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Published in final edited form as: Disabil Health J. 2025 Jan 1;18(3):101772. doi: 10.1016/j.dhjo.2024.101772

Perinatal mental health and risk of severe maternal morbidity in women with physical disabilities, Massachusetts 2003–2015

Anne Valentine a,*, Ilhom Akobirshoev a, Jiangying Zhang a, Tiffany A Moore Simas b, Monika Mitra a
PMCID: PMC13159049  NIHMSID: NIHMS2162416  PMID: 39794218

Abstract

Background:

Perinatal mental health and substance use disorders contribute to adverse maternal outcomes. Women with disabilities experience increased risk for severe maternal morbidity (SMM). No studies have examined the association between perinatal mental health and SMM risk in women with physical disabilities.

Objective:

To examine the association between perinatal mental health and substance use disorders and SMM risk in women with physical disabilities.

Methods:

We analyzed delivery hospitalizations from 2003 to 2015 from the Massachusetts Pregnancy to Early Life Longitudinal (PELL) data system. We identified physical disability using International Classification of Diseases, Ninth Revision codes. Perinatal mental health status was based on the presence of at least one emergency department visit, observational, or in-patient stay attributed to a mental health or substance use disorder anytime from gestation to delivery. We used modified Poisson regressions to obtain risk ratios (RR) for SMM in women with either a physical disability or no disability by perinatal mental health status. Non-disabled women with no perinatal mental health or substance use disorder visit served as the referent group.

Results:

Deliveries in women with no physical disability and a perinatal mental health visit were not associated with risk of SMM. Compared to the referent group, women with a physical disability and a perinatal mental health or substance use disorder visit had greater risk of both SMM (RR = 1.84, 95 % CI:1.32–2.56), and non-transfusion SMM (RR = 2.35 1.52, 3.64), after adjusting for demographic and socioeconomic characteristics.

Conclusions:

Increased attention should be paid to perinatal mental health status in women with physical disabilities.

Keywords: SMM, Physical disability, Perinatal mental health, Substance use disorder

1. Introduction

Severe maternal morbidity (SMM) refers to any number of potentially life-threatening clinical conditions including cardiovascular events, sepsis, and eclampsia, that occur during labor or delivery.1 An important indicator of maternal health and maternity care, SMM occurs in as many as 50,000 to 60,000 US births per year,2 with recent evidence suggesting that its prevalence may be significantly higher.3 Broadly associated with obstetric care quality4 and, specifically, with delays in diagnosis and treatment,5 SMM risk is characterized by the same racial and ethnic disparities observed in estimates of maternal mortality,1,6 underscoring the need for greater attention paid to systems of care and populations at heightened risk for adverse perinatal outcomes.

One such population includes women with physical disabilities. Physical disability, the most prevalent type of disability among reproductive-aged women,7 refers to a range of conditions that impact mobility, physical functioning, or dexterity. While pregnancy and birth rates among women with disabilities have increased markedly in recent years,8,9 the proportion of these pregnancies is highest among women with physical disabilities.10 Studies examining pregnancy-related outcomes in women with physical disabilities point to a heightened risk for adverse maternal and infant outcomes including gestational diabetes, hypertensive disorders, cesarean delivery, and preterm birth.7,11

Similarly, extant research, while limited, finds elevated risk for SMM in women with disabilities generally, and not limited to physical disabilities.12–17 Notable differences in SMM risk by disability type and status warrant further study,17 as does research examining the potential mechanisms behind the heightened SMM risk observed in women with disabilities. The potential pathways by which maternal disability may increase SMM risk are complex and multifaceted, involving interactions between individual, social, environmental, and health-system factors.18 While research demonstrates elevated SMM risk across disability types, the specific mechanisms linking disability to risk of SMM are not well understood.12 Current evidence suggests both direct pathways, through physiological complications and underlying health conditions, and indirect pathways involving healthcare access barriers, provider communication challenges, and systemic factors, including ableism and stigma.19–21

A recent study found that SMM risk in persons with at least one mental health disorder was 50 percent greater than in persons without one, adding to a large body of research demonstrating adverse associations between perinatal outcomes and maternal mental health and substance use disorders.22,23 Focusing on SMM is important as it can be a prelude to maternal mortality and pregnancy-related deaths due to mental health (i.e., suicide and overdose), which have been deemed completely preventable by maternal mortality review committees.24 Mental health and substance use disorders are commonly experienced by reproductive-aged women25; current estimates suggest that one in five individuals are diagnosed with a mental health or substance use disorder during pregnancy or postpartum.26 Far fewer are screened or referred to treatment.27 The deleterious effects of these conditions during the perinatal period include higher rates of tobacco consumption, lower rates of healthcare utilization and an increased risk for adverse maternal and infant outcomes. The consequences for families and communities are devastating. A 2008–2017 examination of pregnancy-related deaths in 14 states attributed eleven percent of all maternal deaths with a determined cause to a mental health or substance use disorder. All of these deaths were associated with a history of depression; nearly two-thirds of decedents had a history of prior or current substance use.28

