A population-based analysis of postpartum acute care use among women with disabilities

Abstract

Background:

Disability is common in reproductive-aged women, and as many as one in eight pregnancies occur in women with a disability. Women with disabilities experience significant social and health disparities, and are at greater risk than their non-disabled counterparts for perinatal complications. Yet, few studies have examined their postpartum acute care use.

Objective:

To examine risks of postpartum emergency department visits and hospital admissions among women with and without physical, sensory, and intellectual/developmental disabilities.

Study design:

In this population-based study in Ontario, Canada, women with a singleton obstetrical delivery from 2003–2019 were classified into those with physical (n=155,500), sensory (n=49,338), intellectual/developmental (n=2,650), and ≥2 of these disabilities (“multiple disabilities”, n=9,904), and women without disabilities (n=1,701,574). Primary outcomes were emergency department visits and hospital admissions 0–365 days after index delivery hospital discharge. Secondary outcomes were emergency department visits and hospital admissions by primary diagnosis (medical, psychiatric) and by timing (0–7, 8–42, 43–365 days postpartum). Relative risks (aRR) comparing each disability group to those without disabilities were adjusted for age; parity; income quintile; rurality; immigrant/refugee status; pre-pregnancy chronic medical conditions, mental illness, and substance use disorders; and prenatal care provider type.

Results:

Any postpartum emergency department visit occurred in 23.5% of women without a disability, with risks elevated in women with physical (32.9%, aRR 1.27, 95% CI 1.26–1.28), sensory (30.0%, aRR 1.16, 95% CI 1.15–1.18), intellectual/developmental (48.8%, aRR 1.38, 95% CI 1.33–1.44), and multiple disabilities (42.0%, aRR 1.44, 95% CI 1.41–1.48) compared to women without disabilities. Similarly, any postpartum hospital admission occurred in 3.0% of women without a disability, with elevated risks in women with physical (4.8%, aRR 1.37, 95% CI 1.34–1.40), sensory (4.0%, aRR 1.19, 95% CI 1.14–1.24), intellectual/developmental (9.6%, aRR 1.96, 95% CI 1.73–2.21), and multiple disabilities (7.3% aRR 1.77, 95% CI 1.64–1.90). Results were consistent by primary diagnosis and timing in the postpartum period.

Conclusion:

Women with disabilities have elevated risk of emergency department visits and hospital admissions in the postpartum period, indicating greater postpartum morbidity, which requires attention through enhanced and extended follow-up across the postpartum period.

Condensation:

Findings of high rates of postpartum acute care use among women with disabilities suggest the need for better postpartum care for this population.

INTRODUCTION

Disability is common in reproductive-aged women, as 12% of 15 to 49 -year-old women have a physical, sensory, or intellectual/developmental disability.¹ Fertility rates among women with disabilities have increased in the last two decades,^2,3 and as many as one in 8 pregnancies occur in women with a disability.^3–5 Women with disabilities experience significant social and health disparities, including high rates of poverty and chronic illness,^6–10 and are at higher risk than their non-disabled counterparts for pregnancy and delivery complications.¹¹

The postpartum period is a time of significant physiological and psychological changes for new mothers. In the general population, up to 25% of women seek care in an emergency department^12–14 and 1–2% are admitted to the hospital^14,15 postnatally for urgent obstetric complications, exacerbation of underlying chronic disease, and psychiatric crises, with these issues sometimes resulting from inadequate outpatient access to routine care.¹⁵ Postpartum acute care use reflects serious and potentially avoidable morbidity and is associated with high health care costs, family burden, and interruption of maternal-infant bonding and breastfeeding.^12–15 As such, identification of high-risk groups is an important priority.

Social marginalization and medical complexity are known risk factors for postpartum emergency department visits and hospital admissions.^12–15 However, few population-based studies have examined the impact of maternal disability on postpartum acute care use. Existing studies suggest that, compared to women without disabilities, those with any disability¹⁶ or intellectual/developmental disabilities^17–19 have higher rates of emergency department visits and hospital admissions within 6 weeks to 2 years postpartum. No studies have examined postpartum acute care use across groups with different disabilities within a single population, and few have examined short- and long-term medical and psychiatric acute care use separately. Such empirical evidence is necessary to inform creation, implementation, and evaluation of responsive post-delivery care for diverse groups of women.

