Rapid repeat pregnancy among women with intellectual and developmental disabilities: a population-based cohort study

Miscarriage after SARS-CoV-2 vaccination: A population-based cohort study

OBJECTIVE

To evaluate the risk of miscarriage following SARS-CoV-2 vaccination, while accounting for the competing risk of induced abortion.

DESIGN

Population-based cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Women aged 15-50 years with a confirmed pregnancy at ≤19 completed weeks' gestation.

METHODS

Exposure to first SARS-CoV-2 vaccination, handled in a time-varying manner, was defined as (i) unvaccinated, (ii) remotely vaccinated >28 days before the estimated conception date or (iii) recently vaccinated ≤28 days before conception and up to 120 days after conception.

MAIN OUTCOME MEASURES

The outcome was miscarriage, occurring between the estimated date of conception and up to 19 completed weeks of pregnancy. Fine-Grey hazard models, accounting for the competing risk of induced abortion, generated hazard ratios (aHR), adjusted for socio-demographic factors, comorbidities, and biweekly periods.

RESULTS

Included were 246 259 pregnant women, of whom 34% received a first SARS-CoV-2 vaccination. Miscarriage occurred at a rate of 3.6 per 10 000 person-days among remotely vaccinated women and 3.2 per 10 000 person-days among those recently vaccinated, in contrast to a rate of 1.9 per 10 000 person-days among unvaccinated women, with corresponding aHR of 0.98 (95% confidence interval [CI] 0.91-1.07) and 1.00 (95% CI 0.93-1.08).

CONCLUSIONS

SARS-CoV-2 vaccination was not associated with miscarriage while accounting for the competing risk of induced abortion. This study reiterates the importance of including pregnant women in new vaccine clinical trials and registries, and the rapid dissemination of vaccine safety data.

Population-level use of gynecological health services by female youth with intellectual/developmental disabilities in British Columbia Canada

BACKGROUND

There is evidence that female youth with intellectual/developmental disabilities (IDD) experience poorer gynecological care compared to female youth without disabilities.

OBJECTIVE

The objective of this study was to obtain baseline data on visits to a health care provider for a gynecological issue for females with IDD and compare that information to the experiences of female youth without IDD.

METHODS

This study is a retrospective cohort study using population-level administrative health data from 2010 to 2019 for females aged 15-24 years, with and without IDD.

RESULTS

6452 female youth with IDD and 637,627 female youth without IDD were identified in the data. Over the ten-year period, 53.77% of youth with IDD and 53.68% of youth without IDD had a visit to a physician for a gynecological issue. However, as females with IDD aged, the number of people seeing a physician for a gynecological issue decreased. In the group aged 20-24 years, 15.25% of females with IDD and 24.47% of females without IDD (p < 0.0001) had a Pap test done at any time; 25.94% of females with IDD had a visit for contraception management and 28.38% of females (p < 0.0001) without IDD had a visit for contraception management. Gynecological care also varied by type of IDD.

CONCLUSIONS

Females with IDD had a similar number of visits for a gynecological issue as female youth without IDD. However, the reasons for visits and the age at which visits occurred differed between youth with and without IDD. As females with IDD transition into adulthood, gynecological care must be maintained and improved.

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.

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.

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.

Pregnancy and Parenthood Among Autistic Adults: Implications for Advancing Maternal Health and Parental Well-Being

Background

Strikingly little research has considered how autistic adults experience pregnancy and parenthood, two key transition periods in adult development with potentially far-reaching implications for physical and psychosocial health outcomes across the lifespan. This article reviews the research on pregnancy and parenthood among autistic adults, to summarize existing research and identify future directions to advance this critical area of study.

Methods

We conducted a systematic review of the literature on pregnancy and parenthood among autistic adults. Researchers extracted selected articles for key information, including methodology and sample size, study location, demographic characteristics of participants, measurement approaches, and key study findings.

Results

Overall, we identified 13 studies that used a range of quantitative and qualitative approaches to study pregnancy experiences and outcomes and parenthood among autistic adults. The findings show that autistic adults (1) experience difficulties and dissatisfaction communicating with health care providers throughout pregnancy and birth, (2) are more likely to experience depression during and after pregnancy, and (3) experience higher rates of pregnancy complications, including preterm birth, cesarean delivery, and pre-eclampsia. During parenthood, autistic adults report lower parenting competence, experience parenthood as isolating, have difficulty communicating with professionals about their child and are questioned by providers about their ability to parent, experience high rates of involvement with child protective services, and express a desire for increased parenting support. Autistic adults also reported parenting strengths, including high levels of finding parenthood rewarding and putting their children's needs ahead of their own.

