credit through: 1/28/2023

processing....

Clinical Context

Maternal mortality is a preventable, pressing public health issue, particularly among traditionally marginalized populations. Little is known about risk for maternal mortality, severe maternal morbidities (SMM), hemorrhage, infection, cardiovascular (CV) events, or thromboembolism in women with disabilities.

Study Synopsis and Perspective

Women with physical, intellectual, and sensory disabilities had higher risk for almost all pregnancy complications, obstetric interventions, and adverse outcomes, including SMM and mortality compared with women without disabilities, according to an analysis of a large, retrospective cohort.

The findings, published in JAMA Network Open,[1] "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," suggested lead author Jessica L. Gleason, PhD, MPH, and co-authors, all from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.

"Women with disabilities have long been ignored in obstetric research and clinical practice," added Hilary K. Brown, PhD, from the University of Toronto, Toronto, Alberta, Canada, in an accompanying editorial.[2] "Inclusion of disability indicators needs to be the norm -- not the exception -- in health administrative data so that these disparities can be regularly tracked and addressed."

The investigators used data from the Consortium on Safe Labor (CSL), a retrospective cohort of deliveries from 12 US clinical centers between January 2002 and January 2008, to analyze obstetric interventions and adverse maternal outcomes in women with and without disabilities.

The analysis included a total of 223,385 women, mean age 27.6 ± 6.2 years, of whom 2074 (0.9%) had a disability, and 221,311 did not. Among persons with disabilities, 1733 (83.5%) were physical, 91 (4.4%) were intellectual, and 250 (12.1%) were sensory. Almost half (49.4%) of the women were White, 22.5% were Black, 17.5% were Hispanic, and 4.1% were Asian or Pacific Islander.

Researchers analyzed outcomes with 3 composite measures:

  • Pregnancy-related complications (pregnancy-related hypertensive diseases, gestational diabetes, placental abruption, placenta previa, premature rupture of membranes (PROM), preterm PROM)
  • All labor, delivery, and postpartum complications (chorioamnionitis, hemorrhage, blood transfusion, thromboembolism, postpartum fever, infection, CV events, cardiomyopathy, and maternal death)
  • SMM only, including severe preeclampsia/eclampsia, hemorrhage, thromboembolism, fever, infection, cardiomyopathy, and CV events during labor and delivery

After adjustment for covariates, women with disabilities had higher risk for pregnancy-related complications. This included a 48% higher risk for mild preeclampsia and double the risk for severe preeclampsia/eclampsia. The composite risk for any pregnancy complication was 27% higher for women with physical disabilities, 49% higher for women with intellectual disabilities, and 53% higher for women with sensory disabilities.

The findings were similar for labor, delivery, and postpartum complications, showing women with disabilities had higher risk for a range of obstetrical interventions, including cesarean delivery -- both planned and intrapartum (aRR = 1.34). In addition, women with disabilities were less likely to have a cesarean delivery that was "solely clinically indicated" (aRR = 0.79), and more likely to have a cesarean delivery for "softer" mixed indication (aRR = 1.16), "supporting a possible overuse of cesarean delivery among women with disability," they suggested.

Women with disabilities also had a higher risk for postpartum hemorrhage (aRR = 1.27), blood transfusion (aRR = 1.64), and maternal mortality (aRR = 11.19), as well as individual markers of severe maternal morbidity, such as CV events (aRR = 4.02), infection (aRR = 2.69), and venous thromboembolism (aRR = 6.08).

The authors speculated that the increased risks for women with disabilities "may be the result of a combination of independent risk factors, including the higher rate of obstetric intervention via cesarean delivery, under-recognition of women with disabilities as a population with higher-risk pregnancies, and lack of healthcare provider knowledge or comfort in managing pregnancies among women with disabilities."

Brown noted in her commentary that there is a need for better education of healthcare professionals in this area: "Given that 12% of reproductive-aged women have a disability, that pregnancy rates are similar among women with and without disabilities, and that women with disabilities are at elevated risk of a range of adverse maternal outcomes, including severe maternal morbidity and maternal mortality, disability modules should be a mandatory component of education for obstetricians and midwives as well as other obstetrical health care professionals."

Calling the study "a serious wake-up call," Monika Mitra, PhD, told this publication that the findings highlight the need for "urgent attention" on improving obstetric care for people with disabilities "with a focus on accessibility and inclusion, changing clinical practice to better serve disabled people, integrating disability-related training for health care practitioners, and developing evidence-based interventions to support people with disabilities during this time."

The associate professor and director of the Lurie Institute for Disability Policy, in Brandeis University, Waltham, Massachusetts, said the risk factors for poor outcomes are present early in pregnancy or even preconception. "We know that disabled women report barriers in accessing health care and receive lower-quality care compared to nondisabled women and are more likely to experience poverty, housing and food insecurity, educational and employment barriers, abuse, chronic health conditions, and mental illness than women without disabilities."

