Prepregnancy Emergency Department Use and Risks of Severe Maternal and Neonatal Morbidity in Canada

Overview

Journal JAMA Netw Open

Publisher American Medical Association

Specialty General Medicine

Date 2022 Sep 2

PMID 36053536

Authors

Catherine E Varner

Alison L Park

Joel G Ray

Affiliations

Soon will be listed here.

Abstract

Importance: Emergency department (ED) use during pregnancy may be associated with worse obstetrical outcomes, possibly because of differences in access to health care. It is not known whether ED use before pregnancy is associated with serious adverse maternal and perinatal outcomes.

Objective: To study the association between prepregnancy ED use and adverse maternal and perinatal outcomes.

Design, Setting, And Participants: This population-based cohort study was conducted in Ontario, Canada, and included all livebirths and stillbirths from April 2003 to January 2020.

Exposures: Main exposure was any ED encounter within 90 days preceding the start of the index pregnancy.

Main Outcomes And Measures: Primary outcome was a composite of severe maternal morbidity (SMM) from 20 weeks' gestation to 42 days' post partum. Secondary outcomes included severe neonatal morbidity (SNM) from 0 to 27 days, neonatal death, and stillbirth. Relative risks (RRs) were adjusted for maternal age, income, and rurality.

Results: Of 2 130 245 births, there were 2 119 335 livebirths (99.5%) and 10 910 stillbirths (0.5%). The mean (SD) maternal age was 29.6 (5.4) years, 212 478 (9.9%) were rural dwelling, and 498 219 (23%) had 3 or more comorbidities. Among all births, 218 011 (9.7%) had a prepregnancy ED visit. The rate of SMM was higher among women with a prepregnancy ED visit than those without (22.3 vs 16.5 per 1000 births), with an RR of 1.34 (95% CI, 1.30-1.38) and an adjusted RR (aRR) of 1.37 (95% CI, 1.33-1.42). Compared with no prepregnancy ED visit, the aRR was higher in those with 1 (1.29; 95% CI, 1.24-1.34), 2 (1.51; 95% CI, 1.42-1.61), and 3 or more (1.74; 95% CI, 1.61-1.90) ED visits. Prepregnancy ED visits for a hematological (aRR, 13.60; 95% CI, 10.48-17.64), endocrine (aRR, 4.96; 95% CI, 3.72-6.62), and circulatory (aRR, 2.27; 95% CI, 1.68-3.07) conditions were associated with the highest aRRs for SMM. The rate of SNM was higher among newborns whose mother visited the ED within 90 days before pregnancy (68.2 vs 55.4 per 1000 births; aRR, 1.24; 95% CI, 1.22-1.26) as was the risk of neonatal death (aRR, 1.26; 95% CI, 1.16-1.37) and stillbirth (aRR, 1.18; 95% CI, 1.11-1.25).

Conclusions And Relevance: In this study, ED use was common before pregnancy. These findings suggest that ED use may not only reflect a woman's access to prepregnancy care but also higher future risk of severe maternal and perinatal morbidity, potentially offering a useful trigger for health system interventions to decrease adverse pregnancy outcomes.

Citing Articles

Emergency Care Use During Pregnancy and Severe Maternal Morbidity.

Declercq E, Liu C, Cabral H, Amutah-Onukagha N, Diop H, Mehta P JAMA Netw Open. 2024; 7(10):e2439939.

PMID: 39412800 PMC: 11581629. DOI: 10.1001/jamanetworkopen.2024.39939.

Antepartum Emergency Department Use and Associations with Maternal and Neonatal Outcomes in a Large Hospital System.

Sabloak T, Yee L, Feinglass J Womens Health Rep (New Rochelle). 2023; 4(1):562-570.

PMID: 38099077 PMC: 10719645. DOI: 10.1089/whr.2023.0072.

Pregnancy and Emergency Department Utilization in North Carolina, 2016-2021: A Population-Based Surveillance Study.

Nazzal E, Waller A, Meyer M, Ising A, Jones-Vessey K, Urrutia E AJPM Focus. 2023; 2(4):100142.

PMID: 37790954 PMC: 10546499. DOI: 10.1016/j.focus.2023.100142.

Patient Sociodemographics and Comorbidities and Birth Hospital Characteristics Associated With Postpartum Emergency Department Care.

Zarrin H, Vargas-Torres C, Janevic T, Stern T, Lin M JAMA Netw Open. 2023; 6(3):e233927.

PMID: 36943266 PMC: 10031389. DOI: 10.1001/jamanetworkopen.2023.3927.

Maternal Emergency Department Use Before Pregnancy and Infant Emergency Department Use After Birth.

Varner C, Park A, Ray J JAMA Netw Open. 2023; 6(3):e232931.

PMID: 36912832 PMC: 10011931. DOI: 10.1001/jamanetworkopen.2023.2931.

