Pregnancy in Women With Physical Disabilities

Maternal Health Experiences of Black Deaf and Hard of Hearing Women in the United States

INTRODUCTION

Deaf and hard of hearing (DHH) women are faced with numerous health inequities, including adverse pregnancy and birth outcomes. These outcomes are likely exacerbated for Black DHH women because of the intersection of disability and race. This study aimed to explore the pregnancy and birth experiences of Black DHH women to identify factors that influence their pregnancy outcomes.

METHODS

Semistructured interviews were conducted between 2018 and 2019 with 67 DHH women who gave birth in the past five years. The present study represents a subgroup analysis of eight of the 67 women who self-identified as Black. Interviews were recorded, transcribed, and analyzed for emerging themes.

RESULTS

Primary themes centered on unmet needs, barriers, and facilitators. Barriers included limited access to health information owing to communication difficulties and challenges obtaining accommodations. Key facilitators included the availability of sign language interpreters, familial support, and cultural understanding from providers. Participants emphasized these facilitators in their recommendations to providers and DHH women. Findings also underscored the critical role of recognizing cultural identity in perinatal health care delivery.

CONCLUSIONS

This study outlines themes that affect pregnancy and birthing experiences among Black DHH women in the United States. Study implications include a call to action for providers to prioritize communication accommodations, accessible information, and compassionate care for all Black DHH women. Furthermore, future work should explore the impact of cultural and racial concordance between patients and their health care providers and staff. Understanding how intersectional identities affect perinatal health care access is crucial for reducing disparities among Black DHH women.

Reproductive Concerns Among Women with Disability: A Host of Opportunities for Reproductive Health Care Professionals

Background

Maternal health in India is likely to move towards an obstetric transition, wherein there is sustained reduction of maternal mortality and focus shifts towards improving quality of care. In such a context, reproductive concerns of special populations gain prominence. One such population group is women with disability.

What this review contains

This mini-review examines the incremental importance given to people with disabilities and the sparse data available on the topic of reproductive concerns among women with disability. The attitudes of the women with disability towards childbearing and the association between disability and obstetric problems are discussed. The limited available data on specific medical and obstetric problems among women with disability are reviewed.

Conclusions

The article calls for all obstetricians to display increased sensitivity and heightened cognizance towards the reproductive concerns among women with disability.

Exploring disability prevalence among childbearing women attending a tertiary maternity service in Melbourne, Australia using an audit and cross-sectional survey

BACKGROUND

Although there is an estimated rate of 10% of women of childbearing age in Australia who have a disability, there is a lack of accurate prevalence data, with the true rate unknown. The timing and questions used to collect women's disability status in pregnancy vary, and there is limited knowledge on how women accessing maternity services in Australia would like to be asked about their disability status.

OBJECTIVE

To explore the prevalence of women with a disability receiving maternity care using a direct and indirect disability identification question. Secondary aims were to explore how women would like to be asked about their disability status and to examine the difference between self-reported and clinician-documented disability status within medical records.

RESEARCH DESIGN/SETTING

The study was conducted at a tertiary maternity hospital in Melbourne, Australia, and included two components. Component one used a cross-sectional survey with two different cohorts of women administered face-to-face on the postnatal ward (Cohort 1 - February 2019, Cohort 2 - December 2019). In Cohort 1, a specific disability identification question asked: 'Can you please tell me if you identify as someone who has a disability?'. In Cohort 2, an indirect disability identification question asked: 'Do you require additional assistance or support?'. Other questions explored women's views on disability identification. Component two consisted of an audit of the medical records to compare disability documentation in the medical records of the women who participated with women's disability self-identification status.

RESULTS

371/467 (79%) of eligible women that were approached participated in Cohort 1 and in Cohort 2, 295/346 (85%) of eligible women that were approached participated in the study. In Cohort 1, 5% (17/371) of women self-identified with having a disability. In Cohort 2 16% (46/295) of women reported needing additional assistance/support, however of these, only nine women viewed this as a disability. In Cohort 1, of the women who self-identified as having a disability, 82% had this recorded in their medical record. An additional 12% (43/354) of women in Cohort 1 who may have had a disability according to the Australian Bureau of Statistics classification, did not self-identify as having a disability. In Cohort 2, 37% (17/43) of women who self-identified as needing additional support did not have these needs documented in the medical record. Less than a quarter of women in both cohorts were asked about their disability status during their maternity care. Women with a disability or additional support needs suggested both direct and indirect ways of being asked about their disability status, and their responses were similar to women who did not self-identify with having a disability or additional support needs.

CONCLUSIONS

Disability prevalence data is highly dependant on the wording of the disability identification question. It may be appropriate to ask about disability both indirectly, in terms of additional support needs, and directly, to enable disclosure for those who do identify with a disability. Disability questioning should be routine and standardised guidelines around disability identification should be developed to allow for tailored adjustments to care on an individual level.

VTE prophylaxis in pregnant people with chronic physical disability: Data from a physicians survey and the need for guidance

Background

International guidelines recommend risk assessment during the antepartum and postpartum period to inform VTE prophylaxis. We aimed to evaluate physicians' approach to VTE prophylaxis of women with chronic physical disability (CPD) during pregnancy.

Methods

A cross-sectional study consisting of a self-administered electronic questionnaire was sent to specialists across Canada.

Results

Seventy-three participants responded to the survey, and 55 (75.3%) completed the survey including 33 (60%) Maternal Fetal Medicine (MFM) specialists and 22 (40%) Internal Medicine (IM) specialists including physicians with an interest in Obstetric Medicine. Our study shows considerable variation in VTE thromboprophylaxis during pregnancy with CPD. Most respondents favoured antepartum (67.3%) and postpartum (65.5%) VTE prophylaxis for pregnancies within a year of spinal cord injury.

Conclusions

In order to better manage this complex population, CPD should be considered as a risk factor for development of VTE.

Depressive symptoms during the perinatal period by disability status: Findings from the United States Pregnancy Risk Assessment Monitoring System

AIMS

The aim of the current study was to compare the prevalence of depressive symptoms during the perinatal period among respondents with a disability as compared to those without a disability.

DESIGN

We conducted a secondary analysis of nationally representative data from the Pregnancy Risk Assessment Monitoring System data from 24 participating United States between 2018 and 2020.

METHODS

A cross-sectional sample of 37,989 respondents provided data on disability, including difficulty in vision, hearing, ambulation, cognition, communication and self-care. The outcome of interest was perinatal depressive symptoms, defined as experiencing depressive symptoms during the antenatal period or postpartum period. Regression models were used to calculate odds of depressive symptoms during these two time periods by disability status while controlling for relevant sociodemographic characteristics and depressive symptoms prior to pregnancy.