We examined the risk of emergency department visits and hospital admissions within 365 days of delivery hospitalization discharge among women with physical, sensory, intellectual/developmental, and multiple disabilities, compared to women without disabilities. We further examined the risk of each outcome by primary diagnosis (medical, psychiatric) and postpartum timing (0–7, 8–42, 43–365 days postpartum).

MATERIALS AND METHODS

Study design and data sources

This population-based cohort study used linked health administrative datasets accessed and analyzed at ICES (Toronto, Ontario), which houses health and demographic data for Ontario, Canada’s 14.7 million residents. Health care services are provided at no direct cost. Participants were identified using the MOMBABY dataset, which holds records for hospital births (i.e., 98% of Ontario births: ~140,000 per year). MOMBABY was linked using unique encoded identifiers with the Canadian Institute for Health Information Discharge Abstract Database, Ontario Mental Health Reporting System, National Ambulatory Care Reporting System, Ontario Health Insurance Plan dataset, Registered Persons Database, and Ontario portion of the Immigration, Refugees, and Citizenship Canada Permanent Residents Database (Table S1). ICES data are complete and valid, with <3% missingness, and with primary diagnoses showing 74%−96% agreement with chart reabstraction.²⁰ ICES is a prescribed entity under Ontario’s Personal Health Information Protection Act (PHIPA). Section 45 of PHIPA authorizes ICES to collect personal health information, without consent, for analysis or compiling statistical information with respect to the management of, evaluation or monitoring of, the allocation of resources to or planning for all or part of the health system. Projects that use data collected by ICES under section 45 of PHIPA, and use no other data, are exempt from research ethics board review. The use of the data was authorized under section 45 and approved by ICES’ Privacy and Legal Office.

Study population

We identified women aged 15 to 49 years with singleton live or stillbirths conceived between April 1, 2003 and March 31, 2019. We used disability definitions from established algorithms for ascertaining disability in administrative data.^21,22 Included codes were those confirmed by 13 clinicians with disability expertise as resulting in functional limitations²³ and defined as chronic.²⁴ Physical disabilities were congenital anomalies, musculoskeletal disorders, neurological disorders, and permanent injuries. Sensory disabilities were hearing and vision loss. Intellectual/developmental disabilities were autism spectrum disorder, chromosomal anomalies resulting in intellectual disability, fetal alcohol spectrum disorder, and intellectual disability.²⁵ A disability was present if a diagnosis was found in ≥2 physician visit records or ≥1 emergency department visit records or hospital admission records from database inception to conception.²⁶ (For physician visits, ≥2 records were required since a single visit might indicate assessment rather than diagnosis.) Women with multiple disabilities (diagnoses in ≥2 of the above categories) were analyzed as a separate category. Non-disabled women were the comparator.

Outcomes

In Ontario, routine postpartum care occurs at 6 weeks after delivery.²⁷ However, the physiological and psychological postpartum transition extends well beyond this time.²⁸ Thus, our primary outcomes were (1) any emergency department visit without admission and (2) any hospital admission between 0 and 365 days after delivery hospitalization discharge. As secondary outcomes, we further classified these encounters by both (a) primary discharge diagnosis, as medical or psychiatric (ICD-10 F-codes, or admission in institutions with mental health beds), and (b) timing, from 0–7, 8–42, and 43–365 days after delivery hospitalization discharge, corresponding to the early, late, and extended postpartum periods, respectively.^28,29

