Pregnancy complications and maternal birth outcomes in women with intellectual and developmental disabilities in Wisconsin Medicaid

Preconception health risks by presence and type of disability among U.S. women

BACKGROUND

Poor preconception health may contribute to adverse perinatal outcomes among women with disabilities. While prior research has found higher prevalence of preconception health risks among women with versus without disabilities, existing U.S. studies have not assessed how preconception health risks may differ by disability type. Understanding such differences is relevant for informing and targeting efforts to improve health opportunities and optimize pregnancy outcomes.

OBJECTIVE

This cross-sectional study examined preconception health in relation to disability type among reproductive-age women in the United States.

METHODS

We analyzed 2016-2019 data from the Behavioral Risk Factor Surveillance System to estimate the prevalence of 19 preconception health risk among non-pregnant women 18-44 years of age. We used modified Poisson regression to compare women with different types of disability to non-disabled women. Disability categories included: 1) hearing difficulty only; 2) vision difficulty only; 3) physical/mobility difficulty only; 4) cognitive difficulty only; 5) multiple or complex disabilities (including limitations in self-care or independent living activities). Multivariable analyses adjusted for other sociodemographic characteristics such as age and marital status.

RESULTS

Women with each disability type experienced a higher prevalence of indicators associated with poor preconception health compared to women with no disabilities. The number and extent of health risks varied substantially by disability type. Women with cognitive disabilities and women with multiple or complex disabilities experienced the greatest risk.

CONCLUSIONS

Addressing the specific preconception health risks experienced by women with different types of disabilities may help reduce adverse perinatal outcomes for disabled women and their infants.

Changes in postpartum insurance and care use by disability status during the COVID-19 pandemic

BACKGROUND

People with disabilities face unique health needs and barriers to perinatal care. The pandemic may have worsened health care access disparities, while pandemic-era Medicaid provisions potentially improved access via increased insurance coverage.

OBJECTIVE

We assessed changes in postpartum insurance, visits, and reproductive health care during the COVID-19 public health emergency (PHE) and PHE Medicaid provisions among individuals with disabilities versus individuals without disabilities.

METHODS

We used the 2019-2020 Pregnancy Risk Assessment Monitoring System survey and Disability Supplement to compare changes in postpartum outcomes by disability status during COVID-19. Adjusted regression models included an interaction term between disability status and postpartum exposure to the PHE. Comparative differences were examined overall, among low-income respondents, and among respondents with Medicaid-paid deliveries.

RESULTS

During the PHE, there was a significant increase in postpartum Medicaid by 7.1% points (95 % CI: 0.6, 13.6) and a decrease in uninsurance by 5.2% points (95 % CI: -9.0, -1.4) among respondents with disabilities relative to those without. There was a significant increase in postpartum contraception during the PHE among respondents with disabilities relative to those without by 6.3% points (95 % CI: -0.1, 12.5). The PHE was associated with larger increases in postpartum Medicaid and larger decreases in postpartum uninsurance among low-income respondents, with similar estimates among respondents with Medicaid-insured deliveries.

CONCLUSIONS

During the COVID-19 PHE, individuals with disabilities saw increased postpartum insurance and improved contraceptive use. As PHE Medicaid provisions are rolled back, these differential improvements should be factored into decisions about postpartum Medicaid eligibility.

