OBJECTIVES

To assess the risk of neonatal complications among women with a disability.

METHODS

This population-based cohort study comprised all hospital singleton livebirths in Ontario, Canada from 2003 to 2018. Newborns of women with a physical (N = 144 187), sensory (N = 44 988), intellectual or developmental (N = 2207), or ≥2 disabilities (N = 8823) were each compared with 1 593 354 newborns of women without a disability. Outcomes were preterm birth <37 and <34 weeks, small for gestational age birth weight (SGA), large for gestational age birth weight, neonatal morbidity, and mortality, neonatal abstinence syndrome (NAS), and NICU admission. Relative risks were adjusted for social, health, and health care characteristics.

RESULTS

Risks for neonatal complications were elevated among newborns of women with disabilities compared with those without disabilities. Adjusted relative risks were especially high for newborns of women with an intellectual or developmental disability, including preterm birth <37 weeks (1.37, 95% confidence interval 1.19–1.58), SGA (1.37, 1.24–1.59), neonatal morbidity (1.42, 1.27–1.60), NAS (1.53, 1.12–2.08), and NICU admission (1.53, 1.40–1.67). The same was seen for newborns of women with ≥2 disabilities, including preterm birth <37 weeks (1.48, 1.39–1.59), SGA (1.13, 1.07–1.20), neonatal morbidity (1.28, 1.20–1.36), NAS (1.87, 1.57–2.23), and NICU admission (1.35, 1.29–1.42).

CONCLUSIONS

There is a mild to moderate elevated risk for complications among newborns of women with disabilities. These women may need adapted and enhanced preconception and prenatal care, and their newborns may require extra support after birth.

What’s Known on This Subject

Prior research suggests that newborns of women with disabilities are at elevated risk for preterm birth and low birth weight. Factors that might explain that relation were not accounted for therein, nor were neonatal morbidity and mortality assessed.

What This Study Adds

There is mild to moderate elevated risk for neonatal complications among newborns of women with disabilities compared with newborns of women without disabilities. Women with disabilities may need customized preconception and prenatal care, and tailored, family-centered supports for their newborns.

Advances in obstetric and newborn care have improved neonatal outcomes in industrialized countries.1,2  Yet, disparities in rates of preterm birth, small for gestational age, and neonatal morbidity and mortality persist.3,4  Such disparities are a public health challenge because of the links between adverse neonatal outcomes and long-term risks of neurodevelopmental impairment and chronic disease,5,6  and the resulting psychosocial and economic burden on families and the health care system. To address population risk factors and improve health care quality, it is imperative to improve identification of groups with disproportionate risk for adverse outcomes. There is longstanding concern about the relationship between social and structural determinants of health, and in particular, poverty and systemic racism, and adverse neonatal outcomes.3,4  However, little research and clinical attention has been paid to mothers with disabilities, who similarly experience social and structural barriers to care and other supports.

About 12% of reproductive-aged women experience a physical, sensory, or intellectual or developmental disability.7  These disabilities affect mobility, flexibility, dexterity, vision, hearing, cognition, and/or social skills.7  Over the last 2 decades, fertility rates among women with disabilities have increased,8,9  driven by medical advances and greater enforcement of the reproductive rights of people with disabilities. Several studies have shown women with disabilities are at elevated risk for pregnancy and delivery complications, including gestational diabetes mellitus, gestational hypertension, and caesarean delivery,10  paralleled by preconception socioeconomic, physical health, and mental health disparities,1117  as well as inequitable access to prenatal care.18,19  Few studies have examined newborn outcomes in women with disabilities; existing studies largely focused on preterm birth and low birth weight.20  Accordingly, there is an urgent need for a more comprehensive understanding of neonatal outcomes among women with disparate disabilities, which would inform development of effective care for mothers and newborns. Thus, we investigated neonatal complications among women with a physical, sensory, and/or intellectual or developmental disability, compared with women without a disability.

We performed a population-based cohort study in Ontario. Ontario is the largest province in Canada, with a population of 14.7 million residents and 140 000 births per year.21  Ontario has a universal health care system, wherein all primary and acute care, including care of mothers and newborns, is delivered at no direct cost. We accessed and analyzed linked health administrative datasets at ICES (Toronto, Ontario), an independent, nonprofit organization that holds medical and sociodemographic data derived from Ontario residents’ health care encounters. We used the MOMBABY dataset, derived from hospital discharge abstracts, to identify maternal-newborn records for all hospital births, which represent >98% of births in Ontario.21  We also used ICES data to identify all hospitalizations, emergency department visits, outpatient physician visits, immigration status, and other sociodemographic characteristics (Table 1). Datasets were linked using a unique encoded identifier. ICES datasets are accurate and complete for primary hospital diagnoses, recorded using International Classification of Diseases and Related Health Problems 10th revision or Diagnostic and Statistical Manual of Mental Disorders fourth edition codes; outpatient physician diagnoses, recorded using billing claims codes; and sociodemographic data.22  The use of data for this study was authorized under section 45 of Ontario’s Personal Health Information Protection Act, which does not require review by a Research Ethics Board.