Covariates

We measured maternal age, parity, and disparities experienced by disabled women.^6–10 Neighborhood income quintile was determined by linking Census dissemination area-level income data with postal codes. Rurality was measured using the Rurality Index of Ontario.³⁰ Immigrants, refugees, and long-term residents (i.e., born in Ontario or immigrated to Ontario before 1985) were identified using the Immigrants, Refugees, and Citizenship Canada Permanent Residents Database. Chronic conditions were measured using the Johns Hopkins Adjusted Clinical Groups (ACG)^® System version 10 collapsed ambulatory diagnostic groups, which classify conditions as stable or unstable based on severity and specialty care over time.³¹ Type 1 and type 2 diabetes,³² chronic hypertension,³³ and cardiovascular disease^34–37 diagnosed before conception were ascertained using validated disease registries. Mental illness and substance use disorders were ascertained using ≥2 physician visits or ≥1 emergency department visits or hospital admissions within 2 years before conception. Type of physician providing the majority of prenatal care was classified as obstetrician, family physician, shared care, and other/none. In additional analyses, we considered factors that could explain increased risk for postpartum acute care use in women with disabilities: pre-pregnancy acute care use (emergency department visits and hospital admissions in the year before conception), pregnancy complications (gestational diabetes, gestational hypertension, preeclampsia, venous thromboembolism, or severe maternal morbidity³⁸), delivery mode (cesarean or vaginal birth), and delivery hospitalization length of stay (≤2 and ≤3 vs. >2 and >3 days for vaginal and cesarean deliveries, respectively).³⁹

Analyses

We described baseline characteristics of women with and without disabilities using frequencies and percentages and compared them using standardized differences.⁴⁰ We used modified Poisson regression⁴¹ to estimate relative risks (RR) and 95% confidence intervals (CI) for (1) any emergency department visit, (2) any hospital admission from 0–365 days postpartum, and (3) medical and psychiatric emergency department visits and hospital admissions from 0–7, 8–42, and 43–365 days postpartum separately, comparing each disability group to women without disabilities. Generalized estimating equations accounted for inclusion of more than one birth per woman during the study period.⁴² We also used generalized ordered logistic regression to compare the odds of ≥1 (vs. 0), ≥2 (vs. ≤1), and ≥3 (vs. ≤2) emergency department visits and hospital admissions from 0–365 days postpartum, in each disability group to women without disabilities. Multivariable models included age, parity, income quintile, rural residence, immigrant/refugee status, chronic medical conditions, mental illness, substance use disorders, and prenatal care provider type; covariates were assessed for collinearity before analysis.

We also (1) described the three most prevalent medical and psychiatric discharge diagnoses in emergency department visits and hospital admissions at 0–42 and 43–365 days postpartum; (2) identified the percentages of all emergency department visits and hospital admissions occurring in each specific week; (3) described the cumulative length of hospital stay across all admissions; (4) stratified models examining any emergency department visit and any hospital admission from 0–365 days postpartum by pre-pregnancy acute care use, presence of pregnancy complications, delivery mode, and delivery hospitalization length of stay; and (5) assessed the risk of any emergency department visit and any hospital admission from 0–365 days postpartum by disability diagnosis. Analyses used SAS 9.4 (SAS Institute Inc., Cary, NC).

RESULTS

There were 155,500 women with physical, 49,338 with sensory, 2,650 with intellectual/developmental, and 9,904 with multiple disabilities, and 1,701,574 women without disabilities. Compared to women without disabilities, women with intellectual/developmental disabilities were younger and more likely to live in low-income neighborhoods, while all disability groups were less likely to be immigrants/refugees. With few exceptions, women with disabilities were more likely to have type 1 or type 2 diabetes, chronic hypertension or cardiovascular disease, stable/unstable chronic conditions, mental illness, and substance use disorders (Table 1).

Table 1. Baseline characteristics of 15 to 49-year-old women with a physical, sensory, intellectual/developmental, or multiple disabilities, and those without a recognized disability, who had a singleton obstetrical delivery in Ontario, Canada, 2003–2019.

Data presented as n (%).

