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

Abstract

IMPORTANCEEmergency 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. RESULTSOf 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

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

“…We previously described some reasons for maternal ED use before pregnancy, which were partly dominated by Main Discharge Diagnosis Groups of "Symptoms, signs, abnormal clinical and laboratory findings," as well as "Injury, poisonings, and consequences of external causes." 14 These findings are also consistent with a select number of considerably smaller studies showing an association between maternal and infant ED use in highly selective populations. 11,15 For example, among a cohort of 4112 Medicaid-insured mother-infant pairs attending a regional perinatal referral center in Delaware, the number of maternal ED visits was associated with infant ED use 6 months after birth, as were the number of maternal medications, young maternal age, and Black race.…”

“…13 Even prepregnancy ED access is associated with a higher risk of severe maternal morbidity, severe neonatal morbidity, stillbirth, and neonatal death, especially as the number of prepregnancy ED visits increases. 14 Prior research observed a higher rate of ED encounters among infants whose mother was affected by a mental health problem or greater medical comorbidity, younger maternal age, and ED visits during pregnancy. 11,15 A major limitation of these studies is that they were restricted to commercially insured or low-income patients in the US, in contrast to regions with universal access to physician and hospital care, such as in Canada.…”

“…ED use in pregnancy is common and is also reflective of poorer access to antenatal care, with worse ensuing maternal and perinatal outcomes . Even prepregnancy ED access is associated with a higher risk of severe maternal morbidity, severe neonatal morbidity, stillbirth, and neonatal death, especially as the number of prepregnancy ED visits increases …”

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

“…Single-institution studies have examined the incidence and reasons for emergency department visits and ICU admissions among pregnant and postpartum patients. [4][5][6][7][8][9][10][11] However, it is unknown whether these findings are generalizable across institutions and populations and to what extent hospital factors contribute to potentially avoidable postpartum ED visits. Therefore, we use a statewide data set to describe the patient and birth hospital characteristics associated with postpartum ED visits within 42 days of giving birth, including racial distribution by hospital type and most common diagnoses associated with postpartum ED visits.…”

“…Interventions to improve communication and care coordination are limited by the lack of knowledge regarding which hospital settings should be targeted for these interventions. Single-institution studies have examined the incidence and reasons for emergency department visits and ICU admissions among pregnant and postpartum patients . However, it is unknown whether these findings are generalizable across institutions and populations and to what extent hospital factors contribute to potentially avoidable postpartum ED visits.…”