RESULTS

Respondents with disabilities experienced a higher prevalence of depressive symptoms in both the antenatal period and postpartum period as compared to those without disabilities. In fully adjusted models, respondents with disabilities had 2.4 times the odds of experiencing depressive symptoms during pregnancy and 2.1 times the odds of experiencing postpartum depressive symptoms as compared to respondents without disabilities.

CONCLUSION

Respondents with disabilities experience a higher prevalence of depressive symptoms throughout the perinatal period thereby increasing the risk for adverse maternal, neonatal and infant health outcomes.

IMPACT

Perinatal depression is a significant public health issue globally, and our findings suggest that persons with disability are at an increased risk for depressive symptoms both during pregnancy and in the postpartum period. Our findings represent a call to action to improve clinical and supportive services for women with disabilities during the perinatal period to improve their mental health and the consequent health of their offspring.

PATIENT OR PUBLIC CONTRIBUTION

We thank our Community Advisory Board members who have been instrumental in the conception of this study.

"It Would Have Been Nice to Have a Choice": Barriers to Contraceptive Decision-making among Women with Disabilities

INTRODUCTION

Engaging in contraceptive decisions is an important part of reproductive health for women and other people with the capacity for pregnancy. However, not all individuals capable of pregnancy have equal access to information and/or opportunities to make fully informed decisions. The goal of this study was to understand barriers women with disabilities experience around contraceptive decision-making and whether these differ based on type of disability.

METHODS

We conducted focus groups with 17 reproductive age adult women (aged 18-45 years). Focus groups were homogenous with regard to disability type and consisted of one group for each of the following disability categories: 1) physical disability, 2) intellectual and developmental disabilities, 3) blind or low vision, and 4) Deaf users of American Sign Language. Data were collected in the Portland, Oregon, metropolitan area during 2016-2017. We analyzed focus group transcripts using content analysis.

RESULTS

Barriers to informed contraceptive decision-making emerged in five main thematic areas: 1) lack of information in accessible formats, 2) incomplete information about contraceptive side effects, 3) limited clinician knowledge and relevant research specific to the care of women with disabilities, 4) taboos around discussing sexual activity, and 5) limited opportunities for shared contraceptive decision-making.

CONCLUSIONS

Women with disabilities faced numerous barriers to contraceptive decision-making. Although the barriers differed somewhat by disability type, many barriers were consistent across groups, suggesting commonalities associated with the experience of disability in the context of contraceptive decision-making. Increased attention to the reproductive health needs of people with disabilities is important for improving health care equity and quality.

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.

Birth outcomes among women with congenital neuromuscular disabilities

BACKGROUND

Women with disabilities are at an increased risk for adverse birth outcomes; however, research among women with congenital neuromuscular disabilities (CNMD) is limited.

OBJECTIVE

To describe characteristics and compare birth outcomes among mothers with and without cNMD.

METHODS

Data were from the Slone Birth Defects Study (case-control, conducted from 1976 to 2015), which collected information on demographic, reproductive, and lifestyle characteristics. cNMD included spina bifida, cerebral palsy, muscular dystrophy, contractures, or arthrogryposis and were identified by participant report. Those with cNMD were matched to participants without cNMD by interview year and study site. We use modified Poisson regression to estimate relative risks (RR) for low birthweight, macrosomia, preterm birth, and small/large-for-gestational age (SGA/LGA). Given the case-control design and overrepresentation of infants with congenital anomalies, data were weighted to reflect a 3% national prevalence of infants with congenital anomalies.

RESULTS

Mothers with cNMD (n = 125) were more likely to be white, nulliparous, have a cesarean section, have an unplanned pregnancy, report a pre-pregnancy BMI ≥25 kg/m², smoke during pregnancy, and report genitourinary infections. Mothers with cNMD had infants with shorter gestational length (mean difference: -7.44 days, 95% CI: -13.94, -0.95) compared to mothers without cNMD. cNMD was associated with higher risk of preterm birth (RR = 3.98, 95% CI: 1.33, 11.95) and SGA (RR = 2.14, 95% CI: 0.74, 6.15).

CONCLUSION

Mothers with cNMD were more likely to deliver preterm and have an SGA infant. These findings highlight disparities faced by mothers with cNMD and stress the need to provide optimal perinatal and reproductive care.

Adverse childhood experiences and maternal disability: Findings from the North Dakota and South Dakota PRAMS, 2019

RATIONALE

Prior research has found adverse childhood experiences (ACEs) to be a risk factor for disability in adulthood. Moreover, accumulating evidence highlights that both ACEs and disability during pregnancy are a risk factor for both maternal and infant wellbeing. Yet, no previous work has assessed whether ACEs increase the risk of maternal disability.

OBJECTIVE

The current study assesses the link between maternal ACE exposure and disability.

METHODS

Data are from the North Dakota and South Dakota Pregnancy Risk Assessment Monitoring System (PRAMS), 2019 (N = 1775). Logistic regression was used to assess the relationship between accumulating ACEs and maternal disability.

RESULTS

Mothers with exposure to a greater number of ACE-notably, 4 or more ACEs- had elevated rates of several disabilities including difficulty communicating, difficulty remembering, difficulty seeing, and difficulty walking.

CONCLUSIONS

Understanding the long-term health repercussions of ACEs for pregnant women and mothers is important to help inform the design and implementation of health care interventions. This study can be used to better understand the prevalence of disabilities among mothers and corroborate early life experiences as an important risk factor for disability.

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.

Whose decision? Caesarean section and women with physical disabilities in Northern Vietnam: A qualitative study

BACKGROUND

Pregnant women with physical disabilities are more likely to have caesarean sections than are women without disabilities. For some women with disabilities, caesarean birth may not be clinically necessary, as they may lack autonomy in decision-making to a greater extent than is the case for other pregnant women.

OBJECTIVE

To explore the relative influence of health staff, family, friends, and the women themselves on key decisions about childbirth of women with physical disabilities in northern Vietnam.

RESEARCH DESIGN/SETTING

A qualitative approach using a phenomenological design was employed. Fifty-six in-depth interviews were conducted with women with physical disabilities who had given birth in the previous three years in two northern provinces in Vietnam (Hanoi and Thaibinh). Twenty-nine women participated in a first interview and 27 completed follow-up interviews several months later. Additionally, semi-structured interviews were conducted with 12 maternal healthcare providers. Interviews were transcribed and thematically analysed.