While adults with disabilities experience heightened risk for mental health and substance use disorders compared to their counterparts without disabilities,29,30 significant gaps in our understanding of the complex relationship between disability and behavioral health remain. Relatively scant information exits, for example, on the prevalence of mood and substance use disorders by disability type or disabling condition. A handful of studies employing large community samples and well-validated measures of mood, anxiety, and substance use find elevated rates of both 12-month and lifetime prevalence of mental health and substance use disorders in individuals with a physical disability compared to individuals with no disability.31,32 Given the increased risk for adverse pregnancy outcomes in women with disabilities, it is important to understand the associations between SMM and mental health in this population to develop policies and interventions to improve outcomes. This study examines the association between SMM and perinatal mental health and substance use disorders in women with physical disabilities. Consistent with recent research, we hypothesized the risk of SMM in women with a physical disability would be higher than in women with no physical disability. Second, we hypothesized that women with both a physical disability and a perinatal emergency department (ED) visit, observational stay, or in-patient stay associated with a mental health or substance use disorder diagnosis would experience a greater risk for SMM risk compared to women with a physical disability alone.

2. Methods

2.1. Data source

We used data from the Massachusetts Pregnancy to Early Life Longitudinal (PELL) data system. PELL is a population-based data set which links all Massachusetts birth certificates, fetal death reports, delivery- and non-delivery-related hospital records of all birthing people and their infants. Non-delivery records include observational stays, ED visits, and inpatient stays. PELL includes >100 clinical and nonclinical data elements, including hospital information, patient demographics and primary and secondary diagnosis and procedural codes for each delivery. Details of the data have been published elsewhere.33 This study included all hospital-based singleton deliveries that occurred in Massachusetts between 2003 and 2015 (Qr3); our analyses were limited to women ages 15–49 years (N = 942,690).

2.2. Measures

Dependent variable.

Our primary outcome of interest was SMM with and without blood transfusion. SMM was measured as a binary variable and defined according to the 21 conditions and procedural codes compiled by the Centers for Disease Control and Prevention (CDC) (see Supplemental Table 1).34 SMM cases were identified from the date of delivery up to 42 days postpartum to capture its incidence following delivery discharge.35 Persons with at least one of the indicators or clinical conditions identified by the CDC were classified as having SMM. Given that blood transfusion is among the most common contributors to SMM36; non-transfusion SMM was also assessed by excluding observations with blood transfusion from the SMM composite.

Independent variables.

Physical disability and any perinatal emergency department (ED) visit, observational stay, or in-patient stay associated with a mental health or substance use disorder diagnosis, heretofore referred to as a hospital-associated mental health visit, were our main independent variables.

Maternal physical disability was defined based on an algorithm established in prior research37 using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes for conditions that primarily affect mobility and physical functioning (e.g., congenital anomalies, musculoskeletal or neurologic disorders, cerebral palsy, and permanent injuries) from discharge records during any non-delivery-related ED visit, observational stay, or inpatient stay from gestation to delivery (see Supplemental Table 2).

A hospital-associated mental health visit was defined as any mental health or substance use disorder-related visit involving the ED, observational stay, or inpatient stay that occurred during the index pregnancy (i.e., between the gestation date and delivery). We classified a person as having a hospital-associated mental health visit if there was at least one diagnosis associated with mental health or substance use disorder38 during any non-delivery-related ED visit, observational stay, or inpatient stay between the gestation date and delivery. We grouped women by physical disability and any perinatal mental health visit status into the following cohorts: 1) no physical disability with no mental health visit (referent group); 2) no physical disability with a mental health visit (cohort 1); 3) physical disability with no mental health visit (cohort 2); and 4) physical disability with a mental health visit (cohort 3).

Covariates.

Sociodemographic and clinical data were derived from delivery, discharge, and birth certificate data, based on previous research.39,40 Sociodemographic variables included maternal age (<20, 20–30, 30–40 and > 40 years); education (less than high school, high school or GED, some college, or unknown); race/ethnicity (non-Latino white, non-Latino Black, Latino, and other); marital status (married, not married, and unknown); and public insurance (no/yes). Clinical characteristics included first trimester prenatal care (no/yes); prenatal care adequacy based on the timing and frequency of visits in relation to the stage of pregnancy as defined by Kotelchuck’s Adequacy of Prenatal Care Utilization (APNCU) Index41 (inadequate, indeterminant, adequate, adequate plus); and cigarette smoking status during pregnancy (no/yes).