	Physical disability only	Sensory disability only	Intellectual/developmental disability only	Multiple disabilities	No disability
Variablea	N=155,500	N=49,338	N=2,650	N=9,904	N=1,701,574
Age, years
15–24	27,368 (17.6)	11,067 (22.4)	1,200 (45.3)	2,379 (24.0)	295,091 (17.3)
25–34	96,328 (61.9)	28,900 (58.6)	1,147 (43.3)	5,541 (55.9)	1,095,614 (64.4)
35–49	31,804 (20.5)	9,371 (19.0)	303 (11.4)	1,984 (20.0)	310,869 (18.3)
Multiparous	90,481 (58.2)	26,905 (54.5)	1,481 (55.9)	5,546 (56.0)	971,917 (57.1)
Neighborhood income quintile (Q)
Q1 (lowest)	33,288 (21.4)	10,854 (22.0)	1,008 (38.0)	2,567 (25.9)	374,994 (22.0)
Q2	30,951 (19.9)	10,030 (20.3)	578 (21.8)	2,066 (20.9)	342,421 (20.1)
Q3	31,619 (20.3)	10,100 (20.5)	446 (16.8)	1,972 (19.9)	348,980 (20.5)
Q4	32,689 (21.0)	10,299 (20.9)	314 (11.8)	1,822 (18.4)	350,618 (20.6)
Q5 (highest)	26,236 (16.9)	7,887 (16.0)	284 (10.7)	1,435 (14.5)	277,929 (16.3)
Missing	717 (0.5)	168 (0.3)	20 (0.8)	42 (0.4)	6,632 (0.4)
Rural region of residence	8,912 (5.7)	2,175 (4.4)	152 (5.7)	569 (5.7)	71,054 (4.2)
Immigrant or refugee	18,326 (11.8)	7,401 (15.0)	176 (6.6)	874 (8.8)	450,714 (26.5)
Stable chronic conditions	42,856 (27.6)	12,794 (25.9)	658 (24.8)	3,217 (32.5)	390,993 (23.0)
Unstable chronic conditions	25,554 (16.4)	7,307 (14.8)	408 (15.4)	2,228 (22.5)	196,105 (11.5)
Type 1 or type 2 diabetes	3,997 (2.6)	1,516 (3.1)	77 (2.9)	527 (5.3)	26,341 (1.5)
Chronic hypertension or cardiovascular disease	5,817 (3.7)	1,555 (3.2)	46 (1.7)	525 (5.3)	38,770 (2.3)
Mental illness	30,181 (19.4)	8,462 (17.2)	1,067 (40.3)	2,657 (26.8)	212,517 (12.5)
Substance use disorder	3,073 (2.0)	602 (1.2)	217 (8.2)	360 (3.6)	15,318 (0.9)
Type of prenatal care provider
Obstetrician only	19,726 (12.7)	6,401 (13.0)	430 (16.2)	1,408 (14.2)	182,853 (10.7)
Family physician only	32,279 (20.8)	9,738 (19.7)	510 (19.2)	1,902 (19.2)	363,738 (21.4)
Shared care	49,977 (32.1)	15,925 (32.3)	939 (35.4)	3,714 (37.5)	511,129 (30.0)
None/unknown	53,518 (34.4)	17,274 (35.0)	771 (29.1)	2,880 (29.1)	643,854 (37.8)
Acute care use ≤1 year before pregnancy
Any emergency department visit	21,485 (13.8)	5,840 (11.8)	691 (26.1)	1,715 (17.3)	191,268 (11.2)
Any hospital admission	64,191 (41.3)	18,177 (36.8)	1,549 (58.5)	4,986 (50.3)	486,503 (28.6)
Any pregnancy complicationb	16,757 (10.8)	5,230 (10.6)	230 (8.7)	1,208 (12.2)	163,313 (9.6)
Cesarean delivery	47,452 (30.5)	14,429 (29.2)	717 (27.1)	3,379 (34.1)	466,355 (27.4)
Extended length of delivery hospital stayc	31,204 (20.1)	9,163 (18.6)	683 (25.8)	2,345 (23.7)	296,828 (17.4)

^aData presented in bold have standardized differences > 0.10 vs. women with no disability.

^bAny pregnancy complication includes gestational diabetes, gestational hypertension, preeclampsia/eclampsia, venous thromboembolism, and/or severe maternal morbidity.