RESULTS

Twenty-eight of the 29 participants underwent caesarean sections. Two themes were identified: (1) The women reported that caesarean section was mandated by attending doctors "because of their disability". Consistently, the healthcare providers said caesarean section is essential for women with physical disabilities; and (2) The women said that their parents and peers supported caesarean birth. Very few women indicated that they could influence this decision, even though one-third said their personal preference was for vaginal birth.

CONCLUSIONS

Many women with physical disabilities are not given the opportunity to exercise informed choices around childbirth options. Women in Vietnam who live with physical disabilities should be empowered to make informed decisions about childbirth. It is recommended that professional guidelines and training are revised to properly engage women with physical disabilities in joint decision-making for the birth of their children.

Women's health guidelines for the care of people with spina bifida

Women and girls with spina bifida have specific health care concerns. It is essential that they, and their health care providers have access to information to help them make healthy choices throughout their lifespan. This article aims to address key aspects of health pertinent to girls and women with spina bifida and outlines the SB Women's Health Guidelines for the Care of People with Spina Bifida. Further research into this area is needed.

Pregnancy decision-making in women with physical disabilities

BACKGROUND

Women with physical disabilities experience barriers to knowledge about pregnancy and adequate reproductive healthcare, which impedes decision-making processes and negatively impacts their pregnancy planning.

OBJECTIVE

The purpose of this study was to learn more about pregnancy decision-making in women with physical disabilities.

METHODS

We conducted a qualitative study utilizing semi-structured interviews with women with physical disabilities. We asked questions regarding pregnancy, parenting, reproductive health, relationships and interactions with the healthcare system. We utilized interview transcripts and notes to form a codebook regarding pregnancy and parenting decision-making, knowledge, and fears. We then organized codes into themes based on pre-existing literature regarding fertility and conceptualization of the self.

RESULTS

We completed and analyzed 16 interviews. Themes overall reflected the participants grappling with their own baseline assumptions that they were infertile, as well as managing similar assumptions from others. However, many of the participants recall an exact point where they began to contemplate the fact that having children was possible for them. Finally, disability-related parenting challenges are considered very early in pregnancy decision-making process.

CONCLUSIONS

Women with physical disabilities experience barriers to contemplating pregnancy including inadequate information on pregnancy and reproductive healthcare that affects their decision-making regarding pregnancy and parenting. All healthcare providers should talk to patients with disabilities about family planning and address possible barriers to contemplating pregnancy.

"Under great anxiety": Pregnancy experiences of Vietnamese women with physical disabilities seen through an intersectional lens

BACKGROUND

There is scant research on pregnancy experiences of women with physical disabilities in low and middle-income countries. This qualitative study used an intersectional lens to explore pregnancy experiences of women with physical disabilities in northern Vietnam. Specifically, socio-cultural, economic, and environmental influences were analysed, drawing upon their lived experiences.

METHODS

Two in-depth interviews were conducted at different time-points in 2018 with women with physical disabilities who had given birth in the previous three years. Twenty-nine women participated in the first interview and 27 in the follow-up interview. The interviews were thematically analysed.

RESULTS

The women were happy and excited when discovering their pregnancy but they also experienced anxiety, fear, and distress. Their ambivalence related to concerns around having a child with disabilities, their capability to carry a pregnancy, and their mothering abilities. Negative community views of disability were internalised by the women. These socio-culturally constructed beliefs led to lack of confidence in their pregnancy journey. This was exacerbated by inaccessible environments that contributed to increased risk of falls, and women who used wheelchairs experienced particular difficulties. Other powerful influences included poverty, lost income, and costs associated with pregnancy. Single mothers with disabilities experienced additional stigma and discrimination as Vietnamese society judged their pregnancies as socially unacceptable.

CONCLUSION

This study contributes to knowledge and understanding about women with physical disabilities, specifically how the intersection of gender, disability, socio-economic, and marital status shaped their pregnancy experiences in Vietnam. Multiple challenges were encountered by the women in their pregnancy journey, including negative community views, inaccessible environments, and poverty. The findings highlight the necessity for Vietnamese women with physical disabilities to be actively engaged in talking about their experiences to ensure maternal and child health providers become more sensitive to their pregnancy and motherhood needs.

Childbirth and motherhood in women with motor disability due to a rare condition: an exploratory study

Background

Rare diseases may result in motor impairment, which in turn may affect parenthood. Our purpose was to evaluate perinatal outcomes, parenting needs, mother-infant interactions and infant development in a set of volunteer women with motor impairment due to a rare disease. In a parenting support institution, we recruited a consecutive series of 22 volunteer pregnant women or young mothers, recorded perinatal outcomes, and followed mother-infant interaction and relationship and infant development up to 14 months postpartum. Cases with intellectual or psychic disability were not included.

Results

There were 11 genetic diseases (2 Spinal Muscular Atrophy, 1 Charcot-Marie-Tooth, 1 autosomal dominants myopathy, 1 mitochondrial disease, 2 Elhers-Danlos, 1 Friedreich ataxia, 1 spinocerebellar ataxia, 1 tetrahydrobiopterine deficiency,1 Ectrodactyly), and 11 rare non-genetic conditions (2 spine tumors, 2 strokes, 1 juvenile chronic arthritis, 3 birth injuries, 1 inflammatory myopathy, 1 congenital amputation, and 1 traumatic amputation). These resulted in 10 impairments of four limbs, 4 impairments of both lower limbs, 7 unilateral impairments, and one distal tremor. Social deprivation Epices score, Cutrona social support scale, Edinburg Postnatal Depression scale, and Spielberger State/Trait Anxiety Inventory were unremarkable. Perinatal outcome: 4 gestational diabetes, 1 pre-eclampsia, 9 caesareans, 6 assisted and 7 spontaneous vaginal deliveries, 20 term live-births and 2 premature deliveries (35–36 weeks). Twelve women declared they were self-sufficient for daily activities; six declared they were self-sufficient to provide basic care to their baby. Distribution of the Brunet-Lezine child development score was normal. The parent-infant relationship global assessment scale (PIR-GAS) was well adapted in 2 cases, adapted in 8, perturbed in 7, significantly perturbed in 2, and distressed in 3 (mean 71.8; 95% CI 49.6–93.9). This was unrelated to any somatic or emotional characteristics of the participants. Coding interactive behavior revealed that infant engagement was lower and infant avoidance greater than in controls (p < 0.05).

Conclusion

Infant development was normal, but mother-infant interactions were altered in half of the participants independently from the degree of motor impairment, underscoring the need for parenting support, even for parents who are self-sufficient in daily activities.