2.3. Statistical approach

Among women with and without a physical disability, we compared demographic, socioeconomic, and clinical characteristics of those with and without a hospital-associated mental health visit. Differences across categorical and continuous variables were evaluated using chi-square and t-tests, respectively. The study’s dependent variables were coded such that higher prevalence indicated higher risk for SMM or non-transfusion SMM. We calculated the rate per 10,000 deliveries and the relative risk of SMM and non-transfusion SMM among women with a physical disability and those without a physical disability by perinatal mental health visit status. We conducted modified Poisson regressions to estimate the unadjusted and adjusted risk ratios (with 95 % confidence intervals) for SMM and non-transfusion SMM risks by physical disability and perinatal mental health status, using those with no physical disability and no hospital-associated mental health visit as the referent group. Multivariate regression models adjusted for covariates mentioned above, including demographic, socioeconomic, and clinical characteristics including maternal age, education, race/ethnicity, insurance status, first trimester prenatal care, adequacy of prenatal care visits, and smoking status. We used SAS software 9.4 for all analyses.

3. Results

3.1. Sample characteristics

Table 1 presents the demographic, socioeconomic, and clinical characteristics of women with and without a perinatal mental health visit, stratified by physical disability status. Women with no physical disability and a perinatal mental health visit were more likely to be younger, to be Black or Latina, and to report fewer years of education, compared to their peers without a perinatal mental health visit. Further, they were less likely to be married, less likely to have private insurance, but were more likely to report cigarette smoking during pregnancy and to have received inadequate prenatal care. Among women with physical disabilities, those with a perinatal mental health visit were more likely to be younger, to be White, and to report fewer years of education. Compared to their counterparts without a perinatal mental health visit, they were less likely to be married, less likely to have public insurance, but were more likely to report cigarette smoking during pregnancy and to have received inadequate prenatal care.

Table 1.

Sample Characteristics of Women with a Physical Disability vs. No Physical Disability by Perinatal Mental Health Visit Status in Massachusetts, 2003–2015 Qr3 (N = 942,690).

Characteristics No Physical Disability
 P-value Physical Disability
 P-value
Perinatal Mental Health Visit
 Perinatal Mental Health Visit
No Yes No Yes
Study Population N = 829,195 N = 2180 N = 109,848 N = 1467
Demographics
 Maternal age at delivery, years <0.001 <0.001
  <20 5.2 15 5.1 7.9
  20–29 38.3 56.8 51.3 59.9
  30–39 51.9 25.7 40.1 29.3
  >30 4.3 2.38 3.3 2.7
  Mean (SD) 29.9 (5.9) 25.97 (6.2) 28.5 (5.8) 27.0 (5.8) <0.001
 Maternal race/ethnicity <0.001 <0.001
  Non-Latino White 68.2 62.6 65.0 70.6
  Non-Latino Black 8.2 13.8 12.8 12.2
  Latino (any race) 14.2 19.6 18.5 15.0
  Non-Latino Other 9.2 3.7 3.5 1.9
 Maternal education <0.001 <0.001
  Less than high school 40.1 44.2 56.2 56.2
  High school graduate 15.7 31.4 18.7 25.9
  Some or more college 44.12 24.3 25.0 17.8
 Marial status <0.001 <0.001
  Not married 29.8 73.4 52.2 78.5
  Married 69.8 26.1 47.4 21
  Unknown 0.2 0.3 0.3 0.6
 Type of health insurance <0.001 <0.001
  Public 20.7 56.0 73.1 51.8
  Private 79.2 43.9 26.8 48.1
Clinical Characteristics
 First trimester prenatal care <0.001 <0.001
  No 20.0 32.7 21.4 35.5
  Yes 79.9 67.2 78.5 64.4
 Kotelchuck’s APNCU Index <0.001 <0.001
  Inadequate 8.6 18.3 9.5 22.8
  Intermediate 6.9 8.39 7.3 7.7
  Adequate 43.2 31.0 38.2 26.8
  Adequate plus 37.9 39.2 41.2 37.7
  Missing 3.1 3.02 3.5 4.8
 Cigarette smoking during pregnancy <0.001 <0.001
  No 94.6 70.4 85.9 62.2
  Yes 5.3 29.5 14.0 37.7
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3.2. Severe maternal morbidity