TABLE 1

Details of Health Administrative Data Sources

Data SourceConstructCoding StructureInception
Canadian Institute for Health Information Discharge Abstract Database Hospital admissions, including those for maternal-newborn records (MOMBABY) Canadian Coding Standards for the International Classification of Diseases and Related Health Problems codes for diagnoses 1988 
Immigration, Refugees, and Citizenship Canada Permanent Residents Database Immigrant and refugee status NA 1985 
National Ambulatory Care Reporting System Emergency department visits Canadian Coding Standards for the International Classification of Diseases and Related Health Problems codes for diagnoses and Canadian Classification of Health Interventions codes for procedures 2000 
Ontario Health Insurance Database Outpatient physician visits Physician billing codes 1991 
Ontario Mental Health Reporting System Psychiatric hospital admissions Diagnostic and Statistical Manual of Mental Disorders 2005 
Registered Persons Database Sociodemographic data, via linkage with Census NA 1991 
Data SourceConstructCoding StructureInception
Canadian Institute for Health Information Discharge Abstract Database Hospital admissions, including those for maternal-newborn records (MOMBABY) Canadian Coding Standards for the International Classification of Diseases and Related Health Problems codes for diagnoses 1988 
Immigration, Refugees, and Citizenship Canada Permanent Residents Database Immigrant and refugee status NA 1985 
National Ambulatory Care Reporting System Emergency department visits Canadian Coding Standards for the International Classification of Diseases and Related Health Problems codes for diagnoses and Canadian Classification of Health Interventions codes for procedures 2000 
Ontario Health Insurance Database Outpatient physician visits Physician billing codes 1991 
Ontario Mental Health Reporting System Psychiatric hospital admissions Diagnostic and Statistical Manual of Mental Disorders 2005 
Registered Persons Database Sociodemographic data, via linkage with Census NA 1991 

NA, not applicable.

We identified all singleton livebirths that were conceived between April 1, 2003 and March 31, 2018 to 15- to 49-year-old women. Maternal disability status was determined using definitions of physical, sensory, and intellectual or developmental disabilities developed from published algorithms for measuring disability in health administrative data.2325  Details have been reported previously.26  Briefly, maternal physical (ie, congenital anomaly, musculoskeletal disorder, neurologic disorder, or permanent injury), sensory (ie, hearing or vision loss), intellectual or developmental (ie, autism spectrum disorder, chromosomal or autosomal anomalies resulting in intellectual disability, or developmental disability such as fetal alcohol spectrum disorder), and multiple disabilities (diagnoses in ≥2 of these categories) were defined as being present if a relevant diagnostic code was recorded in ≥2 physician visits or ≥1 emergency department visits or hospitalizations between database inception and the pregnancy’s conception date. The estimated date of conception was back-calculated from the index birth date minus the gestational weeks at birth.27  Women without any recognized disability were the comparator.

Outcomes were indicators of birth timing, growth, and neonatal morbidity and mortality defined by the Canadian Perinatal Surveillance System,28  namely, preterm birth at <37 and <34 weeks’ gestation; small for gestational age (birth weight <10th percentile for gestational age)29 ; large for gestational age (>90th percentile)29 ; neonatal morbidity (brachial plexus injury or palsy, convulsions of the newborn, grade III or IV intraventricular hemorrhage or periventricular leukomalacia, hypoxic ischemic encephalopathy, neonatal sepsis, persistent fetal circulation or neonatal hypertension, or respiratory distress syndrome) <28 days; neonatal abstinence syndrome; NICU admission; and neonatal mortality at <28 days.

Using Misra et al’s integrated perinatal health framework,30  we measured factors related to the social determinants of health, preconception health, and health care access that reflect disparities between women with and without disabilities.1117  Maternal age and parity were derived from the MOMBABY dataset. Neighborhood income quintile was measured by linking residential postal codes with Census area-level income data. Rural residence was measured using the Rurality Index of Ontario, which is based on community characteristics such as travel time to referral centers.31  Immigrant or refugee status was determined from the Immigrants, Refugees, and Citizenship Canada Permanent Residents Database. Chronic medical conditions were measured using the Johns Hopkins Adjusted Clinical Groups (ACG) System v. 10 collapsed ambulatory diagnostic groups, which classifies nondisability conditions as stable or unstable based on acute health care patterns.32  Mental illness (ie, psychotic, mood or anxiety, or other disorders) and substance use disorders were ascertained based on ≥2 physician visits or ≥1 emergency department visits or hospital admissions less than 2 years before conception. The Revised Graduated Prenatal Care Utilization Index33  measured prenatal care adequacy based on the timing of initiation of care and number of visits and served as an indicator of health care access. In a subsample of births in 2007 to 2018 with data linkable to a clinical birth registry (the Better Outcomes Registry and Network), we measured smoking in pregnancy. Finally, we measured pregnancy complications (ie, gestational diabetes, gestational hypertension, preeclampsia and eclampsia, venous thromboembolism, or severe maternal morbidity)34  and delivery mode.

We used frequencies and percentages to describe women with physical, sensory, intellectual or developmental, and multiple disabilities and computed standardized differences to compare them to women without disabilities.35 

We employed modified Poisson regression36  to directly estimate a relative risk (RR) and 95% confidence interval (CI) for each neonatal outcome, comparing each disability group to women without disabilities. We used generalized estimating equations to account for inclusion of multiple newborns born to the same mother during the study period.37  We derived minimally adjusted models including maternal age, parity, neighborhood income quintile, rural residence, and immigrant status, and models including these variables and further adjusting for stable and unstable chronic conditions, mental illness, substance use disorders, and prenatal care adequacy.

We carried out several additional analyses. In a subsample of births in 2007 to 2018, we further adjusted models for maternal smoking. Since pregnancy and delivery complications may also affect neonatal outcomes, and are more common in women with disabilities,10  we also stratified models according to (1) the presence of pregnancy complications and (2) delivery mode. Finally, we examined neonatal outcomes according to disability subtype.

All analyses used SAS version 9.4.

From 2003 to 2018, there were 144 187 newborns delivered to women with a physical disability, 44 988 to women with a sensory disability, 2207 to women with an intellectual or developmental disability, 8823 to women with multiple disabilities, and 1 593 354 to women without any recognized disability. Compared with women without disabilities, women with intellectual or developmental disabilities were younger and more likely to live in neighborhoods in the lowest income quintile. Women with physical and multiple disabilities were more likely to have stable chronic conditions, and those with physical, intellectual or developmental, and multiple disabilities were more likely to have unstable chronic conditions. All 4 disability groups were more likely to have mental illness and to smoke, and women with intellectual or developmental and multiple disabilities were more likely to have substance use disorders (Table 2).