Conclusions

A key limitation of the literature is the significant lack of sociodemographic diversity among participants, the small number of existing studies, and reliance on cross-sectional mono-method designs. Future research should be conducted in partnership with autistic adults to develop assessment and intervention approaches for supporting pregnancy health and parental well-being among diverse and underserved communities.

Lay summary

Why is this topic important?: Very little is known about how autistic adults experience pregnancy and parenthood. Better understanding these experiences is important, because pregnancy and parenthood are key transition periods in adult development that are associated with a range of health outcomes later in life.What is the purpose of this article?: This article reviews the existing research on pregnancy and parenthood among autistic adults. We wanted to summarize what is already known, evaluate how that knowledge was created, and consider who has and who has not been included in this research to inform future research. We summarized 13 studies that considered pregnancy or parenthood among autistic adults.What did the authors find about pregnancy among autistic adults?: One study used data from hospital and birth records in Sweden, and showed that autistic women experience higher rates of pregnancy complications, such as preterm birth (early delivery before 37 weeks), cesarean delivery, and pre-eclampsia (a condition defined by high blood pressure during pregnancy). Two studies had autistic and nonautistic adults fill out online surveys about their experiences, and found that autistic adults are more likely to have depression during and after pregnancy, have more difficulty interacting with health care professionals at pregnancy appointments and during the birth process, and feel that information and support services for pregnancy do not always meet their needs. Autistic women also reported that sensory differences can make health care visits during pregnancy especially difficult, and described that they may experience anxiety and confusion when interacting with health care staff.What did the authors find about parenthood among autistic adults?: The research we reviewed showed that autistic adults experience strengths and difficulties in parenting. Many autistic adults found parenthood rewarding, but also felt isolated as parents and had difficulty communicating with health care professionals about their children. Autistic adults also had high rates of interacting with child protective services (CPS). Some research also found that autistic adults had lower self-confidence in parenting, although findings are mixed.What are the recommendations for future research and practice?: We need to develop support strategies to promote pregnancy health and parenting satisfaction in partnership with autistic adults. For example, it may be helpful to develop communication tools that can support autistic adults during pregnancy, labor, and birth. We also recommend that future research develop questionnaires to ask autistic adults about their pregnancy and parenting experiences in sensitive ways, so that in the future providers can regularly ask autistic adults about their support needs. Most importantly, it is critical that future research also include more diverse autistic participants in their research, including racial/ethnic and sexual and gender minorities.How will these findings help autistic adults now or in the future?: We hope that this article will help guide future research that strives to better understand how autistic adults experience pregnancy and parenthood. Ultimately, we believe this research can lead to supports and intervention strategies that can improve pregnancy health and parental well-being for autistic adults.

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.

Postpartum Health Care Among Women With Intellectual and Developmental Disabilities

INTRODUCTION

Postpartum health care among women with intellectual and developmental disabilities has not been well studied. This study uses administrative claims to compare postpartum outpatient visits among women with and without intellectual and developmental disabilities.

METHODS

Massachusetts All Payers Claims Database 2012-2015 was used to identify women with intellectual and developmental disabilities and a live birth during 2012-2014, matched by infant birth year to 3 women without intellectual and developmental disabilities. Women were followed up for 1 year after delivery. Analyses were conducted in 2019. Poisson regression compared guideline-concordant postpartum and other outpatient visits during the early (21-56 days after delivery) and late (57-365 days after delivery) periods. Types of nonpostpartum care visits were examined.

RESULTS

Overall, 962 and 2,886 women with and without intellectual and developmental disabilities, respectively, comprised the sample. Among women with intellectual and developmental disabilities, 23.9% had a postpartum visit in the early and 33.3% in the late postpartum periods, compared with 25.2% and 32.1% of women without intellectual and developmental disabilities who had visits in the early and late postpartum periods, respectively (p=0.49, 0.59). Women with intellectual and developmental disabilities were more likely to have other outpatient visits than those without intellectual and developmental disabilities, both in the early (63.1% vs 40.3%, adjusted RR=1.42, 95% CI=1.28, 1.58, p<0.001) and late (94.2% vs 82.3%, RR=1.11, 95% CI=1.08, 1.14, p=0.008) postpartum periods. Ancillary services, home health services, and alcohol/drug-related visits were much more common among women with intellectual and developmental disabilities.

CONCLUSIONS

Women with intellectual and developmental disabilities are equally likely to receive guideline-concordant postpartum visits and more likely to have other outpatient visits than other women. Further research is needed to evaluate visit quality and identify best practices to support mothers with intellectual and developmental disabilities during the postpartum period.

