Medical indications for primary cesarean delivery in women with and without disabilities

Experiences of women with impaired physical mobility during pregnancy, childbirth and postpartum: A case study

INTRODUCTION

The research deals with a little-studied topic in Estonia: the experiences of women with impaired physical mobility (IPM) during pregnancy, childbirth, and in the postpartum period. Women with IPM, a vulnerable group, have a higher risk of complications and a higher probability of missing out on comprehensive maternity care.

METHODS

The method of the present research is qualitative. It is a case study of three women with IPM with whom semi-structured interviews were conducted.

RESULTS

It was found that women with IPM encountered several obstacles and problems during pregnancy, childbirth, and the postpartum period; despite this, women's experiences with maternity care were mostly positive. Furthermore, there are several areas for improvement to ensure more comprehensive maternity care. Women with IPM need more support and help, and midwives are expected to have additional knowledge regarding the specifics or limitations resulting from mobility impairments.

CONCLUSIONS

In the future, the topic needs greater attention and improvement in the Estonian context to ensure more comprehensive maternity care for women with IPM. It is important to provide midwives the knowledge and skills to assist women with IPM during pregnancy, childbirth, and the postpartum period.

The Right to Sexuality, Reproductive Health, and Found a Family for People with Intellectual Disability: A Systematic Review

Although sexuality, reproductive health, and starting a family are human rights that should be guaranteed for all citizens, they are still taboo issues for people with intellectual disability (ID), and even more so for women with ID. This paper systematically reviews the current qualitative and quantitative evidence on the rights of people with ID in regard to Articles 23 (right to home and family) and 25 (health, specifically sexual and reproductive health) of the Convention on the Rights of Persons with Disabilities (CRPD). A systematic review of the current literature, following PRISMA 2020, was carried out in ERIC, PsychInfo, Scopus, PubMed, ProQuest, and Web of Science. In all, 151 articles were included for review. The studies were categorized into six themes: attitudes, intimate relationships, sexual and reproductive health, sexuality and sex education, pregnancy, and parenthood. There are still many barriers that prevent people with ID from fully exercising their right to sexuality, reproductive health, and parenthood, most notably communicative and attitudinal barriers. These findings underline the need to continue advancing the rights of people with ID, relying on Schalock and Verdurgo's eight-dimensional quality of life model as the ideal conceptual framework for translating such abstract concepts into practice and policy.

Severe maternal morbidity and other perinatal complications among women with physical, sensory, or intellectual and developmental disabilities

BACKGROUND

Little is known about severe maternal morbidity (SMM) among women with disabilities.

OBJECTIVE

We assessed differences in SMM and other perinatal complications by presence and type of disability. We hypothesised that SMM and other complications would be more common in births to women with disabilities than to women without disabilities.

METHODS

We conducted a retrospective cohort study of California births from 2000 to 2012, using birth and death certificate data linked with hospital discharge data. We included singleton deliveries with gestational age of 23-42 weeks. We classified women as having any disability or not and identified disability type (physical, hearing, vision, intellectual/developmental disabilities [IDD]). Our primary outcome was a composite indicator of SMM. Secondary outcomes included additional perinatal complications: gestational hypertension, preeclampsia, gestational diabetes, venous thromboembolism, chorioamnionitis, puerperal endometritis and mental health disorders complicating pregnancy, childbirth or the puerperium. We used modified Poisson regression to obtain covariate-adjusted relative risks (RR) and 95% confidence intervals (CI) for the association of disability status and type with SMM and secondary outcomes.

RESULTS

Of 5,787,090 deliveries, 33,044 (0.6%) were to women with disabilities. Of these, 311 per 10,000 were complicated by SMM, compared with 84 per 10,000 deliveries to women without disabilities. In multivariable analyses, risk of SMM for births to women with disabilities was nearly three times that for women without disabilities (RR 2.84, 95% CI 2.67, 3.02). Proportion and risk of SMM were greatest for vision disability (793 per 10,000; RR 4.04, 95% CI 3.41, 4.78). Secondary outcomes were also more common among women with disabilities. In particular, more than a third of births to women with IDD (37.4%) were complicated by mental health disorders (versus 2.2% for women without disabilities).

CONCLUSION

As hypothesised, SMM and other perinatal complications were more common among women with disabilities than among women without disabilities.

Neonatal Outcomes of Mothers With a Disability

OBJECTIVES

To assess the risk of neonatal complications among women with a disability.