TABLE 2

Characteristics of 15- to 49-Year-Old Women With a Physical, Sensory, Intellectual or Developmental, or Multiple Disabilities, and Those Without a Disability, Who had a Singleton Livebirth in Ontario, Canada, 2003 to 2018

VariableaPhysical Disability Only (N = 144 187)Sensory Disability Only (N = 44 988)Intellectual or Developmental Disability Only (N = 2207)Multiple Disabilities (N = 8823)No Disability (N = 1 593 354)
Age, y      
 15–19 6132 (4.3) 2880 (6.4)a 361 (16.4)a 524 (5.9) 66 945 (4.2) 
 20–24 19 700 (13.7) 7616 (16.9)a 639 (29.0)a 1642 (18.6) 214 688 (13.5) 
 25–29 40 940 (28.4) 12 796 (28.4) 540 (24.5)a 2447 (27.7) 479 076 (30.1) 
 30–34 48 117 (33.4) 13 205 (29.4)a 399 (18.1)a 2457 (27.8) 545 561 (34.2) 
 35–39 24 157 (16.8) 6917 (15.4) 212 (9.6)a 1392 (15.8) 244 470 (15.3) 
 40–44 4876 (3.4) 1471 (3.3) 50–55d 340 (3.9) 40 807 (2.6) 
 45–49 265 (0.2) 103 (0.2) 0–5d 21 (0.2) 1807 (0.1) 
 Multiparous 83 978 (58.2) 24 474 (54.4) 1245 (56.4) 4930 (55.9) 909 992 (57.1) 
Neighborhood income quintile (Q)      
 Q1 (lowest) 30 815 (21.4) 9977 (22.2) 830 (37.6)a 2280 (25.8) 351 228 (22.0) 
 Q2 28 717 (19.9) 9101 (20.2) 482 (21.8) 1784 (20.2) 320 726 (20.1) 
 Q3 29 495 (20.5) 9197 (20.4) 393 (17.8) 1747 (19.8) 326 203 (20.5) 
 Q4 30 418 (21.1) 9331 (20.7) 265 (12.0)a 1676 (19.0) 328 279 (20.6) 
 Q5 (highest) 24 132 (16.7) 7243 (16.1) 220 (10.0)a 1306 (14.8) 260 871 (16.4) 
 Missing 610 (0.4) 139 (0.3) 17 (0.8) 30 (0.3) 6047 (0.4) 
Region of residence      
 Rural 8230 (5.7) 2002 (4.5) 112 (5.1) 497 (5.6) 66 671 (4.2) 
 Urban 133 784 (92.8) 42 473 (94.4) 2036 (92.3) 8204 (93.0) 1 506 957 (94.6) 
 Missing 2173 (1.5) 513 (1.1) 59 (2.7) 122 (1.4) 19 726 (1.2) 
Immigrant or refugee 16 899 (11.7)a 6704 (14.9)a 154 (7.0)a 769 (8.7)a 420 564 (26.4) 
Stable chronic conditions 39 708 (27.5)a 11 645 (25.9) 550 (24.9) 2842 (32.2)a 364 775 (22.9) 
Unstable chronic conditions 23 363 (16.2)a 6558 (14.6) 336 (15.2)a 1980 (22.4)a 179 780 (11.3) 
Diabetes mellitus 3606 (2.5) 1344 (3.0) 61 (2.8)a 452 (5.1)a 24 123 (1.5) 
Chronic hypertension 5214 (3.6) 1363 (3.0) 37 (1.7) 450 (5.1)a 35 775 (2.2) 
Cardiovascular disease 257 (0.2) 42 (0.1) 0–5d 37 (0.4) 790 (0.0) 
Mental illness 28 300 (19.6)a 7793 (17.3)a 831 (37.7)a 2360 (26.7)a 200 987 (12.6) 
Substance use disorder 2818 (2.0) 546 (1.2) 141 (6.4)a 301 (3.4)a 14 184 (0.9) 
Smoking in pregnancyb 17 955 (12.5)a 5177 (11.5)a 538 (24.4)a 1426 (16.2)a 128 178 (8.0) 
Inadequate prenatal care 14 421 (10.0) 4764 (10.6) 225 (10.2) 827 (9.4) 163 542 (10.3) 
Any pregnancy complicationc 18 055 (12.5) 5322 (11.8) 237 (10.7) 1313 (14.9)a 170 457 (10.7) 
Gestational diabetes 6137 (4.3) 2008 (4.5) 67 (3.0) 388 (4.4) 74 463 (4.7) 
Gestational hypertension 2447 (1.7) 727 (1.6) 23 (1.0) 152 (1.7) 22 733 (1.4) 
Preeclampsia or eclampsia 7263 (5.0) 2145 (4.8) 98 (4.4) 519 (5.9)a 61 054 (3.8) 
Venous thromboembolism 1868 (1.3) 425 (0.9) 20 (0.9) 182 (2.1)a 10 578 (0.7) 
Severe maternal morbidity 3369 (2.3) 914 (2.0) 64 (2.9) 306 (3.5) 26 665 (1.7) 
Caesarean delivery 44 035 (30.5) 13 153 (29.2) 595 (27.0) 2994 (33.9)a 436 381 (27.4) 
VariableaPhysical Disability Only (N = 144 187)Sensory Disability Only (N = 44 988)Intellectual or Developmental Disability Only (N = 2207)Multiple Disabilities (N = 8823)No Disability (N = 1 593 354)
Age, y      
 15–19 6132 (4.3) 2880 (6.4)a 361 (16.4)a 524 (5.9) 66 945 (4.2) 
 20–24 19 700 (13.7) 7616 (16.9)a 639 (29.0)a 1642 (18.6) 214 688 (13.5) 
 25–29 40 940 (28.4) 12 796 (28.4) 540 (24.5)a 2447 (27.7) 479 076 (30.1) 
 30–34 48 117 (33.4) 13 205 (29.4)a 399 (18.1)a 2457 (27.8) 545 561 (34.2) 
 35–39 24 157 (16.8) 6917 (15.4) 212 (9.6)a 1392 (15.8) 244 470 (15.3) 
 40–44 4876 (3.4) 1471 (3.3) 50–55d 340 (3.9) 40 807 (2.6) 
 45–49 265 (0.2) 103 (0.2) 0–5d 21 (0.2) 1807 (0.1) 
 Multiparous 83 978 (58.2) 24 474 (54.4) 1245 (56.4) 4930 (55.9) 909 992 (57.1) 
Neighborhood income quintile (Q)      
 Q1 (lowest) 30 815 (21.4) 9977 (22.2) 830 (37.6)a 2280 (25.8) 351 228 (22.0) 
 Q2 28 717 (19.9) 9101 (20.2) 482 (21.8) 1784 (20.2) 320 726 (20.1) 
 Q3 29 495 (20.5) 9197 (20.4) 393 (17.8) 1747 (19.8) 326 203 (20.5) 
 Q4 30 418 (21.1) 9331 (20.7) 265 (12.0)a 1676 (19.0) 328 279 (20.6) 
 Q5 (highest) 24 132 (16.7) 7243 (16.1) 220 (10.0)a 1306 (14.8) 260 871 (16.4) 
 Missing 610 (0.4) 139 (0.3) 17 (0.8) 30 (0.3) 6047 (0.4) 
Region of residence      
 Rural 8230 (5.7) 2002 (4.5) 112 (5.1) 497 (5.6) 66 671 (4.2) 
 Urban 133 784 (92.8) 42 473 (94.4) 2036 (92.3) 8204 (93.0) 1 506 957 (94.6) 
 Missing 2173 (1.5) 513 (1.1) 59 (2.7) 122 (1.4) 19 726 (1.2) 
Immigrant or refugee 16 899 (11.7)a 6704 (14.9)a 154 (7.0)a 769 (8.7)a 420 564 (26.4) 
Stable chronic conditions 39 708 (27.5)a 11 645 (25.9) 550 (24.9) 2842 (32.2)a 364 775 (22.9) 
Unstable chronic conditions 23 363 (16.2)a 6558 (14.6) 336 (15.2)a 1980 (22.4)a 179 780 (11.3) 
Diabetes mellitus 3606 (2.5) 1344 (3.0) 61 (2.8)a 452 (5.1)a 24 123 (1.5) 
Chronic hypertension 5214 (3.6) 1363 (3.0) 37 (1.7) 450 (5.1)a 35 775 (2.2) 
Cardiovascular disease 257 (0.2) 42 (0.1) 0–5d 37 (0.4) 790 (0.0) 
Mental illness 28 300 (19.6)a 7793 (17.3)a 831 (37.7)a 2360 (26.7)a 200 987 (12.6) 
Substance use disorder 2818 (2.0) 546 (1.2) 141 (6.4)a 301 (3.4)a 14 184 (0.9) 
Smoking in pregnancyb 17 955 (12.5)a 5177 (11.5)a 538 (24.4)a 1426 (16.2)a 128 178 (8.0) 
Inadequate prenatal care 14 421 (10.0) 4764 (10.6) 225 (10.2) 827 (9.4) 163 542 (10.3) 
Any pregnancy complicationc 18 055 (12.5) 5322 (11.8) 237 (10.7) 1313 (14.9)a 170 457 (10.7) 
Gestational diabetes 6137 (4.3) 2008 (4.5) 67 (3.0) 388 (4.4) 74 463 (4.7) 
Gestational hypertension 2447 (1.7) 727 (1.6) 23 (1.0) 152 (1.7) 22 733 (1.4) 
Preeclampsia or eclampsia 7263 (5.0) 2145 (4.8) 98 (4.4) 519 (5.9)a 61 054 (3.8) 
Venous thromboembolism 1868 (1.3) 425 (0.9) 20 (0.9) 182 (2.1)a 10 578 (0.7) 
Severe maternal morbidity 3369 (2.3) 914 (2.0) 64 (2.9) 306 (3.5) 26 665 (1.7) 
Caesarean delivery 44 035 (30.5) 13 153 (29.2) 595 (27.0) 2994 (33.9)a 436 381 (27.4) 