Contraceptive Use Among Traditional Medicare And Medicare Advantage Enrollees

Medicare is the primary source of health insurance coverage for reproductive-age people with Social Security Disability Insurance. However, Medicare does not require contraceptive coverage for pregnancy prevention, and little is known about contraceptive use in traditional Medicare and Medicare Advantage. We analyzed Medicare and Optum data to assess variations in contraceptive use and methods used by traditional Medicare and Medicare Advantage enrollees, as well as among enrollees with and without noncontraceptive clinical indications. Clinically indicated contraceptives are used for reasons other than pregnancy prevention, including menstrual regulation or to treat acne, menorrhagia, and endometriosis. Contraceptive use was higher among Medicare Advantage enrollees than traditional Medicare enrollees, but use in both populations was low compared with contraceptive use among Medicaid enrollees. We found significant variation by Medicare type with respect to contraceptive methods used. Relative to traditional Medicare, the probability of long-acting reversible contraception was more than three times higher in Medicare Advantage, and the probability of tubal sterilization was more than ten times higher. Overall, Medicare enrollees with noncontraceptive clinical indications had twice the probability of contraceptive use as those without them. Medicare coverage of all contraceptive methods without cost sharing would help address financial barriers to contraceptives and support the reproductive autonomy of disabled enrollees.

Reproductive health of women with intellectual disability: antenatal care, pregnancies and outcomes in the Dutch population

BACKGROUND

Research in a handful of countries found that women with intellectual disability (ID) faced barriers and risks regarding antenatal care and reproductive health. This study tested disparities between women in the Netherlands with and without ID in antenatal care, pregnancy rates and pregnancy outcomes.

METHODS

Secondary analyses on the large representative panel of primary health patients in the Netherlands by the Netherlands Institute for Health Services Research (NIVEL) compared women in their reproductive age (18-49 years) with (n = 2397) and without (n = 228 608) indicators of ID. Bias due to underreporting and under-identification was reduced by linkage with an index of ID for the total Dutch population from Statistical Netherlands.

RESULTS

Women with ID were more likely to receive contraceptive care [95% confidence interval (CI) for odds ratio (OR) = 1.37-1.61] and became somewhat more often pregnant (95% CI OR = 1.06-2.30) than women from the general population, adjusting for age difference and follow-up time. No statistical differences were found in medical complications during pregnancy, delivery and immediately after birth, but women with indicators of ID had a higher risk of losing their pregnancy, including through induced abortion (95% CI OR = 1.26-1.99).

CONCLUSIONS

Women with ID have specific needs around contraceptive care and risks around their pregnancy that may require more awareness among practitioners and better understanding of the processes of care and decision-making.

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.

Mothers with Intellectual/Developmental Disabilities and Behavioral Health Conditions and Community Experts Provide Recommendations for Treatment/Services, Systems, and Research

Mothers with intellectual and developmental disabilities (IDD) are vulnerable to perinatal complications and adverse outcomes. Their vulnerabilities may also be exacerbated by co-occurring behavioral health (BH) conditions. Their wellbeing may be compromised by a lack of tailored treatments or by treatments and services that are inaccessible, irrelevant, and/or ineffective. A five-session virtual Ideas Lab workshop series was implemented to bring together diverse community experts (n = 30), including mothers with IDD/BH, to discuss the experiences of mothers and set priorities for treatment/services, systems, and research. Participants completed background and evaluation surveys and brainstormed, grouped, and ranked items of importance, which fell into two broad categories: (1) cross-cutting themes drawn from lived experience with recommendations applicable to all substantive domains (i.e., accessibility, diversity, adverse experiences and trauma, and trust) and (2) substantive themes with specific recommendations for treatment/services and systems (i.e., services and supports, peer support, provider practices and training, and systems navigation/transformation). Research recommendations were generated in all discussions and emerged in relation to all themes, underscoring the importance of including mother-driven questions and priorities in research agendas and strengthening researcher training and skills to engage mothers with IDD/BH and other community members actively, and in meaningful ways.

Sexual and reproductive health services for autistic young people in the United States: A conceptual model of utilization

BACKGROUND

Sexual and reproductive health services promote the ability of people to have safe, satisfying, non-coercive sexual experiences and make informed decisions about pregnancy. Stakeholder input is needed to understand barriers or facilitators to service access for autistic people, who report unmet needs.

METHODS

We recruited 18 autistic people, 15 parents, and 15 service providers in the United States to participate in an interview and two surveys. Using their input, we created a conceptual model of sexual and reproductive health service needs, access barriers, and facilitators.