For every 10,000 deliveries, 123 SMM deliveries occurred in women with no physical disability and no perinatal mental health visit, 151 occurred in women with no physical disability and a perinatal mental health visit, 202 occurred in women with a physical disability and no perinatal mental health visit, and 252 occurred in women with a physical disability and a perinatal mental health visit (see Table 2). In all covariate-adjusted analyses, deliveries in women with no physical disability and a perinatal mental health visit were not associated with a significant increase in risk of SMM. A significant increase in SMM risk was observed in deliveries in women with a physical disability without a perinatal mental health visit (RR = 1.46 (1.41–1.56), p < 0.001). However, deliveries in women with a physical disability and a perinatal mental health visit had nearly 2-times the risk of SMM (RR = 1.84 (1.32–2.56), p < 0.001) compared to deliveries in women with no physical disability and no perinatal mental health visit, which was higher compared to the risk observed in deliveries to women with a physical disability only (RR = 1.84 vs. RR = 1.46).

Table 2.

Severe Maternal Morbidity in Women with a Physical Disability vs. No Physical Disability by Perinatal Mental Health Visit, Observational Stay or Hospitalization in Massachusetts, 2003–2015 Qr3 (N = 942,690).

Outcomes No Physical Disability
 Physical Disability
Perinatal Mental Health Visit
 Perinatal Mental Health Visit
No Yes No Yes
N = 829,195 N = 2180 N = 109,848 N = 1467
SMM
Rate per 10,000 123 151 202 252
Unadjusted; RR, 95 % CI referent 1.21 (0.85,1.70) 1.63*** (1.56,1.71) 2.03*** (1.48, 2.79)
Adjusted; * RR, 95 % CI referent 1.07 (0.75,1.53) 1.46*** (1.41, 1.56) 1.84*** (1.32, 2.56)
SMM without blood transfusion
Rate per 10,000 58 50 102 150
Unadjusted; RR, 95 % CI referent 0.86 (0.47, 1.55) 1.74*** (1.63,1.86) 2.57*** (1.70, 3.90)
Adjusted; * RR, 95 % CI referent 0.87 (0.48, 1.57) 1.61***(1.50, 1.73) 2.35*** (1.52, 3.64)
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***

p < 0.001,

**

p < 0.01,

*

p < 0.05.

*

Adjusted for demographic and socioeconomic characteristics including maternal age, education and race/ethnicity, insurance status, adequacy of prenatal care, and smoking status.

Source: Pregnancy to Early Life Longitudinal (PELL) Data, 2003–2015

3.3. Non-transfusion severe maternal morbidity

For every 10,000 deliveries, 58 non-transfusion SMM deliveries occurred in women with no physical disability and no perinatal mental health visit, 50 occurred in women with no physical disability and a perinatal mental health visit, 102 occurred in women with physical disability and no perinatal mental health visit, and 150 occurred in women with physical disability and a perinatal mental health visit (see Table 2). We did not observe significant risk for non-transfusion SMM in deliveries in women with no physical disability and a perinatal mental health visit compared to women with no physical disability and no perinatal mental health visit. Women with physical disability without a perinatal mental health visit had 1.6-times the risk (RR = 1.61 (1.50–1.73), p < 0.001). Women with physical disability and a perinatal mental health visit had more than 2-times the risk of non-transfusion SMM (RR = 2.35 (1.52–3.64), p < 0.001) compared to women with no disability and no perinatal mental health visit. Of note, the relative risk for SMM and non-transfusion SMM in deliveries to women with both a physical disability and a perinatal mental health visit was compounded; that is, it was more than the sum of relative risk for women with a perinatal mental health visit only and the relative risk for women with a physical disability only.

4. Discussion

This study tested two hypotheses related to SMM risk in women with physical disabilities; our findings support both hypotheses. First, women with a physical disability experienced a significantly higher risk of SMM compared to women with no physical disability, consistent with previous research7,11,12 Second, women with a physical disability and an emergency department (ED) visit, observational stay, or in-patient stay associated with a mental health or substance use disorder diagnosis experienced an even higher SMM risk, suggesting a compounding effect of physical disability and perinatal mental health and/or substance use disorders. Furthermore, the risk of SMM without blood transfusion was higher among women with a physical disability and an emergency department (ED) visit, observational stay, or in-patient stay associated with a mental health or substance use disorder diagnosis than the risk of SMM overall, which suggests that complications associated with the need for a blood transfusion did not drive the SMM indicators or the differences observed between cohorts in this study.