Data are presented as % unless otherwise indicated.

a

Standardized difference >0.10, comparing women within each respective disability group to women without a disability.

b

Analyses limited to births in 2007 to 2018, linkable with the Better Outcomes Registry and Network, a clinical birth registry.

c

Pregnancy complications included a composite of gestational diabetes, gestational hypertension, preeclampsia or eclampsia, venous thromboembolism, or severe maternal morbidity.

d

Values suppressed to protect patient privacy because of small cell counts <6.

With few exceptions, newborns of women with disabilities, compared with those of women without disabilities, had higher rates of preterm birth at <37 weeks (7.3%–9.9% across disability groups, versus 6.2% in newborns of women without disabilities), preterm birth at <34 weeks (1.8%–2.6%, versus 1.5%), small for gestational age (11.7%–17.0%, versus. 12.3%), and large for gestational age (7.7%–9.6%, versus 8.1%). In the fully adjusted models, newborns of women with disabilities remained more likely to be born preterm at <37 and <34 weeks’ gestation. All disability groups, except newborns of women with physical disabilities, were more likely to be small for gestational age, and all, except newborns of women with intellectual or developmental disabilities, were more likely to be large for gestational age. For all outcomes, newborns of women with intellectual or developmental and multiple disabilities had the highest risks (adjusted risk ratios ranging from 1.37–1.53, and 1.09–1.58, respectively) (Table 3).