RESULTS

Stakeholders rated a variety of sexual and reproductive health services as important for autistic people, including those with intellectual disability or minimal verbal language. Stakeholders identified barriers to sexual and reproductive health service utilization including lack of service availability, lack of service providers with autism or neurodiversity training, lack of accurate information about autism and sexuality, verbal and communication differences that are not accommodated by service providers, and socio-cultural attitudes about sexuality. Stakeholders identified facilitators to service access including person-centered, trauma-informed care, service accommodations such as clear and detailed expectations, and long-enough appointments. We created a conceptual model based on the social ecological model of health to organize these utilization factors and support future research, provider, and policy action. Stakeholders provided feedback and responded favorably on the model's accuracy, utility for spurring research, practice, and policy improvements, and application to diverse groups of autistic people.

CONCLUSIONS

The model shows the many feasible ways to support equitable access to services for autistic people.

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.

Perinatal Health Risks And Outcomes Among US Women With Self-Reported Disability, 2011-19

Women with disabilities experience elevated risk for adverse pregnancy outcomes. Most studies have inferred disabilities from diagnosis codes, likely undercounting disabilities. We analyzed data, including self-reported disability status, from the National Survey of Family Growth for the period 2011-19. We compared respondents with and without disabilities on these characteristics: smoking during pregnancy, delayed prenatal care, preterm birth, and low birthweight. A total of 19.5 percent of respondents who had given birth reported a disability, which is a much higher prevalence than estimates reported in US studies using diagnosis codes. Respondents with disabilities were twice as likely as those without disabilities to have smoked during pregnancy (19.0 percent versus 8.9 percent). They also had 24 percent and 29 percent higher risk for preterm birth and low birthweight, respectively. Our findings suggest that studies using diagnosis codes may represent only a small proportion of pregnancies among people with disabilities. Measurement and analysis of self-reported disability would facilitate better understanding of the full extent of disability-related disparities, per the Affordable Care Act.

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.

Clinician-reported barriers to providing perinatal care to women with intellectual and developmental disabilities

Background

Research suggests that women with intellectual and developmental disabilities are at increased risk for adverse pregnancy outcomes. Further, they report unmet perinatal care needs. This qualitative study examined clinician perspectives on barriers to providing perinatal care to women with intellectual and developmental disabilities.

Method

We conducted semi-structured interviews and one focus group with US obstetric care clinicians (n=17). We used a content analysis approach to code data and analyse them for larger themes and relationships.

Results

The majority of participants were white, non-Hispanic, and female. Participants reported barriers providing care to pregnant women with intellectual and developmental disabilities across individual (e.g., communication challenges), practice (e.g., identification of disability status), and system levels (e.g., lack of clinician training).

Conclusions

Clinician training and evidence-based guidelines for perinatal care of women with intellectual and developmental disabilities as well as services and supports during pregnancy are needed.

Barriers to and facilitators of effective communication in perinatal care: a qualitative study of the experiences of birthing people with sensory, intellectual, and/or developmental disabilities

Background

Effective provider-patient communication is a key element of quality health care, including perinatal care. What constitutes “effective communication” in perinatal care may vary according to the population seeking care, such as women with intellectual and developmental disabilities (IDD) and sensory disabilities. Research broadly indicates that communication issues are among the barriers to perinatal care experienced by women with disabilities. However, few studies have explicitly explored their communication experiences in this context. The purpose of this study was to understand the communication experiences of birthing people with IDD and/or sensory disabilities in perinatal care.

Methods

We conducted semi-structured interviews with 17 people with IDD (e.g., autism, cognitive delay) and/or sensory disabilities (e.g., d/Deaf, blind) in Ontario, Canada, who had recently given birth, to explore barriers to and facilitators of effective communication in perinatal care. A combination of deductive and inductive thematic analysis guided data analysis.

Results

We found that birthing people with IDD and/or sensory disabilities encountered multiple barriers to effective communication in perinatal care, namely, lack of policies and guidelines, lack of provider experience, lack of provider effort, as well as ableism and provider assumptions. Facilitators included knowledgeable, aware, and supportive providers; access to communication aids and services; tailoring information to patients’ disability-related communication needs; empathic communication; and, communication among providers.