Gynecologic Care for Women With Physical Disabilities: A Qualitative Study of Patients and Providers

BACKGROUND

Women with physical disabilities have unmet gynecologic care needs, including disparities in cancer screening and contraceptive care, when compared with women without physical disabilities. Our objective was to qualitatively assess provider and patient perspectives regarding barriers to gynecologic health care for women with physical disabilities.

METHODS

We used purposive sampling to recruit women with physical disabilities and gynecology providers who had experience caring for this population at two university hospitals. Patient and provider participants completed in-depth, semistructured interviews investigating their experiences with and barriers to receiving or providing gynecologic care. Transcripts were systematically analyzed by reviewing assigned codes and performing thematic analysis. We planned a sample size of at least 20 patient and provider participants to allow for saturation of thematic content.

RESULTS

We interviewed 29 women with physical disabilities and 20 providers. Important themes for providers and patients centered around adequate time spent during appointments, challenges with the gynecologic examination, inadequate facilities, clinical space limitations, and lack of formal provider and staff training in caring for this population.

CONCLUSIONS

Providers were motivated to provide quality care for women with disabilities, but encountered systems and training barriers. Patients and providers had concordant impressions of barriers that influenced equitable and patient-centered care, with structural barriers, including a lack of accessible space, closely related to perceptions of health care inequity between women with and without physical disabilities.

Contraceptive Practices and Reproductive Health Considerations for Adolescent and Adult Women with Intellectual and Developmental Disabilities: A Review of the Literature

Whereas progress has been made on increasing access to comprehensive healthcare for individuals with intellectual and developmental disabilities (I/DD), disparities continue in health outcomes, including those related to the reproductive health of adolescent and adult women with I/DD. This review summarizes reproductive care considerations for adolescent and adult women with I/DD and current practices regarding the delivery of contraceptive services to these women. Forty-seven (47) articles based on research conducted in the US between 1999 and 2019 were selected for inclusion in the review. Primary themes discussed include (1) common reproductive health concerns for adolescent and adult women with I/DD, other than pregnancy prevention; (2) contraceptive methods and disability-related concerns; (3) informed consent and reproductive decision-making; and (4) provider knowledge and education. The management of menses and hormonal dysregulation were identified as concerns that providers encounter among patients with I/DD and their families. Disability-related concerns with regard to use of contraception in general and considerations regarding certain methods in particular include challenges with prescription adherence, physical effects of hormonal therapies, drug interactions for individuals with additional health conditions, and legal and ethical concerns involved with decision-making and consent. The results of this review also suggest that focused efforts in partnership with health care providers may be needed to address barriers that adolescent and adult women with I/DD face when trying to obtain quality reproductive health services and contraceptive guidance.

Rapid repeat pregnancy in women with schizophrenia

AIM

Women with schizophrenia are vulnerable to adverse reproductive health outcomes. Short inter-pregnancy interval, or rapid repeat pregnancy, is associated with maternal and infant complications, and may be preventable. Whether women with schizophrenia are at disproportionate risk for rapid repeat pregnancy is unknown.

METHODS

This population-based cohort study in Ontario, Canada (2002-2013) compared women with and without schizophrenia on their risk of rapid repeat pregnancy, defined as pregnancy within 12 months of an index live birth. Among women with public drug coverage, those with and without schizophrenia were compared on their use of non-barrier contraception (hormonal and surgical) post-delivery.

RESULTS

Women with schizophrenia (n = 1565) were at higher risk for rapid repeat pregnancy than women without schizophrenia (n = 924,657) (6.3% vs. 3.9%, adjusted relative risk, aRR 1.31, 95% confidence interval, CI, 1.07-1.59). They had more rapid repeat pregnancies resulting in live births (aRR 1.85, 95% CI 1.26-2.72), but not pregnancy losses (aRR 1.50, 95% CI 0.99-2.29) or induced abortions (aRR 1.07, 95% CI 0.81-1.42). Post-delivery non-barrier contraception use was similar between groups (43.7% vs. 43.6%, aRR 1.06, 95% CI 0.93-1.20), although women with schizophrenia were more likely to use injectable contraception (14.1% vs. 10.1%, aRR 1.67, 95% CI 1.35-2.07).

DISCUSSION

Women with schizophrenia are at higher risk than their peers for rapid repeat pregnancy, but use non-barrier contraception at similar rates. The postnatal period is an opportune time to initiate targeted interventions designed to optimize planning for any future pregnancies, and contribute to improving maternal and child health in this vulnerable group.