^c>2 and >3 days for vaginal and caesarean deliveries, respectively

Any postpartum emergency department visit occurred in 23.5% of women without a disability, with risks elevated in women with physical (32.9%, aRR 1.27, 95% CI 1.26–1.28), sensory (30.0%, aRR 1.16, 95% CI 1.15–1.18), intellectual/developmental (48.8%, aRR 1.38, 95% CI 1.33–1.44), and multiple disabilities (42.0%, aRR 1.44, 95% CI 1.41–1.48) (Table 2). When this outcome was classified by diagnosis and timing, women with disabilities remained at elevated risk (Figure 1). Likewise, they were at elevated risk of multiple emergency department visits (Figure 2). The most prevalent diagnoses for medical emergency department visits at 0–42 days were similar across groups and were postpartum hemorrhage, other puerperal infections, and complications of the puerperium not elsewhere classified; the most prevalent at 43–365 days were abdominal and pelvic pain, disorders of the urinary system, and pain in the throat and chest. The most prevalent diagnoses for psychiatric emergency department visits at 0–42 and 43–365 days were similar across groups and were anxiety disorders, reaction to severe stress and adjustment disorders, and mental and behavioral disorders associated with the puerperium not elsewhere classified (Table S2). In all groups, the largest percentages of all emergency department visits occurred within the first two weeks after delivery discharge, with a high proportion extending to 7–8 weeks, and fewer visits after that (Figure S1).

Table 2.

Risk of any emergency department visit or any hospital admission between 0 and 365 days postpartum, in women with a disability, compared to women without any recognized disability.

Disability type	Number (%) with outcome	Unadjusted RR (95% CI)	Adjusted RR (95% CI)a
Any emergency department visit, 0–365 days postpartum
No disability (N=1,701,574)	399,834 (23.5)	1.00 (Referent)	1.00 (Referent)
Physical only (N=155,500)	51,160 (32.9)	1.38 (1.37–1.40)	1.27 (1.26–1.28)
Sensory only (N=49,338)	14,797 (30.0)	1.27 (1.25–1.28)	1.16 (1.15–1.18)
Intellectual/developmental only (N=2,650)	1,293 (48.8)	2.02 (1.93–2.12)	1.38 (1.33–1.44)
Multiple (N=9,904)	4,164 (42.0)	1.75 (1.71–1.80)	1.44 (1.41–1.48)
Any hospital admission, 0–365 days postpartum
No disability (N=1,701,574)	51,714 (3.0)	1.00 (Referent)	1.00 (Referent)
Physical only (N=155,500)	7,425 (4.8)	1.57 (1.53–1.61)	1.37 (1.34–1.40)
Sensory only (N=49,338)	1,976 (4.0)	1.33 (1.27–1.39)	1.19 (1.14–1.24)
Intellectual/developmental only (N=2,650)	255 (9.6)	3.03 (2.67–3.44)	1.96 (1.73–2.21)
Multiple (N=9,904)	719 (7.3)	2.40 (2.22–2.59)	1.77 (1.64–1.90)

^aAdjusted for maternal age, parity, neighborhood income quintile, region of residence, immigrant/refugee status, stable and unstable chronic conditions, type 1 or type 2 diabetes, chronic hypertension or cardiovascular disease, mental illness, substance use disorders, and type of prenatal care provider.

Figure 1. Risk of (a) medical and (b) psychiatric emergency department visits, by timing, in women with a disability, compared to women without any recognized disability.

CI = confidence interval; IDD = intellectual/developmental disability; RR = relative risk. Adjusted model includes maternal age, parity, neighborhood income quintile, region of residence, immigrant/refugee status, stable and unstable chronic conditions, type 1 or type 2 diabetes, chronic hypertension or cardiovascular disease, mental illness, substance use disorders, and type of prenatal care provider.

Figure 2. Number of emergency department visits between 0 and 365 days postpartum, in women with a disability, compared to women without any recognized disability.

CI = confidence interval; IDD = intellectual/developmental disability; RR = relative risk. Adjusted model includes maternal age, parity, neighborhood income quintile, region of residence, immigrant/refugee status, stable and unstable chronic conditions, type 1 or type 2 diabetes, chronic hypertension or cardiovascular disease, mental illness, substance use disorders, and type of prenatal care provider.