References

Gomez D, Simpson A, Sue-Chue-Lam C, de Mestral C, Dossa F, Nantais J . A population-based analysis of the impact of the COVID-19 pandemic on common abdominal and gynecological emergency department visits. CMAJ. 2021; 193(21):E753-E760. PMC: 8177921. DOI: 10.1503/cmaj.202821. View

Lain S, Algert C, Nassar N, Bowen J, Roberts C . Incidence of severe adverse neonatal outcomes: use of a composite indicator in a population cohort. Matern Child Health J. 2011; 16(3):600-8. DOI: 10.1007/s10995-011-0797-6. View

Abel M, Alavi M, Tierney C, Weintraub M, Avins A, Zaritsky E . Coronavirus Disease 2019 (COVID-19) and the Incidence of Obstetric and Gynecologic Emergency Department Visits in an Integrated Health Care System. Obstet Gynecol. 2021; 137(4):581-583. PMC: 7984631. DOI: 10.1097/AOG.0000000000004331. View

Schummers L, Hutcheon J, Hernandez-Diaz S, Williams P, Hacker M, VanderWeele T . Association of Short Interpregnancy Interval With Pregnancy Outcomes According to Maternal Age. JAMA Intern Med. 2018; 178(12):1661-1670. PMC: 6583597. DOI: 10.1001/jamainternmed.2018.4696. View

Joseph K, Fahey J . Validation of perinatal data in the Discharge Abstract Database of the Canadian Institute for Health Information. Chronic Dis Can. 2009; 29(3):96-100. View

Rizza A, Kaplan V, Senn O, Rosemann T, Bhend H, Tandjung R . Age- and gender-related prevalence of multimorbidity in primary care: the Swiss FIRE project. BMC Fam Pract. 2012; 13:113. PMC: 3557138. DOI: 10.1186/1471-2296-13-113. View

Samiedaluie S, Peterson S, Brant R, Kaczorowski J, Norman W . Validating abortion procedure coding in Canadian administrative databases. BMC Health Serv Res. 2016; 16:255. PMC: 4942914. DOI: 10.1186/s12913-016-1485-4. View

Vigod S, Kurdyak P, Dennis C, Gruneir A, Newman A, Seeman M . Maternal and newborn outcomes among women with schizophrenia: a retrospective population-based cohort study. BJOG. 2014; 121(5):566-74. DOI: 10.1111/1471-0528.12567. View

Rocca W, Boyd C, Grossardt B, Bobo W, Finney Rutten L, Roger V . Prevalence of multimorbidity in a geographically defined American population: patterns by age, sex, and race/ethnicity. Mayo Clin Proc. 2014; 89(10):1336-49. PMC: 4186914. DOI: 10.1016/j.mayocp.2014.07.010. View

10.

Hutcheon J, Nelson H, Stidd R, Moskosky S, Ahrens K . Short interpregnancy intervals and adverse maternal outcomes in high-resource settings: An updated systematic review. Paediatr Perinat Epidemiol. 2018; 33(1):O48-O59. PMC: 7380038. DOI: 10.1111/ppe.12518. View

11.

Lawton B, MacDonald E, Stanley J, Daniells K, Geller S . Preventability review of severe maternal morbidity. Acta Obstet Gynecol Scand. 2018; 98(4):515-522. DOI: 10.1111/aogs.13526. View

12.

Kilfoyle K, Vrees R, Raker C, Matteson K . Nonurgent and urgent emergency department use during pregnancy: an observational study. Am J Obstet Gynecol. 2016; 216(2):181.e1-181.e7. PMC: 5290191. DOI: 10.1016/j.ajog.2016.10.013. View

13.

Ray J, Davidson A, Berger H, Dayan N, Park A . Haemoglobin levels in early pregnancy and severe maternal morbidity: population-based cohort study. BJOG. 2020; 127(9):1154-1164. DOI: 10.1111/1471-0528.16216. View

14.

Dayan N, Shapiro G, Luo J, Guan J, Fell D, Laskin C . Development and internal validation of a model predicting severe maternal morbidity using pre-conception and early pregnancy variables: a population-based study in Ontario, Canada. BMC Pregnancy Childbirth. 2021; 21(1):679. PMC: 8496026. DOI: 10.1186/s12884-021-04132-6. View

15.

Dzakpasu S, Deb-Rinker P, Arbour L, Darling E, Kramer M, Liu S . Severe maternal morbidity surveillance: Monitoring pregnant women at high risk for prolonged hospitalisation and death. Paediatr Perinat Epidemiol. 2019; 34(4):427-439. PMC: 7383693. DOI: 10.1111/ppe.12574. View

16.

Tita A, Szychowski J, Boggess K, Dugoff L, Sibai B, Lawrence K . Treatment for Mild Chronic Hypertension during Pregnancy. N Engl J Med. 2022; 386(19):1781-1792. PMC: 9575330. DOI: 10.1056/NEJMoa2201295. View

17.

Magriples U, Kershaw T, Rising S, Massey Z, Ickovics J . Prenatal health care beyond the obstetrics service: utilization and predictors of unscheduled care. Am J Obstet Gynecol. 2008; 198(1):75.e1-7. PMC: 2276882. DOI: 10.1016/j.ajog.2007.05.040. View

18.

Knight H, Oddie S, Harron K, Aughey H, van der Meulen J, Gurol-Urganci I . Establishing a composite neonatal adverse outcome indicator using English hospital administrative data. Arch Dis Child Fetal Neonatal Ed. 2018; 104(5):F502-F509. PMC: 6703994. DOI: 10.1136/archdischild-2018-315147. View

19.

Aoyama K, Ray J, Pinto R, Hill A, Scales D, Lapinsky S . Temporal Variations in Incidence andOutcomes of Critical Illness Among Pregnant and Postpartum Women inCanada: A Population-Based Observational Study. J Obstet Gynaecol Can. 2018; 41(5):631-640. DOI: 10.1016/j.jogc.2018.07.021. View

20.

Malik S, Kothari C, MacCallum C, Liepman M, Tareen S, Rhodes K . Emergency Department Use in the Perinatal Period: An Opportunity for Early Intervention. Ann Emerg Med. 2017; 70(6):835-839. DOI: 10.1016/j.annemergmed.2017.06.020. View