TABLE 3

Risk of Adverse Neonatal Outcomes Related to Birth Timing and Fetal Growth in Women With a Disability Compared With Women Without Any Recognized Disability

Disability TypeNumber (%) With OutcomeUnadjusted RR (95% CI)Adjusted RR (95% CI)aAdjusted RR (95% CI)b
Preterm birth <37 wk     
 No disability (N = 1 593 354) 98 686 (6.2) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 10 996 (7.6) 1.22 (1.20–1.25)c 1.21 (1.19–1.24)c 1.18 (1.16–1.20)c 
 Sensory only (N = 44 988) 3291 (7.3) 1.18 (1.14–1.22)c 1.17 (1.13–1.21)c 1.15 (1.11–1.19)c 
 Intellectual or developmental only (N = 2207) 204 (9.2) 1.45 (1.25–1.67)c 1.49 (1.29–1.72)c 1.37 (1.19–1.58)c 
 Multiple (N = 8823) 876 (9.9) 1.59 (1.48–1.70)c 1.57 (1.47–1.68)c 1.48 (1.39–1.59)c 
Preterm birth <34 wk     
 No disability (N = 1 593 354) 24 529 (1.5) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 2704 (1.9) 1.21 (1.16–1.26)c 1.22 (1.17–1.27)c 1.19 (1.14–1.24)c 
 Sensory only (N = 44 988) 820 (1.8) 1.18 (1.10–1.27)c 1.17 (1.09–1.26)c 1.16 (1.08–1.25)c 
 Intellectual or developmental only (N = 2207) 56 (2.5) 1.60 (1.19–2.16)c 1.68 (1.24–2.26)c 1.53 (1.13–2.06)c 
 Multiple (N = 8823) 227 (2.6) 1.67 (1.46–1.91)c 1.66 (1.45–1.91)c 1.58 (1.38–1.81)c 
Small for gestational age birth weight     
 No disability (N = 1 593 354) 19 6053 (12.3) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 16 810 (11.7) 0.94 (0.93–0.96) 1.02 (1.00–1.03)c 1.01 (0.99–1.02) 
 Sensory only (N = 44 988) 5675 (12.6) 1.02 (0.99–1.04) 1.06 (1.03–1.08)c 1.05 (1.03–1.08)c 
 Intellectual or developmental only (N = 2207) 375 (17.0) 1.37 (1.24–1.51)c 1.42 (1.28–1.57)c 1.37 (1.24–1.51)c 
 Multiple (N = 8823) 1206 (13.7) 1.08 (1.02–1.15)c 1.15 (1.09–1.22)c 1.13 (1.07–1.20)c 
Large for gestational age birth weight     
 No disability (N = 1 593 354) 12 8513 (8.1) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 13 072 (9.1) 1.14 (1.11–1.16)c 1.05 (1.03–1.07)c 1.03 (1.01–1.05)c 
 Sensory only (N = 44 988) 3897 (8.7) 1.09 (1.05–1.13)c 1.05 (1.01–1.08)c 1.03 (1.00–1.07)c 
 Intellectual or developmental only (N = 2207) 169 (7.7) 0.99 (0.85–1.15) 0.91 (0.78–1.07) 0.91 (0.77–1.06) 
 Multiple (N = 8823) 842 (9.6) 1.21 (1.13–1.30)c 1.12 (1.05–1.20)c 1.09 (1.01–1.17)c 
Disability TypeNumber (%) With OutcomeUnadjusted RR (95% CI)Adjusted RR (95% CI)aAdjusted RR (95% CI)b
Preterm birth <37 wk     
 No disability (N = 1 593 354) 98 686 (6.2) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 10 996 (7.6) 1.22 (1.20–1.25)c 1.21 (1.19–1.24)c 1.18 (1.16–1.20)c 
 Sensory only (N = 44 988) 3291 (7.3) 1.18 (1.14–1.22)c 1.17 (1.13–1.21)c 1.15 (1.11–1.19)c 
 Intellectual or developmental only (N = 2207) 204 (9.2) 1.45 (1.25–1.67)c 1.49 (1.29–1.72)c 1.37 (1.19–1.58)c 
 Multiple (N = 8823) 876 (9.9) 1.59 (1.48–1.70)c 1.57 (1.47–1.68)c 1.48 (1.39–1.59)c 
Preterm birth <34 wk     
 No disability (N = 1 593 354) 24 529 (1.5) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 2704 (1.9) 1.21 (1.16–1.26)c 1.22 (1.17–1.27)c 1.19 (1.14–1.24)c 
 Sensory only (N = 44 988) 820 (1.8) 1.18 (1.10–1.27)c 1.17 (1.09–1.26)c 1.16 (1.08–1.25)c 
 Intellectual or developmental only (N = 2207) 56 (2.5) 1.60 (1.19–2.16)c 1.68 (1.24–2.26)c 1.53 (1.13–2.06)c 
 Multiple (N = 8823) 227 (2.6) 1.67 (1.46–1.91)c 1.66 (1.45–1.91)c 1.58 (1.38–1.81)c 
Small for gestational age birth weight     
 No disability (N = 1 593 354) 19 6053 (12.3) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 16 810 (11.7) 0.94 (0.93–0.96) 1.02 (1.00–1.03)c 1.01 (0.99–1.02) 
 Sensory only (N = 44 988) 5675 (12.6) 1.02 (0.99–1.04) 1.06 (1.03–1.08)c 1.05 (1.03–1.08)c 
 Intellectual or developmental only (N = 2207) 375 (17.0) 1.37 (1.24–1.51)c 1.42 (1.28–1.57)c 1.37 (1.24–1.51)c 
 Multiple (N = 8823) 1206 (13.7) 1.08 (1.02–1.15)c 1.15 (1.09–1.22)c 1.13 (1.07–1.20)c 
Large for gestational age birth weight     
 No disability (N = 1 593 354) 12 8513 (8.1) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 13 072 (9.1) 1.14 (1.11–1.16)c 1.05 (1.03–1.07)c 1.03 (1.01–1.05)c 
 Sensory only (N = 44 988) 3897 (8.7) 1.09 (1.05–1.13)c 1.05 (1.01–1.08)c 1.03 (1.00–1.07)c 
 Intellectual or developmental only (N = 2207) 169 (7.7) 0.99 (0.85–1.15) 0.91 (0.78–1.07) 0.91 (0.77–1.06) 
 Multiple (N = 8823) 842 (9.6) 1.21 (1.13–1.30)c 1.12 (1.05–1.20)c 1.09 (1.01–1.17)c 
a

