A study of low-income women with pregnancy-related complications suggests that long-term health risks could be reduced through better monitoring and combined mother and baby visits.
Low-income women with recent, complicated pregnancies are using the ED at high rates after delivery, and could benefit from better monitoring, according to research published in the September issue of the Journal of Women's Health. This patient population may not be getting the postpartum care and follow-up needed to prevent further health problems, the study data suggests.
Ashley Harris, MD, MHS |
Study lead author Ashley Harris, MD, MHS, a former senior clinical fellow in the Johns Hopkins University School of Medicine's Division of General Internal Medicine, and now a primary care doctor at Mary's Center in Washington, DC, says the research was prompted by the rising prevalence of hypertensive disorders and gestational diabetes among pregnant women, along with questions about the effects of these complications on overall health.
"[Pregnancy] is sort of an opportune time to get them into treatment," Harris says.
Such complications also put these women at long-term risk, not only for subsequent pregnancies, but also for the rest of their lives. The researchers wanted to know how the women were using healthcare postpartum, especially among the Medicaid population.
Nearly 70% of women in the study were eligible for Medicaid because they were pregnant. According to the study, "67% of [the] sample had a temporary form of Medicaid granted to pregnant women, which is discontinued at eight weeks postpartum."
Researchers analyzed more than 26,000 Maryland Medicaid claims made between 2003 and 2010, and linked that data with U.S. Census data to adjust by socioeconomic factors. Of the 26,074 pregnancies studied, 20% were complicated by
- Gestational diabetes
- Gestational hypertension, or
- Preeclampsia
"The key results were that 25% of women had at least one ER visit, which is a big number," Harris says. Women with pregnancy complications had higher rates of ER utilization in the 6 months postpartum compared with women in the comparison pregnancy group (27.7% vs. 23.6%).
In the complicated pregnancy group (six months postpartum):
- 16.8% had 1 ER visit
- 8.5% had 2–3 visits
- 2.3% had 4–10 visits
- 0.13% had more than 10 visits
Women under 25 with complications had an even greater chance of going to the ER. In addition, most ER visits happened before the women's six-week postpartum appointment. All of this suggests that the health system has work to do in order to proactively address women's health needs postpartum, Harris says.
Postpartum Coordinated Care
Proactive, coordinated care isn't just good for new moms; it can dramatically improve outcomes for preterm babies, too, according to the results of a retrospective study, published online in the October 2015 issue of Obstetrics & Gynecology.
Stacy Beck |
It looked at 101 infants born at 23 weeks gestation between 2004 and 2013 who received comprehensive perinatal and neonatal care. Clinician-researchers at Nationwide Children's Hospital and The Ohio State University Wexner Medical Center examined factors such as prenatal care, preterm labor, preterm premature rupture of membranes, surfactants in the delivery room, and prolonged intubation sequences.
"The goal of our care team for births at 23 week, whether anticipated or imminent, is to support families by supporting shared decision-making between families and health care providers," said Stacy Beck, MD, maternal fetal medicine physician at The Ohio State University Wexner Medical Center, in a statement.
"From an obstetrician perspective, when prenatal counseling is possible, we can improve the efficiency of care in the delivery room for these babies born extremely premature."
Researchers found that 60 infants survived to hospital discharge and more than half of the survivors had little to no neurological complications after being evaluated at 18 to 22 months. In past literature, a majority of babies born at 23 weeks had not survived, or had exhibited moderate impairment.
Another researcher, Leif Nelin, MD, Dean W. Jeffers Chair of Neonatology at Nationwide Children's and a Professor of Pediatrics at The Ohio State University College of Medicine, noted in a statement that the "study only describes outcomes in a best-case scenario, as all the neonates were all singleton pregnancies with time for prenatal counseling, which is not always the case."
Clearly, "best-case scenario," coordinated care, isn't always the case. Even with full-term pregnancies, women often aren't ready to go home at discharge, or have specific needs that they should be addressed at discharge, JHUMC's Harris says.
"The hospital visit and hospital stay for birth has gotten shorter and shorter and shorter," she noted. When it comes to maternal health, better and more specific discharge planning measures could help target the women who may need more care, as well as determine the kind of care they need.
Harris also says the study results point to the benefits of post-partum home visits.
"These can really help with the transition," she says. Other studies, including many that are cited in her research, show that home visits can be beneficial for high-risk populations. She notes that there are home visits aimed at infants under Patient Protection and Affordable Care Act, and says it would interesting to see how those might be paired with visits that also address the health of mothers.
That leads to a third possible recommendation based on the findings of the Hopkins study: Combining mother and baby visits, a topic that another Johns Hopkins researcher, Wendy Bennett, MD, MPH is investigating now, Harris says.
"They tend to put aside their own healthcare," Harris says of new mothers. In fact, Bennett's research from last year showed that slightly fewer than half of women make or keep their postpartum appointments. Other factors, such as lack of access, time, social support, and understanding of risks or medical comorbidities, may also cause women to neglect their own health, and ultimately wind up in the emergency department. Combining well-child checks and routine infant immunizations with check-ups for new moms, too, could help alleviate this issue.
"It would be more like one-stop shopping," Harris says.
Alexandra Wilson Pecci is an editor for HealthLeaders.