METHODS

This population-based cohort study comprised all hospital singleton livebirths in Ontario, Canada from 2003 to 2018. Newborns of women with a physical (N = 144 187), sensory (N = 44 988), intellectual or developmental (N = 2207), or ≥2 disabilities (N = 8823) were each compared with 1 593 354 newborns of women without a disability. Outcomes were preterm birth <37 and <34 weeks, small for gestational age birth weight (SGA), large for gestational age birth weight, neonatal morbidity, and mortality, neonatal abstinence syndrome (NAS), and NICU admission. Relative risks were adjusted for social, health, and health care characteristics.

RESULTS

Risks for neonatal complications were elevated among newborns of women with disabilities compared with those without disabilities. Adjusted relative risks were especially high for newborns of women with an intellectual or developmental disability, including preterm birth <37 weeks (1.37, 95% confidence interval 1.19-1.58), SGA (1.37, 1.24-1.59), neonatal morbidity (1.42, 1.27-1.60), NAS (1.53, 1.12-2.08), and NICU admission (1.53, 1.40-1.67). The same was seen for newborns of women with ≥2 disabilities, including preterm birth <37 weeks (1.48, 1.39-1.59), SGA (1.13, 1.07-1.20), neonatal morbidity (1.28, 1.20-1.36), NAS (1.87, 1.57-2.23), and NICU admission (1.35, 1.29-1.42).

CONCLUSIONS

There is a mild to moderate elevated risk for complications among newborns of women with disabilities. These women may need adapted and enhanced preconception and prenatal care, and their newborns may require extra support after birth.

Risk of Adverse Maternal Outcomes in Pregnant Women With Disabilities

IMPORTANCE

Women with disabilities have a higher risk of preterm birth, gestational diabetes, preeclampsia, and cesarean delivery; however, their risk of other obstetric interventions, adverse maternal outcomes, and clinical indications for increased cesarean delivery is unclear.

OBJECTIVE

To evaluate risk of a range of obstetric interventions and adverse maternal outcomes, including severe maternal morbidities (SMM) and mortality, among women with and without disabilities.

DESIGN, SETTING, AND PARTICIPANTS

The Consortium on Safe Labor was a retrospective cohort that included comprehensive medical chart review for deliveries between January 2002 and January 2008. Data were collected from 12 clinical sites, which included 19 hospitals across the United States. This secondary analysis was conducted in February to July 2021.

EXPOSURES

Using International Classification of Diseases, Ninth Revision, codes and a validated algorithm to define disability, participants were classified as having physical, intellectual, sensory, or any disability, and compared with women with no documented disability.

MAIN OUTCOMES AND MEASURES

The relative risk (RR) of 23 obstetric interventions and adverse maternal outcomes, including SMM and mortality, was evaluated.

RESULTS

Of the 223 385 women in the study, 9206 (4.1%) were Asian or Pacific Islander, 50 235 (22.5%) were Black, 39 039 (17.5%) were Hispanic, and 110 443 (49.4%) were White, with a mean (SD) age of 27.6 (6.2) years. There were 2074 (0.9%) women with disability and 221 311 (99.1%) without. Among women with disabilities, 1733 (83.5%) were physical, 91 (4.4%) were intellectual, and 250 (12.1%) were sensory. Compared with women with no disability, women with disabilities had higher risk of gestational diabetes, placenta previa, premature rupture of membranes, preterm premature rupture of membranes, and postpartum fever as well as maternal death (adjusted relative risk [aRR], 11.19; 95% CI, 2.40-52.19) and individual SMMs: severe preeclampsia/eclampsia (aRR, 2.15; 95% CI, 1.80-2.56), hemorrhage (aRR, 1.27; 95% CI, 1.09-1.49), and fever (aRR, 1.32; 95% CI, 1.03-1.67), with the highest risk observed for thromboembolism (aRR, 6.08; 95% CI, 4.03-9.16), cardiovascular events (aRR, 4.02; 95% CI, 2.87-5.63), and infection (aRR, 2.69; 95% CI, 1.97-3.67). Women with any disability also had higher risk of interventions, including oxytocin augmentation, operative vaginal delivery, and cesarean delivery (aRR, 1.33; 95% CI, 1.25-1.42), with the cesarean indication less likely to be medically indicated (aRR, 0.79; 95% CI, 0.70-0.89). Risk of adverse outcomes and interventions remained consistent across disability categories.

CONCLUSIONS AND RELEVANCE

In this study, women with physical, intellectual, and sensory disability during pregnancy were at higher risk of adverse outcomes, including a broad range of SMM and maternal mortality.

Pregnancy-related outcomes among women with physical disabilities: A systematic review

BACKGROUND

Disability among women of reproductive age is common; many of these women desire children and do not have impaired fertility.

OBJECTIVES

To examine the epidemiological literature on perinatal health outcomes among women with physical disabilities.

