Abstract and Introduction
Abstract
Objectives: Our objective was to use maternal self-reported data to estimate the prevalence of urinary tract infections, placenta disorders, and preterm rupture of the membranes (PROM) and to explore the association between these complications and race, ethnicity, and economic status.
Methods: We used data for the years 2000-2002 from the Pregnancy Risk Assessment Monitoring System (PRAMS), an ongoing survey of women with a recent live birth, to examine the prevalence of and hospitalizations for self-reported urinary tract infections, placenta disorders, and PROM and to investigate differences by maternal race, Hispanic ethnicity, and economic status. Prevalence and hospitalizations were calculated as a percent of the represented population using SUDAAN to account for the sampling design.
Results: Urinary tract infections were commonly reported, occurring in more than 17% of women during their pregnancy. Placenta disorders and PROM were each reported by approximately 6% of women. Poverty and race had independent effects on each of the pregnancy complications examined. Fewer than half of the women who experienced these pregnancy complications were hospitalized.
Conclusions: Pregnancy complications are common and not adequately measured by hospitalizations alone. Both more research and improved surveillance are needed to understand the effect of pregnancy complications on women's health and the reasons for the increased risk among poor or black women.
Introduction
The negative impact of pregnancy on women's health has traditionally been measured by maternal mortality, but interest in routinely measuring maternal morbidity and pregnancy complications is increasing. Information on pregnancy-related morbidity could enhance our understanding of both the range of effects pregnancy has on the health of women and the events preceding maternal death. Much of the research on pregnancy-related morbidity has focused on pregnancy-related hospitalizations. State and national hospital discharge data have been used to estimate antenatal hospitalizations, a hospitalization during pregnancy that does not include a delivery or pregnancy loss, and complications that occur during labor and delivery hospitalizations. Hospitalizations prior to delivery do not capture all antenatal morbidity, but they represent the most severe cases and a substantial financial and health burden to women. According to hospital discharge data, there were 10.5 antenatal hospitalizations in the United States per 100 deliveries in 1999-2000. Like other health care costs, the cost of treating pregnancy complications is rising rapidly. In California, the mean cost of each antenatal hospitalization was $2,717 in 1987 and $5,158 in 1992. Among members of a managed care organization in 1997, hospitalizations during pregnancy, including antenatal hospitalizations and prolonged hospitalizations that resulted in delivery, cost $7,696 (excluding delivery day costs) per hospitalization.
Both research studies and surveillance have shown differences in the groups of women likely to suffer pregnancy-related morbidity or mortality. Women who are African-American, aged 35 years or older, of relatively high parity, or who have 12 or fewer years of education or no prenatal care are more likely to die from pregnancy-related causes. African-American women, girls aged 14 years or younger, or women aged 40 or older, uninsured women, and those covered by Medicaid are more likely to be hospitalized for pregnancy-related morbidity.
Although hospital discharge data have provided valuable information on pregnancy-related morbidity, the number of hospitalizations per delivery is a poor measure of prevalence. This count is sensitive to changes in medical practice. For example, antenatal hospitalizations declined 29% between 1986-1987 and 1999-2000, even though pregnancy complications such as preterm birth and placenta previa, abruption, and accreta became more prevalent. In addition, complications resulting in a hospital stay that terminates after delivery are not included as antenatal complications, and consequently morbidity may be significantly underestimated. Among enlisted servicewomen who were pregnant between 1987 and 1990, 3.8% had complications that led to a sole hospitalization ending in delivery, and among managed care enrollees who were pregnant in 1997, 0.9% had one prolonged (≥4 days) hospitalization ending in delivery. Finally, the ratio of hospitalizations to deliveries may be a biased estimate of the prevalence of complications if some groups of women are less likely than others to be hospitalized for similar medical conditions. Such bias may explain why enlisted servicewomen had a higher prevalence of non-delivery hospitalizations in 1987-1990 (20.7%) than did the overall population (14.6 per 100 births) in 1986-1987.
In this study, we used maternal self-reported data to estimate the prevalence of urinary tract infections, placenta disorders, and PROM, and to explore the association between these complications and race, ethnicity, and economic status. Information on racial, ethnic, and economic differences in the prevalence of these complications may suggest other risk factors for pregnancy-related morbidity, as the association between economic status and neural tube defects suggested a nutritional deficiency in the etiology.