Model 1 adjusts for maternal age, parity, neighborhood income quintile, rural residence, and immigrant status.

b

Model 2 further adjusts for stable chronic conditions, unstable chronic conditions, mental illness, substance use disorders, and prenatal care adequacy.

c

Identifies statistically significant RRs.

Likewise, newborns of women with disabilities, compared with those of women without disabilities, had higher rates of neonatal morbidity (8.9%–12.1%, versus 7.7%), neonatal abstinence syndrome (0.62%–2.7%, versus 0.48%), NICU admission (13.2%–20.6%, versus 11.7%), and neonatal mortality (0.22%–0.29%, versus 0.19%). In fully adjusted models, all disability groups remained at increased risk for neonatal morbidity, and all, except newborns of women with sensory disabilities, were at increased risk for neonatal abstinence syndrome. All disability groups were at increased risk for NICU admission. Risks for neonatal mortality were elevated but were nonsignificant, likely because of the small numbers for this rare but serious outcome. Again, for all outcomes, newborns of women with intellectual or developmental and multiple disabilities had the highest risks (adjusted risk ratios 1.27–1.53, and 1.28–1.87, respectively) (Table 4).

TABLE 4

Risk of Adverse Neonatal Outcomes Related to Morbidity and Mortality, in Women With a Disability, Compared With Women Without Any Recognized Disability

Disability TypeNumber (%) With OutcomeUnadjusted RR (95% CI)Adjusted RR (95% CI)aAdjusted RR (95% CI)b
Neonatal morbidity     
 No disability (N = 1 593 354) 123 396 (7.7) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 13 103 (9.1) 1.17 (1.15–1.19)c 1.16 (1.13–1.18)c 1.12 (1.10–1.14)c 
 Sensory only (N = 44 988) 3991 (8.9) 1.15 (1.11–1.18)c 1.13 (1.09–1.16)c 1.11 (1.07–1.14)c 
 Intellectual or developmental only (N = 2207) 267 (12.1) 1.55 (1.38–1.74)c 1.54 (1.37–1.73)c 1.42 (1.27–1.60)c 
 Multiple (N = 8823) 957 (10.8) 1.40 (1.32–1.49)c 1.36 (1.28–1.45)c 1.28 (1.20–1.36)c 
Neonatal abstinence syndrome     
 No disability (N = 1 593 354) 7756 (0.48) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 1926 (1.3) 2.98 (2.81–3.16)c 2.45 (2.31–2.60)c 1.78 (1.68–1.89)c 
 Sensory only (N = 44 988) 281 (0.62) 1.33 (1.16–1.53)c 1.06 (0.92–1.22) 0.99 (0.86–1.14) 
 Intellectual or developmental only (N = 2207) 60 (2.7) 6.00 (4.50–8.01)c 3.54 (2.68–4.69)c 1.53 (1.12–2.08)c 
 Multiple (N = 8823) 185 (2.1) 4.73 (4.01–5.57)c 3.47 (2.94–4.10)c 1.87 (1.57–2.23)c 
NICU admission     
 No disability (N = 1 593 354) 186 742 (11.7) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 20 233 (14.0) 1.19 (1.18–1.21)c 1.19 (1.18–1.21)c 1.14 (1.12–1.16)c 
 Sensory only (N = 44 988) 5931 (13.2) 1.12 (1.10–1.15)c 1.12 (1.09–1.15)c 1.09 (1.06–1.12)c 
 Intellectual or developmental only (N = 2207) 455 (20.6) 1.71 (1.57–1.87)c 1.73 (1.58–1.89)c 1.53 (1.40–1.67)c 
 Multiple (N = 8823) 1584 (18.0) 1.52 (1.44–1.59)c 1.49 (1.42–1.56)c 1.35 (1.29–1.42)c 
Neonatal mortality     
 No disability (N = 1 593 354) 3065 (0.19) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 318 (0.22) 1.14 (1.02–1.28)c 1.15 (1.02–1.29)c 1.12 (0.99–1.26) 
 Sensory only (N = 44 988) 100 (0.22) 1.15 (0.94–1.41)c 1.17 (0.96–1.44) 1.15 (0.94–1.41) 
 Intellectual or developmental only (N = 2207) 6 (0.27) 1.37 (0.60–3.10)c 1.38 (0.61–3.13) 1.27 (0.56–2.89) 
 Multiple (N = 8823) 26 (0.29) 1.53 (1.03–2.29)c 1.55 (1.04–2.32)c 1.46 (0.98–2.18) 
Disability TypeNumber (%) With OutcomeUnadjusted RR (95% CI)Adjusted RR (95% CI)aAdjusted RR (95% CI)b
Neonatal morbidity     
 No disability (N = 1 593 354) 123 396 (7.7) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 13 103 (9.1) 1.17 (1.15–1.19)c 1.16 (1.13–1.18)c 1.12 (1.10–1.14)c 
 Sensory only (N = 44 988) 3991 (8.9) 1.15 (1.11–1.18)c 1.13 (1.09–1.16)c 1.11 (1.07–1.14)c 
 Intellectual or developmental only (N = 2207) 267 (12.1) 1.55 (1.38–1.74)c 1.54 (1.37–1.73)c 1.42 (1.27–1.60)c 
 Multiple (N = 8823) 957 (10.8) 1.40 (1.32–1.49)c 1.36 (1.28–1.45)c 1.28 (1.20–1.36)c 
Neonatal abstinence syndrome     
 No disability (N = 1 593 354) 7756 (0.48) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 1926 (1.3) 2.98 (2.81–3.16)c 2.45 (2.31–2.60)c 1.78 (1.68–1.89)c 
 Sensory only (N = 44 988) 281 (0.62) 1.33 (1.16–1.53)c 1.06 (0.92–1.22) 0.99 (0.86–1.14) 
 Intellectual or developmental only (N = 2207) 60 (2.7) 6.00 (4.50–8.01)c 3.54 (2.68–4.69)c 1.53 (1.12–2.08)c 
 Multiple (N = 8823) 185 (2.1) 4.73 (4.01–5.57)c 3.47 (2.94–4.10)c 1.87 (1.57–2.23)c 
NICU admission     
 No disability (N = 1 593 354) 186 742 (11.7) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 20 233 (14.0) 1.19 (1.18–1.21)c 1.19 (1.18–1.21)c 1.14 (1.12–1.16)c 
 Sensory only (N = 44 988) 5931 (13.2) 1.12 (1.10–1.15)c 1.12 (1.09–1.15)c 1.09 (1.06–1.12)c 
 Intellectual or developmental only (N = 2207) 455 (20.6) 1.71 (1.57–1.87)c 1.73 (1.58–1.89)c 1.53 (1.40–1.67)c 
 Multiple (N = 8823) 1584 (18.0) 1.52 (1.44–1.59)c 1.49 (1.42–1.56)c 1.35 (1.29–1.42)c 
Neonatal mortality     
 No disability (N = 1 593 354) 3065 (0.19) 1.00 (Referent) 1.00 (Referent) 1.00 (Referent) 
 Physical only (N = 144 187) 318 (0.22) 1.14 (1.02–1.28)c 1.15 (1.02–1.29)c 1.12 (0.99–1.26) 
 Sensory only (N = 44 988) 100 (0.22) 1.15 (0.94–1.41)c 1.17 (0.96–1.44) 1.15 (0.94–1.41) 
 Intellectual or developmental only (N = 2207) 6 (0.27) 1.37 (0.60–3.10)c 1.38 (0.61–3.13) 1.27 (0.56–2.89) 
 Multiple (N = 8823) 26 (0.29) 1.53 (1.03–2.29)c 1.55 (1.04–2.32)c 1.46 (0.98–2.18) 
a