DATA SOURCES

We searched Medline and CINAHL for articles published January 2009-April 2020 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

STUDY SELECTION AND DATA EXTRACTION

Eligible studies were observational, quantitative, and reported on physical disabilities in association with prenatal, perinatal, postpartum, and/or infant health outcomes. We included studies that grouped physical and non-physical disabilities, such as surveys that queried only about general daily life limitations. We excluded case reports, descriptive studies without comparison groups, and studies conducted in low- or middle-income countries. Data extraction was done using predefined data fields.

SYNTHESIS

All authors were involved in screening activities, data extraction, and/or quality assessment (rating and areas for bias).

RESULTS

A total of 2650 articles were evaluated, of which sixteen met inclusion criteria (8 cross-sectional studies and 8 retrospective cohort studies). Assessments of disability status and perinatal outcomes widely varied across studies. Studies were rated as poor (n = 8) or fair quality (n = 8). Findings suggested that women with physical disabilities were at risk of several adverse outcomes, including caesarean delivery, infections, preterm complications, and maternal post-delivery hospitalisations, while their infants may be at risk of low birthweight and small-for-gestational age. Women classified as having complex/severe disabilities were often observed to be at higher risk of adverse outcomes compared to women with less severe disabilities.

CONCLUSIONS

Research assessing how physical, functional, and medical restrictions influence health outcomes among women with physical disabilities, from preconception through postpartum, is limited. Longitudinal studies with comprehensive data collection that accurately identify women with physical disabilities are critical to understanding their reproductive health risks and outcomes.

Perinatal outcomes of women with a disability who received pregnancy care through a specialised disability clinic in Melbourne, Australia

BACKGROUND

In Australia, it is estimated that 9.5% of women of childbearing age have a disability; however, little is known about their perinatal outcomes. Disability status is not routinely recorded in perinatal datasets.

AIMS

To compare the outcomes of women with a disability who received pregnancy care through a specialised disability clinic at the Royal Women's Hospital (the Women's) in Melbourne, Australia with hospital-wide perinatal outcome data.

MATERIALS AND METHODS

Routinely collected perinatal data for women who received pregnancy care from the 'Women with Individual Needs' (WIN) clinic from 2014-2018 (N = 111) were analysed and then compared with routinely collected electronic hospital data obtained from all women who had given birth at the Women's in 2017 and 2018 (N = 15 024).

RESULTS

Women who attended the WIN clinic were more likely to have a caesarean section birth (52% vs 32%; P < 0.001) and give birth preterm (17% vs 4%; P < 0.001) than those in the hospital-wide cohort. Their infants were more likely to be low birthweight (20% vs 9%; P < 0.001), require resuscitation (35% vs 11%; P < 0.001), be admitted to the Neonatal Intensive Special Care Unit (29% vs 13%; P < 0.001) and receive formula in hospital (54% vs 28%; P < 0.001) compared to infants in the other group.

CONCLUSIONS

Routine maternity data collection should include identification of women with a disability to enable appropriate support and to allow further exploration of potential poorer outcomes on a larger sample, to help identify factors amenable to interventions that may improve outcomes.

Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities

OBJECTIVE

To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada.

TARGET POPULATION

This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline.

OUTCOMES

Safe and compassionate care for people with physical disabilities who are giving birth.

BENEFITS, HARMS, AND COSTS

Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth.

EVIDENCE

A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

RECOMMENDATIONS

Prolonged postpartum length of hospital stay among women with disabilities

BACKGROUND

Prior studies have found higher proportions of cesarean deliveries and longer postpartum hospital stays among women with disabilities compared to women without disabilities. However, no research has assessed how length of stay may differ for women with different types of disability while also considering mode of delivery.

OBJECTIVE

To examine the association of disability status and disability type with length of stay, taking into account disability-related differences in mode of delivery.

METHODS

We conducted a retrospective cohort study using linked maternal and infant hospital discharge and vital records data for all births in California between 2000 and 2012 (n = 6,745,201). We used multivariable regression analyses to assess association of disability status and type with prolonged length of stay (>2 days for vaginal delivery or >4 days for cesarean) while controlling for covariates.

RESULTS

Women with disabilities had significantly elevated adjusted odds of prolonged length of stay compared to women without disabilities (aOR = 1.40, 95% CI = 1.32-1.49). Adjusted odds were highest for women with vision disabilities (aOR = 1.67, 95% CI = 1.46-1.90), followed by women with IDD (aOR = 1.53, 95% CI = 1.30-1.80), and women with physical disabilities (aOR = 1.41, 95% CI = 1.32-1.50). Women with hearing disability had the lowest adjusted odds of prolonged length of stay (aOR = 1.17, 95% CI = 1.03-1.33).