Any postpartum hospital admission occurred in 3.0% of women without a disability. Compared to these women, risks were elevated in women with physical (4.8%, aRR 1.37, 95% CI 1.34–1.40), sensory (4.0%, aRR 1.19, 95% CI 1.14–1.24), intellectual/developmental (9.6%, aRR 1.96, 95% CI 1.73–2.21), and multiple disabilities (7.3% aRR 1.77, 95% CI 1.64–1.90) (Table 2). When this outcome was classified by primary discharge diagnosis and timing, women with disabilities remained at elevated risk (Figure 3). They were also at elevated risk of multiple hospital admissions of all types (Figure 4). The most prevalent diagnoses for medical hospital admissions at 0–42 days postpartum were similar across groups and were postpartum hemorrhage, puerperal sepsis, and other puerperal infections, whereas the most prevalent at 43–365 days were cholelithiasis, acute appendicitis, and abdominal and pelvic pain. The most prevalent diagnoses for psychiatric hospital admissions at 0–42 and 43–365 days were similar across groups and were bipolar affective disorder, depressive episode, and reaction to severe stress and adjustment disorders (Table S3). In all groups, the largest percentages of all hospital admissions occurred within the first two weeks after delivery discharge, with a high proportion extending to 7–8 weeks, and fewer admissions after that (Figure S2). Cumulative length of stay was highest in women with intellectual/developmental and multiple disabilities (Table S4).

Figure 3. Risk of (a) medical and (b) psychiatric hospital admissions, by timing, in women with a disability, compared to women without any recognized disability.

CI = confidence interval; IDD = intellectual/developmental disability; RR = relative risk. Adjusted model includes maternal age, parity, neighborhood income quintile, region of residence, immigrant/refugee status, stable and unstable chronic conditions, type 1 or type 2 diabetes, chronic hypertension or cardiovascular disease, mental illness, substance use disorders, and type of prenatal care provider.

Figure 4. Number of hospital admissions between 0 and 365 days postpartum, in women with a disability, compared to women without any recognized disability.

CI = confidence interval; IDD = intellectual/developmental disability; RR = relative risk. Adjusted model includes maternal age, parity, neighborhood income quintile, region of residence, immigrant/refugee status, stable and unstable chronic conditions, type 1 or type 2 diabetes, chronic hypertension or cardiovascular disease, mental illness, substance use disorders, and type of prenatal care provider.

Risks for emergency department visits (Table S5) and hospital admissions (Table S6) remained elevated in women with disabilities after stratification by pre-pregnancy acute care use, pregnancy complications, delivery mode, and length of delivery hospitalization stay. Finally, risks of the outcomes were elevated across all disability diagnoses (Table S7).

COMMENT

Principal findings

In this Ontario population-based study, women with disabilities were at elevated risk for emergency department visits and hospital admissions for medical and psychiatric reasons across the first year postpartum. Risks were especially high for women with intellectual/developmental and multiple disabilities, particularly for psychiatric acute care. While patterns were similar across women with and without disabilities in terms of the most common diagnoses and temporal distribution of acute care across the postpartum period, women with disabilities showed marked risks for acute care use, and for multiple such encounters, that were robust to adjustment, stratification by pre-pregnancy acute care use, pregnancy complications, delivery mode, and length of delivery hospitalization stay, and in analyses by disability diagnosis.

Results in the context of what is known

Our results are consistent with existing research on this topic. A US study of Medicaid recipients found women with disabilities were more likely than their peers to be re-hospitalized within 3 months of delivery discharge.¹⁶ A US study of the Pregnancy to Early Life Longitudinal Data System found women with intellectual/developmental disabilities had elevated risk of emergency department visits at 1–42, 43–90, and 91–365 days, and hospitalization at 1–42 and 91–365 days.¹⁷ In contrast, a US study of Washington State administrative data found no increased risk for hospitalization for women with intellectual/developmental disabilities within 2 years of delivery.¹⁹ Prior Ontario research found women with intellectual/developmental disabilities were at elevated risk for emergency department visits and hospital readmission within 6 weeks of delivery.¹⁹ Our top reasons for acute care use are consistent with prior Canadian research,⁴³ but baseline hospital admission rates (3.0%)^14,15 and emergency department visit rates (23.5%)^12–14 were toward the higher end of the reported range; this may be because we followed women to the end of the first year postpartum, rather than the shorter follow-ups in many prior studies. Our study makes an important contribution by identifying increased risk for medical and psychiatric acute care use across the entire postpartum year in women with different types of disabilities, in a universal health care system where outpatient care with a physician is provided at no cost.