She noted that the study's sample of people with disabilities was small, and the measure of disability used was based on International Classification of Disease, Ninth Revision (ICD-9) codes, which captures only severe disabilities: "As noted in the commentary by [Dr.] Brown, our standard sources of health administrative data do not give us the full picture on disability, and we need other, more equitable ways of identifying disability based, for example, on self-reports of activity or participation limitations if we are to be able to understand the effects on obstetric outcomes of health and health care disparities and of social determinants of health. Moreover, researchers have generally not yet begun to incorporate knowledge of the experiences of transgender people during pregnancy, which will impact our measures and study of obstetric outcomes among people with disabilities as well as the language we use."

The study was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The study authors and Brown reported no conflicts of interest. Mitra receives funding from the NICHD and the National Institute on Disability, Independent Living for research on pregnancy outcomes among people with disabilities.

Study Highlights

  • The CSL retrospective cohort included comprehensive medical chart review for 223,385 women delivering between January 2002 and January 2008 at 12 clinical US sites.
  • Disability was defined using ICD-9 codes and a validated algorithm.
  • Mean age was 27.6+6.2 years; 0.9% had a disability (83.5% physical, 4.4% intellectual, 12.1% sensory); 4.1% were Asian or Pacific Islander, 22.5%, Black; 17.5%, Hispanic; and 49.4%, White.
  • Women with vs without disability had a higher risk for gestational diabetes, placenta previa, PROM, preterm PROM, postpartum fever, and maternal death (aRR = 11.19 [95% CI: 2.4, 52.19]).
  • For individual SMMs, aRRs were severe preeclampsia/eclampsia 2.15 (95% CI: 1.8, 2.56) blood transfusion 1.64 (95% CI: 1.27, 2.12); postpartum hemorrhage 1.27 (95% CI: 1.09, 1.49), and fever 1.32 (95% CI: 1.03, 1.67).
  • Highest risk was for thromboembolism (aRR = 6.08 [95% CI: 4.03, 9.16]), CV events (aRR = 4.02 [95% CI: 2.87, 5.63]), and infection (aRR = 2.69 [95% CI: 1.97, 3.67]).
  • Women with disability also had higher risk for interventions, including oxytocin augmentation, operative vaginal delivery, and cesarean delivery (aRR = 1.34 [95% CI: 1.26. 1.43]), with cesarean less likely to be solely medically indicated (aRR = 0.8 [95% CI: 0.71, 0.9]) and more likely to have a "softer" mixed indication (aRR = 1.16 [1.06, 1.28]).
  • Risk for adverse outcomes and interventions remained consistent across disability categories.
  • Composite risk for any pregnancy complication was 27% higher for women with physical disabilities, 49% higher with intellectual, and 53% higher with sensory disabilities.
  • The investigators concluded that women with physical, intellectual, and sensory disability during pregnancy had elevated risk for adverse maternal outcomes, including a broad range of SMM and obstetric intervention that may increase mortality risk.
  • Understanding risk for individual SMM components may inform specific interventions among women with disabilities to reduce SMM and maternal mortality risk.
  • The findings suggest possible overuse of cesarean delivery, a noted risk factor for SMM, and maternal mortality, among women with disability.
  • Increased risks for women with disabilities may result from various independent risk factors, including higher cesarean rate, under-recognition of higher-risk pregnancies among women with disabilities, and limited clinician knowledge or comfort in managing these pregnancies.
  • Interventions are needed to lower rates of SMM, maternal mortality, and other pregnancy complications in this population, including systemic implementation of evidence-based obstetric practice and care processes, and changes in the medical education system and other strategies to help clinicians be more comfortable managing care for reproductive-age women with disabilities before and during pregnancy.
  • Future research should examine whether changes to medical education, such as including disability modules as a mandatory education component for obstetrical clinicians, would improve outcomes.
  • An expert commenting for Medscape recommended urgent attention on improving obstetric care for people with disabilities, focusing on accessibility and inclusion, changing clinical practice to better serve disabled people, integrating disability-related training for clinicians, and developing evidence-based interventions to support people with disabilities.
  • Women with vs without disabilities have risk factors for poor outcomes early in pregnancy or even preconception, including healthcare access barriers, lower-quality care, poverty, housing and food insecurity, educational and employment barriers, abuse, chronic health conditions, smoking, substance use, depression and mental illness.
  • Study limitations include small sample of women with disabilities and failure of ICD-9 codes to capture less severe disabilities, actual functional limitation, and access to antenatal care.

Clinical Implications

  • Pregnant women with disability had elevated risk for adverse maternal outcomes.
  • Understanding risk for individual SMM components may inform specific interventions among women with disabilities to reduce SMM and maternal mortality risk.
  • Implications for the Healthcare Team: Risk factors for poor outcomes occur early in pregnancy or even preconception. The healthcare team should be mindful of these risk factors and other barriers to care that may contribute to poor outcomes.

 

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