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

Pilot Study of a Self-Management Program for Parents With Spinal Cord Injury or Disease

IMPORTANCE

This study lays the groundwork for a self-management program run by occupational therapy practitioners for parents with spinal cord injury or disease (SCI/D).

OBJECTIVE

To develop and implement the Parenting Self-Management Program with people with SCI/D and evaluate the potential impact on knowledge, self-efficacy, and participation.

DESIGN

A mixed-methods approach was used to develop (Phase 1) and implement and evaluate (Phase 2) a pilot group intervention for parents with SCI/D.

SETTING

Community-based occupational therapy settings.

PARTICIPANTS

Phase 1 participants were professionals working in the field of disability and SCI/D (n = 11) and experienced parents with SCI/D (n = 9). Phase 2 participants were people with SCI/D who were newly injured or inexperienced in parenting (n = 10). All participants were paid volunteers.

INTERVENTION

The 4-wk Parenting Self-Management Program was piloted with 10 parents with SCI/D. Participants attended a weekly program with other parents with SCI/D led by occupational therapists in which they received parenting resources and presentations and set weekly goals.

OUTCOMES AND MEASURES

The General Self-Efficacy Scale, a modified version of the Participation Survey/Mobility, and open-ended questions regarding parents' participation in parenting tasks were administered during Phase 2.

RESULTS

Significant increases (p < .05) in perceived knowledge were found for the topics of emergency preparedness, home modifications, adapted equipment, fatigue management, pain management, and community resources among Phase 2 participants.

CONCLUSIONS AND RELEVANCE

A self-management approach combined with pertinent resources for parents with SCI/D yielded positive outcomes.

WHAT THIS ARTICLE ADDS

This research demonstrates that a self-management structure for a specific population (people with SCI/D) in combination with a targeted occupation (parenting) and delivered through group occupational therapy services, improved client outcomes.

Successful pregnancy outcome in two sisters with cerebral palsy and phocomelia: a case report and literature review

BACKGROUND

Little is known about pregnancy rates and outcome in women with motoric disabilities like cerebral palsy (CP) and even less in phocomelia.

OBJECTIVE

To show complications and psychosocial issues in relation to pregnancy burdened by impaired mobility in CP and phocomelia.

CASE REPORT

We present an overview of the pregnancy outcome in two cases of sisters with cerebral palsy and phocomelia. We show complications and psychosocial issues in relation to pregnancy burdened by impaired mobility. Both sisters had a successful pregnancy outcome.

CONCLUSION

There is a need to increase awareness, education, support, and advocacy in order to optimize pregnancy course and outcome in women with CP and phocomelia.

Health of Newborns and Infants Born to Women With Disabilities: A Meta-analysis

CONTEXT

Women with disabilities are at elevated risk for pregnancy, delivery, and postpartum complications. However, there has not been a synthesis of literature on the neonatal and infant health outcomes of their offspring.

OBJECTIVE

We examined the association between maternal disability and risk for adverse neonatal and infant health outcomes.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature, Embase, Medline, and PsycINFO were searched from database inception to January 2020.

STUDY SELECTION

Studies were included if they reported original data on the association between maternal physical, sensory, or intellectual and/or developmental disabilities and neonatal or infant health outcomes; had a referent group of women with no disabilities; were peer-reviewed journal articles or theses; and were written in English.

DATA EXTRACTION

We used standardized instruments to extract data and assess study quality. DerSimonian and Laird random effects models were used for pooled analyses.

RESULTS

Thirty-one studies, representing 20 distinct cohorts, met our inclusion criteria. Meta-analyses revealed that newborns of women with physical, sensory, and intellectual and/or developmental disabilities were at elevated risk for low birth weight and preterm birth, with smaller numbers of studies revealing elevated risk for other adverse neonatal and infant outcomes.

LIMITATIONS

Most studies had moderate (n = 9) or weak quality (n = 17), with lack of control for confounding a common limitation.

CONCLUSIONS

In future work, researchers should explore the roles of tailored preconception and perinatal care, along with family-centered pediatric care particularly in the newborn period, in mitigating adverse outcomes among offspring of women with disabilities.

The Intersection of Disability and Pregnancy: Risks for Maternal Morbidity and Mortality

It is estimated that 1 in 4 women in the United States live with a disability, and using population-based estimates, 10–12% of women of childbearing age have a disability. There are limited data to suggest that women with disabilities experience higher rates of or risks for adverse outcomes related to pregnancy, delivery, and access to appropriate postpartum care. Research on specific disabling conditions demonstrates variable risk for syndromes that threaten the health of the mother, such as preeclampsia, infection, and coagulation disorders. Much of the literature suggests that normal, healthy pregnancy is possible but points to the need for tailored information for patients and providers about the intersection of their condition with pregnancy and specific care needs. Given the lack of systematic evidence in this area across conditions and functional impairments, more research is needed to clarify the interaction of specific disabilities with pregnancy and provide evidence-based information to the field to decrease the risks to mothers and their infants. This article will provide an overview of conditions that contribute to maternal morbidity and mortality as they relate to pregnancy in women with disabilities and provide resources to the field to further the investigation of this area.

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

Background: Prior research has found that women with disabilities are more likely to deliver by cesarean than are women without disabilities. It is not clear whether all of the cesarean deliveries among women with disabilities are medically necessary.Objectives: To examine the associations between maternal disability status and type, mode of delivery, and medical indications for cesarean delivery in California deliveries.Study design: Retrospective cohort study of all nulliparous births in California between 2000 and 2012. We classified births as to whether or not women underwent a trial of labor and determined if medical indications for cesarean delivery were present. Multivariable logistic regression models examined the association of disability with trial of labor and indications for cesarean delivery.Results: Women with disabilities had lower odds of having a labored delivery, compared to women without disabilities (adjusted odds ratio (aOR) = 0.45, 95% confidence interval (CI) 0.41-0.49). In the sample of women who labored (90.5% of total), women with disabilities were more likely to have a medical indication for cesarean delivery (aOR = 1.15, 95% CI 1.10-1.21) and were more likely to have a cesarean delivery (aOR = 1.46, 95% CI = 1.38-1.54). In the subsample of unlabored cesarean deliveries, women with disabilities were less likely to have documented medical indications for cesarean delivery (aOR = 0.45, 95% CI = 0.41-0.50).Conclusions: Women with disabilities were less likely to labor, and these unlabored cesarean deliveries were less likely to have a medical indication for cesarean, compared to women without disabilities.