Clinical implications

As part of efforts to de-medicalize childbirth and minimize health care costs, women in Ontario receive little routine obstetric care postnatally, with only one obstetric visit at 6 weeks postpartum²⁷ based on the traditionally defined “puerperium” which assumes most physiological and psychological changes related to pregnancy have resolved by this time.⁴⁴ US postpartum care models are shifting toward extended postpartum care;⁴⁵ such changes would be useful in Canada for women with disabilities and other populations. Indeed, our findings of elevated acute care use across the first year postpartum in women with disabilities show the need to restructure their care. Starting in prenatally, anticipatory guidance should be used to develop a postpartum care plan.⁴⁶ Such guidance should include planning for disability-related supports needed postpartum (e.g., adaptive equipment, specialized services). Women with disabilities may benefit from longer delivery stays for better physical recovery and coordination of post-discharge support.⁴⁷ The high number of acute care encounters within 6 weeks in women with disabilities suggests the need for enhanced early follow-up, with attention to factors that might increase risk of complications, including poverty and physical and mental illness. Continued acute care use after 6 weeks, although for general medical and psychiatric rather than obstetric reasons, shows the need to extend care beyond 6 weeks. This care might use more frequent office visits, nurse home visits,⁴⁸ or telephone calls,⁴⁹ or be organized with pediatricians who see women during well-baby visits and can assist with care such as depression screening.⁵⁰ Midwifery models, which provide more frequent and extended postpartum care—often at home where disabled women would need fewer accommodations—may be useful examples. Finally, a transition plan to shift care from obstetrical to primary and disability providers should be in place early to ensure care continuity.

Research implications

We hypothesized women with disabilities would have elevated risks of postpartum acute care use due to social marginalization, pre-pregnancy medical and psychiatric morbidity, and pregnancy risks. Risks of acute care use in women with disabilities persisted after accounting for these factors. Other factors may also explain results and should be a priority for future research. Elevated risks of medical acute care, in early postpartum, could reflect a difficult physiological recovery from childbirth for women with disabilities,⁵¹ while psychiatric acute care could reflect stressors such as chronic stigma, marginalization, and fears about child welfare involvement.⁵² Women with disabilities report barriers navigating the health care system, including inaccessible spaces, communication difficulties, negative provider attitudes, and inadequate information,^53–57 with low satisfaction with postpartum care reported by women with disabilities.^56,58 These issues may result in delays recognizing complications, leading to more severe complications than if symptoms had been managed earlier. Our findings could reflect higher pre-pregnancy acute care use in this population;⁵⁹ however, risks were elevated even in those without pre-pregnancy acute care use. Our findings show the need for better postpartum care for women with disabilities.

Strengths and limitations

Strengths include our large, population-based cohort. However, use of diagnoses to ascertain disability reflects a medical model of disability and does not capture the influence of the environment on women’s lived experience.⁵⁹ While we searched for disabilty diagnoses since database inception—a strength over US studies which are confined to diagnoses in the birth record—disability status may have been misclassified if providers did not record diagnoses, or if women did not access health care for their disability. Such errors would introduce conservative biases whereby fewer women would be classified as having disabilities than actually did. On the other hand, frequent medical care seekers would be more likely to be diagnosed with a disability; if such care-seeking also related to postpartum acute care use, this could bias results toward the differences in outcomes we observed. Confounding may also affect our findings. We could not capture data on race/ethnicity, lifestyle factors such as smoking, the presence of other supports, or medical care quality, which could affect risk of acute care. Finally, findings are only representative of women with a singleton birth and not those with multiple births.

Conclusions

Our findings suggest the need to restructure postpartum care for women with disabilities, including providing enhanced and extended postpartum follow-up.

AJOG at a glance:

1. Why was this study conducted?

   • Postpartum acute care use reflects serious morbidity and is associated with high health care costs and family burden, but acute care use among women with disabilities in the postpartum period has been minimally studied.
2. What are the key findings?

   • Women with physical, sensory, intellectual/developmental, and multiple disabilities were at increased risk for postpartum emergency department visits and hospital admissions compared to those without disabilities; results were consistent by primary diagnosis and timing in the postpartum period.
3. What does this study add to what is already known?

   • Increasing evidence suggests women with disabilities are at elevated risk for pregnancy and delivery complications; our data show that such risks extend across the postpartum period, demonstrating the need for enhanced and extended postpartum follow-up.