Conclusion

Unmet communication needs may contribute to negative health and social outcomes for birthing people with disabilities and their newborns. Accessibility policy implementation and practice change are needed to meet the communication needs of people with IDD and/or sensory disabilities in perinatal care to ensure positive experiences and outcomes.

Reproductive and pregnancy health care for women with intellectual and developmental disabilities: A scoping review

BACKGROUND

Women with intellectual and developmental disabilities face poorer reproductive and pregnancy outcomes partially due to health care inequity. Our objective was to conduct a scoping review of reproductive and pregnancy related health care among women with intellectual and developmental disabilities.

METHODS

We systematically reviewed three databases for keywords pertaining to pregnancy, reproductive health, and intellectual and developmental disabilities. Two reviewers screened abstracts and extracted full text. We synthesised included papers, identifying common themes.

RESULTS

Thirty-six papers met review criteria. Women with intellectual and developmental disabilities had lower fertility rates and were less likely to receive adequate sexual education compared to peers. While most women received prenatal care, uptake was lower and received later than women without intellectual and developmental disabilities.

CONCLUSIONS

Pregnancy-related health care is often lacking for women with intellectual and developmental disabilities. There are gaps inhibiting our understanding which prevents action to reduce health disparities.

Clinician perspectives on the need for training on caring for pregnant women with intellectual and developmental disabilities

BACKGROUND

Women with intellectual and developmental disabilities (IDDs) experience disparities in obstetric care access and quality, in addition to communication gaps with healthcare providers. Many obstetric providers are untrained and uneducated about critical aspects of providing care to persons with IDDs.

OBJECTIVE

The study was conducted to describe obstetric clinicians' training experiences related to providing obstetric care to women with IDDs, to assess the perceived need for formalized training, and to identify recommendations for training content.

METHODS

This study involved qualitative individual interviews (n = 9) and one focus group (n = 8) with obstetric clinicians who self-reported experience caring for women with IDDs during pregnancy. Descriptive coding and content analysis techniques were used to develop an iterative codebook related to education and training; codes were applied to the data. Coded data were analyzed for larger themes and relationships.

RESULTS

Analysis revealed three main themes: 1. Need for obstetric training and education: No participant reported receiving any training in caring for pregnant women with IDDs. Participants expressed a need for formal education. 2. Recommendations for formal training: Participants noted the need for training during residency and beyond, and all healthcare staff members should be included in training. 3. Training outcomes should increase knowledge, enhance attitudes, and develop practical skills related to care for pregnant women with IDDs.

CONCLUSION

Results indicate a need for systematic training efforts regarding obstetric care for women with IDDs. Improved training and education may decrease health inequities and improve the quality of care, and thus pregnancy outcomes, for women with IDDs.

LEVEL OF EVIDENCE

VI.

A Socio-Ecological Approach to Understanding the Perinatal Care Experiences of People with Intellectual and/or Developmental Disabilities in Ontario, Canada

BACKGROUND

Accessible and quality care during the perinatal period is critical for optimal maternal and neonatal health. Using the socio-ecological model, the purpose of this study was to explore barriers and facilitators that shape the perinatal care experiences of people with intellectual and/or developmental disabilities (IDD).

METHODS

Semi-structured interviews were conducted with 10 individuals with IDD in Ontario, Canada, who had given birth within the past 5 years. Interviews focused on care experiences before, during, and after pregnancy. Data were analyzed using a directed content analysis approach, and the socio-ecological model guided analysis.

RESULTS

Barriers at the societal (e.g., cultural norms of motherhood), policy/institutional (e.g., child protection policies and practices), interpersonal (e.g., inadequate formal and informal support), and intrapersonal levels (e.g., internalized stigma) contributed to participants having negative perinatal care experiences. Conversely, we identified facilitators on the interpersonal level (e.g., positive interactions with perinatal care providers and familial and social service supports) as positively shaping participants' perinatal care experiences.