Disability and Pregnancy: A Cross-Federal Agency Collaboration to Collect Population-Based Data About Experiences Around the Time of Pregnancy

Many reproductive-aged women with a disability can achieve successful healthy pregnancies; however, they may face challenges accessing prenatal and postpartum care and finding providers who are knowledgeable about their specific condition. Depending on the nature of the disability, some women may also be at increased risk for adverse maternal and infant outcomes such as pre-eclampsia, infection, anemia, primary cesarean delivery, or preterm birth. Population-based data are needed to better understand the pregnancy and postpartum experiences of women living with disability. The National Institutes of Health and the Centers for Disease Control and Prevention (CDC) collaborated to address these data gaps by leveraging CDC's Pregnancy Risk Assessment Monitoring System (PRAMS) to gather information about disability among women who have had a recent live birth. Data collection began in 2019. Information gathered through PRAMS can be used to guide the development of clinical practices guidelines, intervention programs, and other initiatives of federal, state, and local agencies to improve services and the health of women of reproductive age living with disability.

Pregnancy and neonatal outcomes of women with disabilities: a nationwide population-based study in South Korea

We investigated (1) pregnancy and neonatal outcomes in women with and without disabilities, (2) time trends in deliveries, and (3) risks of pregnancy and neonatal complications among women with various disability types and severity. This was a nationwide population-based study merging the database of the Korea National Health Insurance claims, National Health Screening Program for Infants and Children, and Disability Registration System to compare perinatal outcomes in women with and without disabilities. Pregnancy and neonatal outcomes were analyzed during 2007 and 2015, as were time trends of deliveries. Multivariate logistic regression was used to evaluate risk of perinatal outcomes among women with various disability types and severities. Women with disabilities showed higher rates of cesarean section (aOR, 1.73; 95% CI, 1.69–1.77), hypertensive disorders (aOR, 1.74; 95% CI, 1.63–1.86), placenta abruption (aOR, 1.27; 95% CI, 1.12–1.45), placenta previa (aOR, 1.14; 95% CI, 1.05–1.24), stillbirths (aOR, 1.30; 95% CI, 1.17–1.45), preterm births (aOR, 1.67; 95% CI, 1.57–1.78), and LBW (aOR, 1.87; 95% CI, 1.78–1.97) than those without disabilities. From 2007 to 2015, although delivery rate in women with disabilities decreased steeply compared with that in women without disabilities, the rate of cesarean section increased in women with disabilities. Women with intellectual disability and those with vision impairment had the highest number of perinatal complications among women with various types of disabilities. Women with disability had more adverse pregnancy and neonatal outcomes than those without disabilities. Specific disability types & severities are more vulnerable to specific perinatal complications.

Reproductive Health in Women with Physical Disability: A Conceptual Framework for the Development of New Patient-Reported Outcome Measures

Background: Barriers in the built environment, enduring stereotypes and biases, and limited disability competency of health care providers compromise access to and quality of reproductive health care for women with physical disabilities. One way to improve our understanding of critical factors that drive reproductive health inequity and its impact on access to care is to use patient-reported outcome measures (PROMs) that capture relevant and meaningful information about experience. In this study, we developed a conceptual framework as the foundation for relevant and clinically meaningful patient-reported outcome measures targeting the interface of disability and reproductive health. Materials and Methods: We conducted semistructured focus groups and interviews to assess women's experiences around their reproductive health and contextual factors related to disability. We used deductive and inductive qualitative coding approaches to develop the conceptual framework. Results: Eighty-one women between the ages of 16 and 50 with a self-reported physical disability, defined by an impairment of mobility, participated in 13 focus groups (N = 64) and 17 individual interviews. Five major themes characterized the conceptual framework that emerged-knowledge about reproductive health, communication about reproductive health, relationships, the reproductive health care environment, and self-advocacy/identity-all of which had some relationship with five major reproductive health issues-pregnancy and labor/delivery, periods and menstrual management, contraception, sexuality and sexual functioning, and pelvic examinations. Conclusions: This conceptual framework will serve as a foundation for PROM and guide intervention development to reduce reproductive health inequity and improve reproductive health outcomes of women with physical disabilities.

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.

Using Visual Timelines in Telephone Interviews: Reflections and Lessons Learned From the Star Family Study

Visual timeline methods have been used as part of face-to-face qualitative interviewing with vulnerable populations to uncover the intricacies of lived experiences, but little is known about whether visual timelines can be effectively used in telephone interviews. In this article, we reflect on the process of using visual timelines in 16 telephone interviews with women as part of the "STarting a family when you have an Autoimmune Rheumatic disease" study (STAR Family Study). The visual timeline method was used to empower women to organize and share their narratives about the sensitive and complex topic of starting a family. We conducted a thematic analysis of the audio-recorded interview data, using researchers' field notes and reflections to provide context for our understanding of the benefits of using timelines and to understand the process of using visual timelines during telephone interviews. Resource packs were sent to women before study participation; 11 of the 16 women completed a version of the timeline activity. Six themes were identified in the methodological data analysis: (1) use and adaptation of the timeline tool, (2) timeline exchange, (3) framing the interview: emphasizing that women are in control, (4) jumping straight in, (5) taking a lead, and (6) disclosing personal and sensitive experiences. The use of visual timelines facilitated interviewee control and elicited rich narratives of participants' experiences in telephone interviews. Women created their visual timelines autonomously and retained ownership of their timeline data; these features of the data generation process need to be considered when using visual timelines in telephone rather than face-to-face interviews. Use of visual methods within telephone interviews is feasible, can generate rich data, and should be further explored in a wider range of settings.

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.

Guideline for the management of pre-, intra-, and postpartum care of women with a spinal cord injury

The German Association of the Scientific Medical Societies guideline for pregnancy, childbirth, and puerperium in women with a spinal cord injury (SCI) addresses a range of topics from the desire to have a child to different stages of pregnancy and birth. Given that a generally accessible and evidence-based presentation of this complex issue does not yet exist, this new guideline contributes to the standardization of gynecological, obstetric, and maternal care of women with SCI. This guideline aims to provide practice-oriented support for the care and counseling of women in the pre-, intra-, and postpartum periods; to close identified gaps in medical care; foster collaboration among clinicians of relevant disciplines; and inspire research.

Intimate partner violence, reproductive coercion, and unintended pregnancy in women with disabilities

BACKGROUND

Women with disabilities experience higher rates of intimate partner violence (IPV) than the general population. Reproductive coercion, a type of intimate partner violence, is associated with an increased risk of unintended pregnancy (UIP), yet little is known about this relationship among women with disabilities.