Model 1 adjusts for maternal age, parity, neighborhood income quintile, rural residence, and immigrant status.

b

Model 2 further adjusts for stable chronic conditions, unstable chronic conditions, mental illness, substance use disorders, and prenatal care adequacy.

c

Identifies statistically significant RRs.

In additional analyses, risks were slightly reduced when further adjusting for maternal smoking (Supplemental Tables 5 and 6). Some risks were attenuated among mothers who experienced pregnancy complications (Supplemental Tables 7 and 8); findings were largely consistent whether newborns were delivered by caesarean or vaginal delivery (Supplemental Tables 9 and 10). Risks were elevated across all specific disability subtypes (Supplemental Tables 11 and 12).

In this large, population-based study, we found that newborns of women with disabilities were at increased risk for a range of relatively rare neonatal complications. Elevations in risk were mild to moderate across all disability groups compared with women without a disability and were highest for newborns of women with intellectual or developmental and multiple disabilities. Risks largely remained elevated after adjustment, after stratification by the presence of delivery mode, and, to a lesser extent, pregnancy complications, and in analyses by specific subtype of disability. These findings demonstrate that, to support the best possible outcomes for all newborns, women with disabilities may benefit from enhanced preconception and prenatal care, followed by family-centered supports after birth, that are tailored to their unique needs.

A growing number of studies, mostly from the United States, have examined neonatal outcomes in women with disabilities.20  A recent meta-analysis of these studies showed higher risk of preterm birth in newborns of women with sensory (pooled unadjusted odds ratio [pOR] 1.37, 95% CI 1.27–1.48; 7 studies) and intellectual or developmental disabilities (pOR 1.76, 95% CI 1.59–1.96; 12 studies), compared with newborns of women without disabilities.20  There was also elevated risk of low birth weight in newborns of women with physical (pOR 1.81, 95% CI 1.47–2.23; 3 studies), sensory (pOR 1.36, 95% CI 1.18–1.57; 4 studies), and intellectual or developmental disabilities (pOR 1.98, 95% CI 1.50–2.61; 5 studies).20  However, most of these studies were rated as having low or moderate quality, with lack of control for confounding being the most common limitation. Moreover, few studies examined other important newborn outcomes, such as neonatal morbidity and mortality.20  Therefore, the current study adds to the literature by examining risks of a broad range of neonatal outcomes, overall and after adjusting for preexisting maternal disparities related to the social determinants of health, preconception health, and prenatal care adequacy, and after stratifying by pregnancy and delivery-related factors.