CONCLUSIONS

Findings reveal that the perinatal care experiences of people with IDD are shaped by several interrelated factors that largely stem from societal-level barriers, such as dominant (stigmatizing) discourses of disability. To improve the perinatal care experiences of people with IDD, there is a need for interventions at multiple levels. These include the development of policies to support perinatal care for diverse populations and training care providers to enact policies at the institutional and interpersonal levels.

Birth outcomes affecting infants of mothers with intellectual and developmental disabilities

BACKGROUND

Women with intellectual and developmental disabilities (IDD) face increased risk of adverse maternal pregnancy outcomes, yet less is known about infant outcomes.

OBJECTIVES

To examine birth outcomes of infants born to mothers with IDD and assess associations with demographics and IDD-type.

METHODS

We used data from the Big Data for Little Kids project, which links Wisconsin birth records to Medicaid claims for live births covered by Medicaid from 2007 to 2016. We identified IDD using maternal prepregnancy Medicaid claims and ran Poisson regression (with a log link function) with robust variance clustered by mother to compare prevalence of outcomes between singleton births with and without mothers with IDD. We adjusted the associations for demographic factors and estimated prevalence ratios (PR) as the effect measure. We assessed outcomes by IDD-type (intellectual disability, genetic conditions, cerebral palsy, and autism spectrum disorder) to explore differences by categories of IDD.

RESULTS

Of 267,395 infants, 1696 (0.6%) had mothers with IDD. A greater percentage of infants with mothers with IDD were born preterm (12.8% vs 7.8%; PR 1.64, 95% confidence interval [CI] 1.42, 1.89), small for gestational age (8.5% vs 5.4%; PR 1.42, 95% CI 1.25, 1.61), and died within 12 months of birth (3.2% vs 0.7%; PR 4.93, 95% CI 3.73, 6.43) compared to infants of mothers without IDD. Prevalence ratios were robust to adjustment for demographics factors. Estimates did not meaningfully differ when comparing different IDD-types.

CONCLUSIONS

A greater porportion of infants born to mothers with IDD who were covered by Medicaid had poor outcomes compared to other infants. Prevalence of poor infant outcomes was greater for mothers with IDD even after accounting for demographic differences. It is imperative to understand why infants of mothers with IDD are at greater risk so interventions and management can be developed.

Complications following hysterectomy in women with intellectual and developmental disabilities

BACKGROUND

Limited data exist on complications following hysterectomy among women with intellectual and developmental disabilities (IDD).

OBJECTIVE

The objective was to assess the frequencies of postoperative complications in women with IDD following hysterectomy.

METHODS

The National Inpatient Sample from 2014 to 2017 was queried using codes from the International Classification of Disease 9th and 10th revisions to identify women over 15 years of age with a diagnosis of an IDD undergoing hysterectomy. Comparisons were made to women without IDD undergoing the same procedure. Logistic regression analysis was performed to examine between group differences in the frequency of clinical post-surgical complications while adjusting for potential confounding variables.

RESULTS

Of eligible women undergoing hysterectomy, 1,370 were identified as having IDD and 624,700 did not. Compared to controls, women with IDD were significantly younger (45 vs. 50 years, p < 0.001). Women with IDD were also more likely to have had governmental health insurance (83% vs. 34%, p < 0.001), an open hysterectomy approach (78% vs. 69%, p = 0.002), and longer hospital stays (4 vs. 3 days, p < 0.001). After adjusting for potential confounders, women with IDD had greater odds of postoperative urinary complications (OR 3.74, 95% CI 1.18-11.83) and complications related to decubitus ulcer formation (OR 8.97, 95% CI 2.10-38.36).

CONCLUSIONS

Women with IDD have increased odds having urinary and decubitus ulcer complications following hysterectomy, compared to women without IDD. These results inform surgical decision-making and anticipatory guidance for these women and their caregivers.