Preconception care and severe maternal morbidity in the United States

Dude, Annie; Schueler, Kellie; Schumm, L. Philip; Murugesan, Manoradhan; Stulberg, Debra

doi:10.1016/j.ajogmf.2021.100549

Cited by 8 publications

(15 citation statements)

References 24 publications

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“…Roughly similar patterns were also observed in MAX for the likelihood of having received contraceptive services and related preventative health services, both domains of preconception care associated with decreased risk of severe maternal morbidity. 24 Notable differences included somewhat different patterns with age, and negligible or smaller differences in the likelihood of having received contraceptive services for those with diabetes or hypertension versus those without, with odds ratios of 1.04 (95% CI 0.98, 1.11) and 1.10 (95% CI 1.04, 1.15), respectively.…”

Section: Resultsmentioning

confidence: 99%

“…25 In addition, PRAMS does not assess rare but serious maternal complications such as severe maternal morbidity, 28 which would be difficult to identify through self-report but can be quantified and assessed for association with preconception services using Medicaid claims. 24 Furthermore, PRAMS asks postpartum women to recall if a healthcare provider counseled them about their health prior to pregnancy, which may be subject to recall bias. Because of these inherent limitations in using surveys for tracking preconception care, it is encouraging to see claims-based measures offer a promising alternative for population-wide surveillance.…”

Section: Resultsmentioning

confidence: 99%

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Preconception Care for Women with Medicaid: Self-report vs. Claims-based Utilization Measures

Stulberg

Schumm

Schueler

et al. 2022

Preprint

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BackgroundPreconception care may improve perinatal outcomes and reduce disparities, but there is no standard population measure of preconception care utilization (PCU).ObjectiveWe compared claims-based PCU from Medicaid Analytic Extract (MAX) data to self-report in the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey.MethodsAmong Medicaid-enrolled women ages 15-45 with births during 2012, we identified preconception services in MAX using 55 ICD9 codes published by Health and Human Services. We estimated the proportion reporting preconception care from 26 PRAMS states and compared this to the states’ proportion who received services in MAX. We fit mixed-effects logistic regression models of the probability of PCU on demographic factors (age, race/ethnicity) and diagnoses (depression, diabetes, or hypertension), separately for each dataset. Finally, we computed the population proportions receiving care by state (MAX) and the empirical Bayes means of the state-level effects (MAX and PRAMS).ResultsAmong 652,929 deliveries in MAX from the included states, 28.1% received at least one preconception service. In PRAMS, 23.6% (95% CI [22.1, 25.3]) of Medicaid-covered respondents reported preconception care. In both datasets, PCU rates were higher for Black non-Hispanic vs. White non-Hispanic women (PRAMS OR 2.05 [1.60, 1.62]; MAX OR 1.51 [1.49, 1.54]) and for those with diabetes (PRAMS OR 1.82 [1.16, 2.85]; MAX OR 1.34 [1.29, 1.40]) or hypertension (OR 1.85 [1.41, 2.44]; MAX OR 1.22 [1.18, 1.27]). In PRAMS, Asian (OR 3.37 [2.28, 4.98]) and Hispanic women (OR 2.07 [1.5, 2.80]) were more likely to report PCU than White non-Hispanic women, but in MAX they were less likely to receive services. The correlation between the PRAMS state-specific effects and those from MAX was 0.31 (p = 0.124).ConclusionsClaims-based estimates of PCU are moderately concordant with self-reported rates at the state level; however, rates measured through Medicaid claims vs. self-report diverge in some groups.SynopsisStudy QuestionHow do Medicaid claims-based measures of preconception care utilization compare to self-reported receipt of preconception counseling among Medicaid-covered respondents in the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey?What’s already knownPRAMS provides population-level estimates of preconception care utilization, while claims-based measures quantify specific services received.What this study addsClaims-based preconception care utilization among the Medicaid population varies by race (Black/White) and diagnosis of diabetes or hypertension in similar patterns as self-report in PRAMS, but ethnicity (Hispanic/non-Hispanic) and depression demonstrate divergent patterns between the two data sources. State-level variation in preconception care utilization is greater in claims data. Both data sources can be used by researchers with an understanding of their methodological benefits and limitations.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Preconception Care for Women with Medicaid: Self-report vs. Claims-based Utilization Measures

Stulberg

Schumm

Schueler

et al. 2022

Preprint

Self Cite

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“…This excess mortality burden is related, in part, to the rising prevalence of pregnant people with chronic diseases, such as systemic lupus erythematosus, pulmonary hypertension, asthma, cystic fibrosis, diabetes, hypertension, epilepsy, chronic kidney disease, and inflammatory bowel disease 2–6 . Patients with chronic diseases are significantly more likely to experience adverse pregnancy and perinatal outcomes than healthy people 7–9 . In addition, people of color, people who are poor, or who are otherwise socially marginalized, experience the worst pregnancy outcomes as a result of the complex intersections between chronic disease and social determinants of health, structural and medical racism, and inadequate access to quality health care 10,11 …”

Section: A New Model Is Needed To Provide High‐quality Sexual and Rep...mentioning

confidence: 99%

“…[2][3][4][5][6] Patients with chronic diseases are significantly more likely to experience adverse pregnancy and perinatal outcomes than healthy people. [7][8][9] In addition, people of color, people who are poor, or who are otherwise socially marginalized, experience the worst pregnancy outcomes as a result of the complex intersections between chronic disease and social determinants of health, structural and medical racism, and inadequate access to quality health care. 10,11 Medicine subspecialists are often consulted to provide expert clinical care to people whose chronic diseases are particularly severe, complicated, or rare.…”

