Impact of maternal social vulnerability and timing of prenatal care on outcome of prenatally detected congenital heart disease

Abstract

Objectives Early prenatal detection of congenital heart disease (CHD) allows mothers to plan for their pregnancy and delivery; however, the effect of certain sociodemographic and fetal factors on prenatal care has not been investigated thoroughly. This study evaluated the impact of maternal and fetal characteristics on the timing of prenatal diagnosis of CHD and fetal and postnatal outcomes. Methods This retrospective multicenter cohort study included women with a fetal echocardiographic diagnosis of CHD between 2010 and 2019. Women were grouped into quartiles of social vulnerability (quartiles 1–4; low–high) using the 2014 social vulnerability index (SVI) provided by the Centers for Disease Control and Prevention. A fetal disease severity score (range, 1–7) was calculated based on a combination of CHD severity (mild = 1; moderate = 2; severe, two ventricles = 3; severe, single ventricle = 4 points) and prenatally diagnosed genetic abnormality, non‐cardiac abnormality and fetal hydrops (1 point each). Late diagnosis was defined as a fetal echocardiographic diagnosis of CHD after 24 weeks' gestation. Univariate and multivariable regression analyses were used to identify factors associated with late diagnosis, termination of pregnancy (TOP), postnatal death, prenatal–postnatal discordance in CHD diagnosis and severity and, for liveborn infants, to identify which prenatal variables were associated with postnatal death or heart transplant. Results Among 441 pregnancies included, 94 (21%) had a late diagnosis of CHD. Late diagnosis was more common in the most socially vulnerable quartile, 38% of women in this group having diagnosis > 24 weeks, compared with 14–18% in the other three quartile groups. Late diagnosis was also associated with Catholic or other Christian religion vs non‐denominational or other religion and with a lower fetal disease severity score. There were 93 (21%) TOP and 26 (6%) in‐utero fetal demises. Factors associated with TOP included early diagnosis and greater fetal disease severity. Compared with the other quartiles, the most socially vulnerable quartile had a higher incidence of in‐utero fetal demise and a lower incidence of TOP. Among the 322 liveborn infants, 49 (15%) died or underwent heart transplant during the follow‐up period (range, 0–16 months). Factors associated with postnatal death or heart transplant included longer delay between obstetric ultrasound examination at which CHD was first suspected and fetal echocardiogram at which CHD was confirmed and greater fetal disease severity. Conclusions High social vulnerability, Catholic or other Christian religion and low fetal disease severity are associated with late prenatal CHD diagnosis. Delays in CHD diagnosis are associated with fewer TOPs and worse postnatal outcome. Therefore, efforts to expedite fetal echocardiography following abnormal obstetric screening, particularly for at‐risk women (e.g. those with high SVI), have the potential to impact pregnancy and postnatal outcome among the prenatally diagnosed CHD population. ...

Inequities in Availability of Evidence-Based Birth Supports to Improve Perinatal Health for Socially Vulnerable Rural Residents

“…SVI scores are reported at the county and census tract level as an overall score for vulnerability and a score for each of the four themes. While the SVI was initially intended to identify the most vulnerable areas during public health and natural disaster emergencies, it has also been used for public health/epidemiology research as an objective measure of neighborhood and county-level social vulnerability and disadvantage [ 44 , 46 , 67 , 68 , 69 , 70 ].…”

“…Descriptive statistics, including median SVI scores and interquartile ranges (IQR) were calculated. Overall SVI score was dichotomized into two groups: the counties that fell into the most vulnerable quartile of counties on the national SVI scale (SVI score ≥ 0.75) and the remaining counties with less vulnerability (SVI score < 0.75), similar to other work using the SVI [ 44 ]. Logistic regression was used to determine the likelihood of availability of each of the evidence-based supports associated with county-level social vulnerability, comparing counties in the most vulnerable SVI quartile to the less vulnerable counties.…”

“…Race and ethnicity, a variable considered in the calculation of social vulnerability [ 38 , 39 ] can be considered as a proxy for exposure to racism [ 40 , 41 ], which impacts health when experienced both interpersonally and due to the upstream effects of social and political structures within society (i.e., institutional and structural racism) [ 36 , 42 , 43 ]. High social vulnerability has been linked to inequities in maternal and infant health outcomes, including delayed diagnosis of congenital heart anomalies and a resulting higher rate of infant mortality [ 44 ], increased preterm birth rates [ 45 ], higher teen birth rates [ 46 ], and COVID-19-related maternal and infant complications [ 47 ]. Specific social determinants of health that are components of social vulnerability have also been linked to adverse maternal and infant outcomes.…”

Barriers to accessing care: challenges in early prenatal diagnosis of congenital anomalies

“…Two articles in this issue of the Journal evaluate some of the barriers to improvement in the rate of early diagnosis in fetuses with CHD. The first, by Perez et al 1 , explores the impact of social vulnerability and the timing of prenatal care on the outcome of a cohort of pregnancies assembled from a group of five hospitals in Boston where a prenatal diagnosis of CHD had been made. A comprehensive list of variables, including maternal, pregnancy and fetal characteristics, were evaluated to try to elucidate the relationship between sociodemographic factors and early vs late prenatal diagnosis of CHD.…”

“…Two articles in this issue of the Journal evaluate some of the barriers to improvement in the rate of early diagnosis in fetuses with CHD. The first, by Perez et al 1 ,. explores the impact of social vulnerability and the timing of prenatal care on the outcome of a cohort of pregnancies assembled from a group of five hospitals in Boston where a prenatal diagnosis of CHD had been made.…”