OBJECTIVE

This qualitative descriptive study explored perspectives of women with disabilities who had experienced an UIP as a result of reproductive coercion.

METHOD

In-depth, semi-structured telephone interviews were conducted with nine women living with diverse disabilities across the United States as part of a larger study examining facilitators and barriers to UIP among women with disabilities.

RESULTS

Analysis revealed three broad themes related to the ways in which physical violence and reproductive coercion elevated women's risk of UIP. They included (1) inadequate health care provider or system response, (2) disability-related risks for IPV, and (3) resource needs to optimize safety.

CONCLUSIONS

This is the first in-depth exploration of ways in which reproductive coercion may lead to an increased risk of UIP among women with disabilities. Health care providers must screen for IPV and reproductive coercion and provide the necessary supports and resources for women with disabilities experiencing unintended pregnancy as a result of violence.

What Women With Disabilities Write in Personal Blogs About Pregnancy and Early Motherhood: Qualitative Analysis of Blogs

BACKGROUND

More than 1 in 10 women of reproductive age identify as having some type of disability. Most of these women are able to become pregnant and have similar desires for motherhood as women without disability. Women with disability, however, face greater stigma and stereotyping, additional risk factors, and may be less likely to receive adequate reproductive health care compared with their peers without disability. More and more individuals, including those with disability, are utilizing the internet to seek information and peer support. Blogs are one source of peer-to-peer social media engagement that may provide a forum for women with disability to both share and obtain peer-to-peer information and support. Nevertheless, it is not clear what content about reproductive health and pregnancy and/or motherhood is featured in personal blogs authored by women with spinal cord injury (SCI), traumatic brain injury (TBI), spina bifida, and autism.

OBJECTIVE

The objective of this study was twofold: (1) to examine the information being shared in blogs by women with 4 types of disabilities, namely, SCI, TBI, spina bifida, and autism, about reproductive health, disability, health care, pregnancy, and motherhood; and (2) to classify the content of reproductive health experiences addressed by bloggers to better understand what they viewed as important.

METHODS

Personal blogs were identified by searching Google with keywords related to disabilities, SCI, TBI, spina bifida, and autism, and a variety of keywords related to reproductive health. The first 10 pages of each database search in Google, based on the relevance of the search terms, were reviewed and all blogs in these pages were included. Blog inclusion criteria were as follows: (1) written by a woman or care partner (ie, parent or spouse) of a woman with a self-identified diagnosis of SCI, TBI, spina bifida, or autism; (2) focused on the personal experience of health and health care during the prepregnancy, prenatal, antepartum, intrapartum, and/or postpartum periods; (3) written in English; and (4) published between 2013 and 2017. A descriptive and thematic qualitative analysis of blogs and corresponding comments was facilitated with NVivo software and matrix analysis.

RESULTS

Our search strategy identified 125 blogs that met all the inclusion criteria; no blogs written by women with spina bifida were identified. We identified 4 reproductive health themes featured in the blog of women with disabilities: (1) (in)accessible motherhood, (2) (un)supportive others, (3) different, but not different, and (4) society questioning motherhood.

CONCLUSIONS

This analysis of personal blogs about pregnancy and health care written by women with SCI, TBI, and autism provides a glimpse into their experiences. The challenges faced by these women and the adaptations they made to successfully navigate pregnancy and early motherhood provide insights that can be used to shape future research.

Differences in Prenatal Care by Presence and Type of Maternal Disability

INTRODUCTION

Prior studies have found that women with disabilities are less likely to receive adequate prenatal care than women without disabilities. However, little is known about differences in patterns of prenatal care by type of disability. Therefore, this study examined timing and frequency of prenatal care among women with physical, sensory, or intellectual/developmental disabilities compared with women without disabilities.

METHODS

This was a retrospective cohort study using linked maternal and infant hospital discharge and birth certificate data for all births in California in 2000-2012 (N=6,745,201). Analyses were conducted in 2017-2018. Modified Poisson regression analyses compared women with each type of disability with women without disabilities on trimester of prenatal care initiation and number of prenatal care visits.

RESULTS

Women with intellectual/developmental disabilities or with limited hearing had significantly higher RR of delaying prenatal care initiation until the second or third trimester (intellectual/developmental disabilities: adjusted RR=1.21, 95% CI=1.09, 1.33; hearing: adjusted RR=1.11, 95% CI=1.02, 1.21), whereas women with physical disabilities and limited vision had lower risk of delaying care (physical: adjusted RR=0.91, 95% CI=0.88, 0.94; vision: adjusted RR=0.85, 95% CI=0.73, 0.99). Women with limited hearing or vision or intellectual/developmental disabilities had higher risk of receiving fewer prenatal visits than recommended, compared with women without disabilities. Women with physical disabilities or intellectual/developmental disabilities had higher RR of receiving more than the typical number of visits.

CONCLUSIONS

There were key differences in prenatal care utilization by disability type, reflective of particularly pronounced disparities for women with intellectual/developmental disabilities and women with limited hearing. Delays in receipt of prenatal care and low numbers of prenatal care visits may contribute to the poorer birth outcomes that have been observed previously in these groups. Targeted interventions are needed to improve uptake of prenatal care in these vulnerable populations.

Validity and reliability of maternal recall of pregnancy history and service use among signing Deaf women: a cross-sectional descriptive study from South Africa

INTRODUCTION

There is little credible quantitative data on pregnancy histories and outcomes for disabled women in low-income and middle-income countries. The purpose of this study, based in Cape Town, South Africa, was to test the reliability and validity of maternal recall of pregnancy history and service use among a sample of Deaf women who use South African Sign Language (SASL).

METHODS

We interviewed 42 signing Deaf women of childbearing age (18-49 years) in SASL using a structured questionnaire in July 2016. To assess reliability, seven participants (16% of the sample) were reinterviewed by different interviewers under the same conditions after 10-30 min. For the analysis we used (1) Cohen's kappa, an inter-rater statistical method, and (2) overall percentage agreement. Validity was explored by comparing the participants' pregnancy history to the Western Cape Provincial Health Data Centre (PHDC) database.

RESULTS

The reliability results showed that out of 19 questions 14 demonstrated substantial to perfect agreement kappa scores (kappa between 0.61 and 1) and 5 had the lowest kappa agreement scores (kappa <0.61). With respect to percentage agreement, participants provided identical responses in 87% cases. Overall, women provided more reliable responses to pregnancy outcomes compared with demographic information. Validity results showed that 29 out of 35 Deaf women provided survey responses that matched or nearly matched (83% agreement) the PHDC database for birth history and delivery location.