In this analysis of Massachusetts delivery hospitalization data, 2003–2015, women with a physical disability and a perinatal hospital-associated mental health visit experienced a two-fold higher risk for SMM at delivery and up to 42 days postpartum compared to women with no physical disability and no hospital-associated mental health visit. Moreover, irrespective of disability status, deliveries to any women with a perinatal hospital-associated mental health visit were associated with an increased risk for SMM relative to deliveries to women without a hospital-associated mental health visit.

The pathways through which these risks manifest are multifaceted. Women with physical disabilities often face unique challenges in accessing prenatal care, including physical barriers to healthcare facilities, a lack of accommodations within the healthcare setting, inadequate or inaccessible communication provider team, and a lack of disability-informed care.40,42,43 These barriers may be more pronounced or challenging in the presences of a mental health and/or substance use disorder.

This study contributes to a small body of research examining SMM risk in women with disabilities. To our knowledge, it is the first population-based estimate of SMM risk in women with both a physical disability and a perinatal mental health or substance use disorder visit. Our findings provide insight into one potential driver of elevated risk for adverse maternal outcomes observed in women with disabilities. However, the presence of a perinatal mental health or substance use disorder diagnosis does not necessarily portend an adverse maternal outcome. In fact, the proportion of mental health and substance use disorder diagnoses identified in the study sample was similar in women with a physical disability compared to women with no physical disability. Increased awareness regarding the risks associated with perinatal mental health and substance use disorders may prompt provider teams to implement universal screening protocols for depression, alcohol and substance use, as recommended by the American College of Obstetrics and Gynecology and the US Preventative Services Task Force.44–47 Attention paid to perinatal mental health and substance use disorders is essential to improving pregnancy-related outcomes for women with physical disabilities, a population whose reproductive healthcare needs have been notably neglected.

5. Limitations

Several limitations to this study warrant consideration. First, we were reliant on ICD-9 codes to identify physical disability status. It is possible that we do not have an accurate count of the number of women with a physical disability who gave birth during the study period. The findings likely underestimate the magnitude of the observed effects, given evidence suggesting that diagnosis codes may miss many women with disabilities.48 Second, the use of any hospital-associated mental health visit as a proxy for a perinatal mental health or substance use disorder is deliberately broad; we have no information about the course or severity of the conditions identified. If only the most severe case presentations were given a diagnosis code, however, it is possible that the association between a perinatal mental health or substance use disorder diagnosis and SMM risk is biased. On the other hand, it may be that only the most severe presentations were associated with a hospital-based mental health visit, potentially attenuating the association between perinatal mental health concerns and the SMM risk observed. The absence of information about outpatient mental health service utilization is a limitation; ongoing efforts to improve data collection related perinatal mental health and substance use disorders are warranted. Third, we were unable to examine temporal associations between mental health and/or substance use disorder diagnoses and pregnancy, limiting our ability to distinguish pre-existing conditions from pregnancy-related onset. It is likely that some proportion of the sample experienced a mental health or substance use disorder prior to the pregnancy; how an incident diagnosis versus a relapse or refractory diagnosis relates to SMM risk is unknown, but research suggests that persons with a mental health condition prior to pregnancy experience increased risk for poor obstetric outcomes.49 Finally, our analysis relied on hospital discharge data, which may not capture all relevant clinical information or social determinants of health that could influence SMM risk.

6. Conclusions

Findings from this population-based study show that women with a physical disability experience a heightened risk for SMM, and this risk is further elevated when mental health and/or substance use disorders are present during pregnancy. These findings underscore the need for enhanced perinatal screening for mental health and substance use disorders in women with physical disabilities in tandem with disability-informed maternity care and supports that address both accessibility and quality of care.

Supplementary Material

Supplemental Table 1
Supplemental Table 2

Funding

The contents of this publication were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant numbers 90DPHF0011, 90DPHF0013). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this publication do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the Federal Government.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.dhjo.2024.101772.

Footnotes

Declaration of competing interest

The authors have no conflicts of interest to declare.

CRediT authorship contribution statement

Anne Valentine: Conceptualization, Formal analysis, Writing – original draft, Writing – review & editing. Ilhom Akobirshoev: Conceptualization, Formal analysis, Writing – original draft, Writing – review & editing. Jiangying Zhang: Conceptualization, Formal analysis, Methodology. Tiffany A. Moore Simas: Writing – original draft, Writing – review & editing. Monika Mitra: Funding acquisition, Conceptualization, Supervision, Writing – original draft, Writing – review & editing.

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Supplemental Table 1
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Supplemental Table 2
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