Emergency care use during pregnancy linked to increased SMM risk

Emergency care use during pregnancy linked to increased SMM risk | Image Credit: © nilsversemann - © nilsversemann - stock.adobe.com.

The risk of severe maternal morbidity (SMM) is increased among patients with high emergency care use during pregnancy, according to a recent study published in JAMA Network Open.¹

Pregnancy often includes extensive care, and lifetime health outcomes may be affected. However, there is little data about the impact of unscheduled hospital visits during pregnancy and associated outcomes.

Data has indicated unmet clinical and psychosocial needs among patients with 4 or more unscheduled hospital visits during pregnancy.² Additionally, an emergency department (ED) encounter within 90 days before pregnancy was linked to a risk ratio of 1.37 for SMM.¹

Investigators conducted a study to evaluate patterns of unscheduled care during pregnancy and its association to SMM at birth. Data was obtained from the Massachusetts Pregnancy to Early Life Longitudinal (PELL) Data System.

Through PELL, investigators were able to obtain birth and fetal death records in Massachusetts linked to maternal hospital encounters, including admissions, outpatient stays, and ED visits. Hospital discharge records from January 1, 1998, to December 31, 2020, are available in the database.

Individuals with births or fetal deaths in Massachusetts between October 1, 2002, and March 31, 2020, were included in the analysis. The obstetrical estimate of gestational age was subtracted from the date of birth to determine the pregnancy period, and only the individual’s most recent pregnancy was included.

Race and ethnicity categories included Hispanic, non-Hispanic Asian or Pacific Islander, non-Hispanic Black, non-Hispanic White, and non-Hispanic other. This data was based on self-identification.

There were 774,092 individuals aged a mean 31.2 years included in the analysis. Of participants, 16.8% were Hispanic, 9.3% non-Hispanic Asian or Pacific Islander, 9.5% non-Hispanic Black, 63.1% non-Hispanic White, and 1.3% non-Hispanic other. SMM was reported in 0.7%.

An unscheduled hospital visit was reported in 31.3% of participants, with 24.8% being ED and 10.5% observational stay. A single unscheduled hospital visit was observed in 18.1%, 2 in 6.8%, 3 in 3%, and 4 or more in 3.3%.

Younger individuals had increased rates of emergency care use, at a prevalence of 8.7% for 4 or more visits in patients aged under 25 years vs 1.4% in those aged 35 years and older. Hispanic individuals had the highest rate of use at 5.7%, followed by non-Hispanic Black individuals at 4.9%, non-Hispanic White at 2.9%, and non-Hispanic Asian at 0.6%.

Additional factors increasing the odds of having 4 or more unscheduled visits included having public insurance, having a comorbidity excluding opioid use, being born in the United States, having reduced education, giving birth under 36 weeks’ gestation, and having preexisting diabetes. A peak of unscheduled visits was seen at 32 to 36 weeks’ gestation.

An association was reported between visits for hematologic and cardiovascular conditions with SMM. Hematologic condition-related visit rates were 6.4% among those with SMM vs 2% among those without SMM, while cardiovascular condition-related visit rates were 8.6% vs 3.6%, respectively.

Using more than 1 hospital was reported by 43.8% of patients with 4 or more visits and using 3 or more by 12.6%. A positive correlation was identified between the number of hospitals visited during pregnancy and the rate of SMM, from 85.9 per 10,000 deliveries at 1 hospital to 141.1 per 10,000 at 3 or more hospitals.

An SMM rate of 66.2 per 10,000 deliveries was estimated among patients with 0 unscheduled hospital visits, vs 119.1 per 10,000 deliveries among patients with 4 or more visits. Adjusted odds ratios for SMM were 1.31 for 3 unscheduled prenatal hospital visits and 1.46 for 4 or more visits when compared to 0 visits.

These results indicated an association between unscheduled prenatal hospital visits and SMM. Investigators concluded integrated responses to granular signals of need or urgently required for this period of pregnancy.

References

1. Declercq ER, Liu C, Cabral HJ, Amutah-Onukagha N, Diop H, Mehta PK. Emergency care use during pregnancy and severe maternal morbidity. JAMA Netw Open. 2024;7(10):e2439939. doi:10.1001/jamanetworkopen.2024.39939
2. Akpovi EE, Carter T, Kangovi S, Srinivas SK, Bernstein JA, Mehta PK. Medicaid member perspectives on innovation in prenatal care delivery: a call to action from pregnant people using unscheduled care.Healthc (Amst). 2020;8(4):100456. doi:10.1016/j.hjdsi.2020.100456