CONCLUSION

This study suggests that for this sample of signing Deaf women recall of pregnancy history and service use is reliable and valid. Extending this approach to other similar populations will require further research, but it is important that methods to access hard-to-reach disabled populations are developed so that health system responsiveness to marginal populations can be based on robust evidence.

Pregnancy in Disability: Community Perceptions and Personal Experiences in a Rural Setting in Ghana

Background

Persons with disabilities (PWDs) generally face strong discrimination and exclusion, especially with regard to their sexual and reproductive health. There is a prevailing social myth in Ghana that women with disabilities are asexual and cannot experience a positive motherhood experience. Although the World Health Organization recommends that research is conducted in this regard, community attitudes towards pregnant women living with disabilities remain largely unexplored. The purpose of this study was to explore community attitudes to pregnancy among women living with disabilities.

Methodology

The study design was a mixed method cross-sectional study involving quantitative face-to-face individual interviews with 400 randomly selected community members (both males and females) in three communities in the Adaklu District of Volta Region in Ghana. In addition, in-depth interviews were held with five female PWDs. Simple and multiple logistic regression analysis were used to examine the factors associated with perceptions towards pregnant PWDs.

Results

Majority of respondents agreed that pregnant women with disabilities should be kept in special institutions until delivery to prevent transmission of their disability to fetuses of pregnant women without disabilities. People also believed that pregnant PWDs are incapable of a safe motherhood experience. Among the strongly influencing factors for negative attitudes towards pregnancy of PWDs were educational status (p<0.001) and perceptions that the disability is caused by accidents (p<0.001) or spiritual issues (p<0.01). Regarding the relationship between perceived cause of disability and the resultant attitudes, respondents were three times more likely to have negative attitude and perceptions towards pregnant women with disabilities if their causes of disabilities were perceived to be spiritual compared to the cause being medical.

Conclusion

Our findings indicate that there are generally negative societal attitudes towards pregnant PWDs. The evidence suggests that a degree of prejudice and misconceptions exists towards the pregnancy of women living with disabilities. Generally, there is a public perception that women living with disabilities cannot have a safe motherhood experience and are capable of transferring their disability to an unborn child of another pregnant woman.

Perinatal Care for Women with Spinal Cord Injuries: A Collaborative Workshop for Consensus on Care in Canada

Background: In North America, there are currently no clearly defined standards of care for women with spinal cord injury (SCI) during the perinatal periods of preconception, pregnancy, labour/delivery, and postpartum. Women with SCI and their partners say resources specific to their needs are hard to find. Little evidence-informed research exists to guide clinicians in the care of women with SCI during pregnancy. Objectives: To further explore these gaps in knowledge and practices for perinatal care for women with SCI, a 1-day workshop was held in Vancouver, British Columbia (BC), Canada in November 2013. Methods: Twenty-nine attendees included women with SCI, SCI-community service providers, researchers, and health care providers from maternal/fetal medicine, rehabilitation, anesthesiology, and psychiatry. A pre-meeting online survey of stakeholders elucidated 3 themes: lack of knowledge for both consumers and care providers, gaps in access to services and information, and a need for collaboration throughout the perinatal journey. The workshop addressed issues of care providers' lack of knowledge of nonmedical issues during the perinatal period, physical and attitudinal barriers to access to care for women with SCI, and the need for better collaboration and communication between care providers, the latter potentially initiated by providing information to care providers through the women with SCI themselves. Results: Content experts attending the workshop collectively made recommendations for knowledge generation and research priorities, clinical application priorities, and the need for policy and guideline development in this field. Conclusion: Two information sources for women have since been developed and are available online.

Provision of Reproductive Healthcare to Women with Disabilities: A Survey of Obstetrician-Gynecologists' Training, Practices, and Perceived Barriers

Purpose: The purpose of this study was to document current awareness, attitudes, and training regarding the care of women with disabilities by obstetrician-gynecologists (ob-gyns) and explore barriers that may explain observed discrepancies in care. Methods: One thousand ob-gyns, including 500 members of the Collaborative Ambulatory Research Network (CARN), were surveyed on practice accessibility, training, awareness, barriers, beliefs, comfort, challenges, practices, contraceptive counseling, and preconception/pregnancy counseling. Results: CARN, 49.0%, and non-CARN, 19.4%, members completed the survey for an overall response rate of 33.9%. Most respondents indicated feeling "somewhat" (57.5%) or "very" (21.9%) aware of the special healthcare needs of women with disabilities. Only 17.2%, however, received any information or training on the provision of healthcare to women with disabilities. Eighty-one percent agreed somewhat or strongly that women with disabilities are less likely to receive comprehensive reproductive healthcare. Respondents who provided contraceptive counseling (94.3%) initiated it with women of reproductive age who did not have a disability more frequently than those who had a disability. Finally, only 19.3% felt "definitely" adequately equipped to manage the pregnancies of women with disabilities. Conclusion: Women with disabilities require reproductive healthcare no less than women without disabilities; however, the evidence consistently identifies disparities. This study suggests that while ob-gyn providers are aware of these issues, they lack adequate training and resources to provide equal care.

Reaching a consensus on research priorities for supporting women with autoimmune rheumatic diseases during pre-conception, pregnancy and early parenting: A Nominal Group Technique exercise with lay and professional stakeholders

Background:Women with autoimmune rheumatic diseases (ARDs) find it difficult to get information and support with family planning, pregnancy, and early parenting. A systematic approach to prioritising research is required to accelerate development and evaluation of interventions to meet the complex needs of this population.  Methods:A Nominal Group Technique (NGT) exercise was carried out with lay and professional stakeholders (n=29). Stakeholders were prepared for debate through presentation of available evidence. Stakeholders completed three tasks to develop, individually rank, and reach consensus on research priorities: Task 1 - mapping challenges and services using visual timelines; Task 2 - identifying research topics; Task 3 - individually ranking research topics in priority order. Results of the ranking exercise were fed back to the group for comment.   Results:The main themes emerging from Task 1 were the need for provision of information, multi-disciplinary care, and social and peer support. In Task 2, 15 research topics and 58 sub-topics were identified around addressing the challenges and gaps in care identified during Task 1.  In Task 3, a consensus was reached on the ten research topics that should be given the highest priority. These were individually ranked, resulting in the following order of priorities (from 1 - highest to 10 - lowest): 1. Shared decision-making early in the care pathway; 2. Pre-conception counseling; 3. Information about medication use during pregnancy/breastfeeding; 4. Personalised care planning; 5. Support for partners/family members; 6. Information about local support/disease specific issues; 7. Shared decision-making across the care pathway; 8. Peer-support; 9. Social inequalities in care, and; 10. Guidance on holistic/alternative therapies.    Conclusions:This systematic approach to identification of research priorities from a multi-disciplinary and lay perspective indicated that activities should focus on development and evaluation of interventions that increase patient involvement in clinical decision-making, multi-disciplinary models of care, and timely provision of information.

