The substantial increase in the rate of severe maternal morbidity (SMM) over the past few decades has garnered a great deal of attention, which has resulted in increased research to ascertain who is at greatest risk of SMM as well as implementation of policies and practices to reduce the observed disparities. The risk of SMM among individuals with disabilities has been overlooked; there are several potential reasons for this oversight. First, persons with disabilities have often been excluded from discussions of sexuality and parenthood.1 Second, most population-based research on SMM has used data without high-quality information on preexisting disabilities.2 For example, the National Inpatient Sample of the Healthcare Cost and Utilization Project does not link multiple health care encounters for the same individual and would therefore only capture a preexisting disability if a disability-related diagnosis code was included in the birth hospitalization.
In this issue of JAMA Network Open, Brown et al3 use data from more than 1.8 million births in Ontario, Canada to assess the risk of SMM and maternal morbidity among persons with a preexisting disability. The data included more than 98% of births in Ontario from 2003 to 2018, and allowed for individual-level links with hospitalizations, emergency department visits, and physician visits from data set inception (approximately 1990) to the end of the study period. This meant that the authors were able to identify physical, sensory, and intellectual/developmental disabilities using data from 13 to 28 years before the pregnancy. The use of multiple data sources over many years to identify disability in administrative data substantially increased accuracy. In the cohort, approximately 11% of pregnant persons had at least 1 preexisting disability. The risk of SMM or death was higher for those with a physical disability (adjusted relative risk [aRR], 1.29; 95% CI, 1.25-1.34), sensory disability (aRR, 1.14; 95% CI, 1.06-1.21), intellectual/developmental disability (aRR, 1.57; 95% CI, 1.23-2.01), and for those who with 2 or more disabilities (aRR, 1.74; 95% CI, 1.55-1.95) compared with those without a preexisting disability.
Brown et al3 note that other risk factors for SMM, such as diabetes, cardiovascular disease, and poverty, occur in higher rates among women with disabilities; however, even after adjusting for these variables, the risk of SMM among those with preexisting disabilities remained elevated. Race/ethnicity was a factor that they could not adjust for because of limitations of the data; the prevalence of both disability and SMM are higher among racial/ethnic minorities.4,5 The elevated risk of SMM among racial/ethnic minorities has been attributed to experiences of racism in the health care system, among other factors.4 Future research in this area should examine the intersectionality of disability, race/ethnicity and the risk of SMM.
The findings reported by Brown et al3 are an important step in highlighting the increased risk of poor reproductive outcomes for individuals with disabilities. As the authors mention, there is a need for better preconception and perinatal care for pregnant persons with disabilities. However, the authors did not discuss whether greater efforts should be made to ensure women with disabilities have access to the same preconception and perinatal programs available to women without disabilities, or if specific programs need to be developed to address the unique needs of women with disabilities. Understanding the scope of the issue is an important first step. Future work should focus on how to best address the observed disparities and improve reproductive outcomes for women with disabilities.
Published: February 8, 2021. doi:10.1001/jamanetworkopen.2020.35121
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Wall-Wieler E. JAMA Network Open.
Corresponding Author: Elizabeth Wall-Wieler, PhD, Department of Community Health Sciences, Max Rady College of Medicine, S113-750 Bannatyne Ave, Winnipeg, Manitoba, Canada R3E 0W3 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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Wall-Wieler E. Understanding Reproductive Outcomes Among Women With Disabilities. JAMA Netw Open. 2021;4(2):e2035121. doi:10.1001/jamanetworkopen.2020.35121
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