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confidence: 99%

A blueprint for a new model of sexual and reproductive health care in subspecialty medicine

Talabi

Callegari

Kazmerski

et al. 2022

Health Services Research

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The United States has the highest rate of maternal mortality of any developed country in the world. 1 This excess mortality burden is related, in part, to the rising prevalence of pregnant people with chronic diseases, such as systemic lupus erythematosus, pulmonary hypertension, asthma, cystic fibrosis, diabetes, hypertension, epilepsy, chronic kidney disease, and inflammatory bowel disease. [2][3][4][5][6] Patients with chronic diseases are significantly more likely to experience adverse pregnancy and perinatal outcomes than healthy people. [7][8][9] In addition, people of color, people who are poor, or who are otherwise socially marginalized, experience the worst pregnancy outcomes as a result of the complex intersections between chronic disease and social determinants of health, structural and medical racism, and inadequate access to quality health care. 10,11 Medicine subspecialists are often consulted to provide expert clinical care to people whose chronic diseases are particularly severe, complicated, or rare. 12 Subspecialists are responsible for helping to manage the pregnancies of some of the most complex and severely ill patients-the very patients who are at greatest risk of death during pregnancy. Subspecialists who are armed with salient knowledge and experience may be better able to prepare patients for a healthy pregnancy; counsel patients with accurate and up-to-date information; address issues that might complicate a pregnancy, such as the use of teratogenic medications; advise patients about the safety of their contraception options; identify "red flags" that might suggest worsening disease severity of life-threatening sequelae during pregnancy (e.g., preeclampsia); and make referrals for abortion care when needed and if available. Such competencies may be lifesaving. However, at present, subspecialty medical practice may paradoxically potentiate adverse reproductive outcomes. 10 Subspecialists across the internal medicine disciplines of rheumatology, pulmonary and critical care medicine, gastroenterology/transplant hepatology, cardiology, nephrology, endocrinology, infectious disease, and hematology-oncology, indicate that they do not have the basic knowledge, skills, or resources to manage disease-related aspects of sexual and reproductive health (SRH). [13][14][15][16][17][18][19][20][21][22] Our collective of multidisciplinary subspecialty clinicians and health services researchers has described some of the common challenges that subspecialists feel undermine their provision of SRH

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“…The following potential confounders were abstracted from hospital discharge records and included in the analysis: maternal age (<19 years, 20-29 years, 30-39 years, 40+ years), race/ethnicity (non-Hispanic Black, non-Hispanic White, Hispanic, Other), insurance (Medicare/Medicaid, Private Insurance, Self-pay, Other), education status (high school or less, some college, college, more than college, college), chronic hypertension (ICD9: 401.0,401.1 or 401.9), obesity (ICD9: 278), cesarean delivery (ICD9: 654.20), abnormal presentation (ICD9: 652.2), Type 2 diabetes mellitus (ICD9: 250), parity (none, one previous live birth, two or more), year of birth, placental disorder (presence of placenta previa, placenta accreta, placenta increta or placenta percreta), chronic renal disease (585.9), and Kotelchuck index, a proxy for Adequacy of Prenatal Care Utilization (27)(28)(29)(30)(31)(32). BMI was only available starting in 2004 and was not included in the analysis.…”

Section: Covariatesmentioning

confidence: 99%

Contribution of prenatal exposure to ambient temperature extremes and severe maternal morbidity: A retrospective Southern birth cohort

Runkle

Sugg

Stevens

2022

Preprint

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BACKGROUND: Health disparities have persisted in severe maternal morbidity (SMM), an event in which a woman nearly dies from a complication during pregnancy, with limited data on environmental risk factors. OBJECTIVE: To examine the association between prenatal exposure to high and low ambient temperatures and SMM during critical windows of pregnancy for a birth cohort in the Southeastern United States. METHODS: This retrospective, population-based birth cohort included hospital deliveries from 1999 to 2017 (570,660 women, 921,444 deliveries). Daily average temperatures at the county-scale were merged with delivery discharge records and days of exposure to very hot and very cold were estimated over the following critical windows: preconception, and first, second, and third trimesters (T1-T3). Generalized estimating equations with multivariable Poisson models examined the association between temperature extremes and SMM for each critical window. RESULTS: Women exposed to a low compared to a high number of cold days during the first and third trimesters were 1.11 (CI: 1.03, 1.20) and 1.30 (CI: 1.20, 1.42) times more likely to experience SMM, respectively. Compared to the no exposure group, women exposed to a high number of very hot temperatures during preconception were 1.09 (95%CI:1.02,1.18) more likely to experience SMM. Sustained exposure to a high or moderate-intensity heat wave during the summer months was associated with a 45% or 39% increase in SMM risk during T2, respectively. Pregnant populations residing in rural locations were more sensitive to cold exposure in T3. Women exposed to a high number of very hot days in T2 compared to no exposure were 20% more likely to experience preterm SMM. SIGNIFICANCE: Findings suggest that maternal exposure to hot or cold temperature extremes around the time or during pregnancy may be a contributing environmental risk factor for SMM. More attention should be focused on prenatal counseling in pregnant populations around the risk of thermal extremes.

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Preconception care and severe maternal morbidity in the United States

Cited by 8 publications

References 24 publications

Preconception Care for Women with Medicaid: Self-report vs. Claims-based Utilization Measures

Preconception Care for Women with Medicaid: Self-report vs. Claims-based Utilization Measures

A blueprint for a new model of sexual and reproductive health care in subspecialty medicine

Contribution of prenatal exposure to ambient temperature extremes and severe maternal morbidity: A retrospective Southern birth cohort

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