Bladder management during pregnancy in women with spinal-cord injury: an observational, multicenter study

INTRODUCTION AND HYPOTHESIS

Pregnancy in women with spinal-cord injury (SCI) poses a clinical challenge. We hypothesized that changes in the management of neurogenic bladder during pregnancy are commonly required and should receive more attention.

METHODS

Data were collected by retrospective analysis of medical records and via cross-sectional survey of 52 women with SCI, representing 67 pregnancies, at ten Italian neurourological clinics. All participants provided informed consent.

RESULTS

Between 1976 and 2013, 39 participants had one child, 11 had two children, and two had three children. Mean age at the time of SCI was 18 years and at the time of first pregnancy was 30 years. Delivery occurred from weeks 32 to 40 in 98% of first and second pregnancies, and 94% of neonates were healthy. Oxybutynin was used by four women during five pregnancies, which resulted in delivery of healthy babies. Intermittent catheterization was used before 54% of first pregnancies and 39% of second pregnancies. Bladder management was altered during 45% of these pregnancies, and the most common changes were increased use or frequency of intermittent catheterization or use of an indwelling catheter. Urinary tract infections occurred in 48% of pregnancies, and an irregular course was reported in 13% of pregnancies mainly related to tetraplegia and urological complications.

CONCLUSIONS

Pregnancy in women with SCI generally has good outcomes and limited risks but frequently necessitates changes in the management of neurogenic bladder. High levels of awareness and focused monitoring of bladder issues are recommended.

Contraceptive use at last intercourse among reproductive-aged women with disabilities: an analysis of population-based data from seven states

OBJECTIVE

To assess patterns of contraceptive use at last intercourse among women with physical or cognitive disabilities compared to women without disabilities.

STUDY DESIGN

We analyzed responses to 12 reproductive health questions added by seven states to their 2013 Behavioral Risk Factor Surveillance System questionnaire. Using responses from female respondents 18-50 years of age, we performed multinomial regression to calculate estimates of contraceptive use among women at risk for unintended pregnancy by disability status and type, adjusted for age, race/ethnicity, marital status, education, health insurance status, and parity.

RESULTS

Women with disabilities had similar rates of sexual activity as women without disabilities (90.0% vs. 90.6%, p=.76). Of 5995 reproductive-aged women at risk for unintended pregnancy, 1025 (17.1%) reported one or more disabilities. Contraceptive use at last intercourse was reported by 744 (70.1%) of women with disabilities compared with 3805 (74.3%) of those without disabilities (p=.22). Among women using contraception, women with disabilities used male or female permanent contraception more often than women without disabilities (333 [29.6%] versus 1337 [23.1%], p<.05). Moderately effective contraceptive (injection, oral contraceptive, patch, or ring) use occurred less frequently among women with cognitive (13.1%, n=89) or independent living (13.9%, n=40) disabilities compared to women without disabilities (22.2%, n=946, p<.05).

CONCLUSIONS

The overall prevalence of sexual activity and contraceptive use was similar for women with and without physical or cognitive disabilities. Method use at last intercourse varied based on presence and type of disability, especially for use of permanent contraception.

IMPLICATIONS

Although women with disabilities were sexually active and used contraception at similar rates as women without disabilities, contraception use varied by disability type, suggesting the importance of this factor in reproductive health decision-making among patients and providers, and the value of further research to identify reasons why this occurs.

Sexuality and reproduction in women with spinal cord injury

Abstract Introduction: Spinal cord injury (SCI) is debilitating and results in different social representations for the women affected in terms of their sexuality and reproduction. Objective: Describe the experience of women with SCI regarding sexuality and reproduction under these conditions. Methods: Participants were 11 women with SCI who were submitted to a semi-structured interview. The content of the interviews was inputted into ALCESTE software, a computerized technique used for text analysis. Results: The dendrogram obtained shows two clusters and five subcategories. Cluster I contains issues related to living with SCI and consists of four classes: everyday life, sexuality and reproduction, difficulties, and coping. The so-called class of perceptions is in cluster II, which addresses subjective aspects. The classes in cluster I revealed symbolism associated with sexual relations, reproduction, affective relationships before and after SCI and relationships with the body. The results indicate that sexuality among women with SCI is marked by a mixture of feelings. While they are insecure about expressing themselves sexually, they also report fear of abandonment and loneliness, possibly due to conflicts about accepting their new image, which in most cases was characterized by low self-esteem. Conclusion: The representations of the sexuality and reproduction of the women studied here are vital in the process of accepting and coping with SCI, as well as recovering their social, affective and sexual relationships.

Use of Reversible Contraceptive Methods Among U.S. Women with Physical or Sensory Disabilities

CONTEXT

Women with disabilities experience a higher rate of adverse pregnancy outcomes than women without disabilities. Preventing or delaying pregnancy when that is the best choice for a woman is a critical strategy to reducing pregnancy-related disparities, yet little is known about current contraceptive use among women with disabilities.

METHODS

A cohort of 545 reproductive-age women with physical disabilities (i.e., difficulty walking, climbing, dressing or bathing) or sensory disabilities (i.e., difficulty with vision or hearing) was identified from among participants in the 2011-2013 National Survey of Family Growth. Those at risk for unplanned pregnancy were categorized by whether they were using highly effective reversible contraceptive methods (IUD, implant), moderately effective ones (pill, patch, ring, injectable), less effective ones (condoms, withdrawal, spermicides, diaphragm, natural family planning) or no method. Multinomial regression was conducted to examine the association between disability and type of contraceptive used.

RESULTS

Some 39% of women with disabilities were at risk of unplanned pregnancy, and 27% of those at risk were not using contraceptives. The presence of disability was associated with decreased odds of using highly effective methods or moderately effective methods, rather than less effective ones (odds ratio, 0.6 for each), but had no association with using no method.

CONCLUSION

There is a significant need to reduce contraceptive disparities related to physical or sensory disabilities. Future research should explore the extent to which contraceptive use differs by type and severity of disability, as well as identify contextual factors that contribute to any identified differences.