CONCLUSIONS

Prolonged length of stay did not appear to be due solely to the higher proportion of cesarean deliveries in this population. Further research is needed to better understand the reasons for prolonged length of stay among women with disabilities and develop strategies to assist women with disabilities in preparing for and recovering from childbirth.

Maternal disability and risk for pregnancy, delivery, and postpartum complications: a systematic review and meta-analysis

BACKGROUND

Women with disabilities are increasingly becoming pregnant, and growing evidence suggests maternal disability may be associated with increased risk for perinatal complications.

OBJECTIVE

A systematic review and meta-analysis were undertaken to examine the association between maternal disabilities and risk for perinatal complications.

STUDY DESIGN

Medline, CINAHL, EMBASE, and PsycINFO were searched from inception to July 2018 for full-text publications in English on pregnancy, delivery, and postpartum complications in women with any disability and those with physical, sensory, and intellectual and developmental disabilities specifically. Searches were limited to quantitative studies with a comparison group of women without disabilities. Reviewers used standardized instruments to extract data from and assess the quality of included studies. Pooled odds ratios and 95% confidence intervals were generated using DerSimonian and Laird random effects models for outcomes with data available from ≥3 studies.

RESULTS

The review included 23 studies, representing 8,514,356 women in 19 cohorts. Women with sensory (pooled unadjusted odds ratio, 2.85, 95% confidence interval, 0.79-10.31) and intellectual and developmental disabilities (pooled unadjusted odds ratio, 1.10, 95% confidence interval, 0.76-1.58) had elevated but not statistically significant risk for gestational diabetes. Women with any disability (pooled unadjusted odds ratio, 1.45, 95% confidence interval, 1.16-1.82) and intellectual and developmental disabilities (pooled unadjusted odds ratio, 1.77, 95% confidence interval, 1.21-2.60) had increased risk for hypertensive disorders of pregnancy; risk was elevated but not statistically significant for women with sensory disabilities (pooled unadjusted odds ratio, 2.84, 95% confidence interval, 0.85-9.43). Women with any (pooled unadjusted odds ratio, 1.31, 95% confidence interval, 1.02-1.68), physical (pooled unadjusted odds ratio, 1.60, 95% confidence interval, 1.21-2.13), and intellectual and developmental disabilities (pooled unadjusted odds ratio, 1.29, 95% confidence interval, 1.02-1.63) had increased risk for cesarean delivery; risk among women with sensory disabilities was elevated but not statistically significant (pooled unadjusted odds ratio, 1.28, 95% confidence interval, 0.84-1.93). There was heterogeneity in all analyses, and 13 studies had weak-quality ratings, with lack of control for confounding being the most common limitation.

CONCLUSION

Evidence that maternal disability is associated with increased risk for perinatal complications demonstrates that more high-quality research is needed to examine the reasons for this risk and to determine what interventions could be implemented to support women with disabilities during the perinatal period.

Miscarriage Occurrence and Prevention Efforts by Disability Status and Type in the United States

Background: Very little is known about early pregnancy loss in women with disabilities. To address this gap, we analyzed nationally representative data on miscarriage and receipt of care focused on miscarriage prevention among women with and without disabilities. Materials and Methods: We used 2011-2015 National Survey of Family Growth data on women with at least one completed pregnancy within the past 5 years. Bivariate and multivariate analyses assessed the association of six disability categories (any, hearing, vision, cognitive, physical, independent living) with miscarriage occurrence and receipt of services intended to prevent miscarriage. Results: Our analytic sample included 3,843 women with 5,776 completed pregnancies within the past 5 years. Overall, 31.63% of women with disabilities and 21.83% of women without disabilities had had a miscarriage within the past 5 years. Compared to women without disabilities, women with any, cognitive, physical, and independent living disability had higher adjusted odds of experiencing miscarriage (any disability aOR = 1.65 [95% CI: 1.21-2.25]). These women also had higher odds of receiving services to prevent miscarriage compared with women without disabilities (any disability aOR = 1.71 [95% CI: 1.20-2.45]). Among women who received services, higher proportions of women with any, vision, physical, or independent living disability received recommendations for bed rest (e.g., 65.007% of women with independent living disability vs. 33.98% of women without disability, p = 0.018). Conclusions: In a representative sample of U.S. women, we found significant differences in the odds of miscarriage and in receipt of care to prevent miscarriage between women with and without disabilities. Further research is needed to understand why women with disabilities are more likely to experience a miscarriage. Such research is important for informing care recommendations.