It is understood that women with disabilities are disproportionately impacted by socioeconomic disparities, physical and mental health conditions, and health behaviors, such as smoking,1117,38  and often have difficulty accessing prenatal care.18,19  They are also at elevated risk for pregnancy complications and caesarean delivery.10,26  In the general population, these factors are known predictors of neonatal complications.39,40  Observed risks of adverse outcomes in newborns of women with disabilities were partly, but not completely, explained by adjustment for prepregnancy social and health disparities and smoking in pregnancy, and stratification by pregnancy complications and caesarean delivery. This finding is an important indicator of the multifaceted nature of the observed risks, given that women with disabilities experience many known risk factors for neonatal complications.1117,38  Other unmeasured factors could also partly explain our results. At the provider and system level, women with disabilities encounter barriers to timely, coordinated, and high-quality care, including physically inaccessible care environments; communication that does not address sensory or cognitive needs; inadequate provider knowledge about disability; negative provider attitudes about disability, pregnancy, and parenting; and fragmentation of health and social services.4143  At the individual level, factors such as medication use44  could also contribute to risks for specific outcomes such as preterm birth, small for gestational age, and neonatal abstinence syndrome; however, medication use could not be measured. Future studies should examine how these factors contribute to neonatal complications in this population to improve understanding of risk attributable to modifiable provider and system-level and individual-level risk factors, and to generate targets for support.

Although most neonatal complications are rare, our findings have important implications for clinical practice. Many of the outcomes we examined, including preterm birth and small for gestational age, are preventable through better access to preconception and prenatal care.45,46  Our data suggest women with disabilities could benefit from improved access to high-quality health care before and during pregnancy that is adapted to their needs. Although women with disabilities in our cohort had similar rates of prenatal care access as those without disabilities, we had no indicators of the quality or appropriateness of that care. However, prior research has shown gaps in these areas.4143  Given high rates of chronic disease, mental illness, and smoking among these women,1417  prenatal care should emphasize chronic condition management and health promotion using accessible approaches that meet the needs of women with disabilities. Higher rates of preterm birth, neonatal morbidity, and NICU admission in newborns of women with disabilities show a need to consider the physical, communication, and other disability accommodation needs of mothers with a newborn in the NICU, as well as additional practical and emotional supports for mothers in the immediate newborn period. Post discharge, family-centered approaches to newborn care should consider barriers new mothers with disabilities may encounter, including physical inaccessibility of physician offices; hearing, vision, or cognitive-related communication barriers; cognitive difficulties related to memory and organizational skills; as well as difficulties navigating other community supports such as breastfeeding clinics.41,42  Since obstetric supports for women in Canada drop off after 6 weeks postpartum, such family-centered approaches are critical for new mothers with disabilities who are at risk for postpartum complications themselves.47,48  Finally, the structural barriers experienced by women with disabilities18,19  make it imperative for clinicians to address the social determinants of health, including poverty. All of these efforts will require robust training and resources for obstetricians, pediatricians, and other health care providers to understand the unique needs of women with disabilities.

Study strengths include the use of a large, population-based cohort, and the ability to adjust for factors related to the social determinants of health, preconception health, smoking, and health care access that prior studies have not considered.20  Several limitations must be noted. We used diagnoses to measure disability; this approach reflects a medical model of disability, and does not consider functional limitations or how the environment influences women’s lived experience of disability.49  This approach, although well-established in prior research,9,17,2326  likely conservatively biased the findings in that some women who had disabilities may not have been accurately classified—for example, if their disability was undiagnosed, or their diagnosis was not recorded. The disability groups examined represent diverse populations whose experiences may differ. Consistent with prior research,26  we conducted analyses by disability subtype, and showed findings were largely consistent in newborns of women with different disabilities within larger categories used in our main analyses. However, some heterogeneity in outcomes could exist at an even more granular level of specific disability diagnosis. We examined several outcomes, thus increasing the risk of type 1 error. However, the focus of our discussion is on the magnitude of the effects rather than their statistical significance. Unmeasured confounding may partly explain our results. For example, we had no individual-level data on socioeconomic status, nor did we have data on race and ethnicity.50  The dual impact of experiences of ableism and racism on neonatal outcomes is an important are for future research. We also had no information on pathway variables that might explain the relation between maternal disability and neonatal complications, including medication use.44  Further, our measures of prenatal care timing and number of visits could not assess care quality, including negative provider attitudes, lack of provider knowledge, and other factors that might impact quality.18,19  We also could not measure additional supports women might have received outside the health care system because of their disability. Despite these limitations, this is one of the largest and most comprehensive analyses of neonatal outcomes in women with disabilities to date.20 

This population-based cohort study found a mild to moderate elevated risk of complications in newborns of women with disabilities, with the highest risks observed in those with an intellectual or developmental disability, or with multiple disabilities. Whereas most of the observed outcomes are rare, the findings indicate a need for improved health care to prevent them. Women with disabilities may benefit from customized preconception and prenatal care, followed by tailored, family-centered supports after birth to reduce their risks. Birth outcomes and the neonatal period are important predictors of lifelong health and development,5,6  indicating improved preconception, prenatal, and neonatal care are critical for this under-served population.

Parts of this material are based on data and/or information compiled and provided by the Canadian Institute for Health Information (CIHI) and Immigration, Refugees and Citizenship Canada (IRCC) current to March 31, 2018. However, the analyses, conclusions, opinions and 358 statements expressed in the material are those of the author(s), and not necessarily those of CIHI or IRCC. This Study is based in part on data provided by Better Outcomes Registry and Network (“BORN”), part of the Children’s Hospital of Eastern Ontario. The interpretation and conclusions contained herein do not necessarily represent those of BORN Ontario.

Dr Brown undertook the conception and design of the study, the analysis and interpretation of the data, and drafting of the manuscript; Mr Chen contributed to the design of the study, undertook the analysis of the data, and critically revised the manuscript for important intellectual content; Drs Guttmann, Havercamp, Parish, Ray, Vigod, and Tarasoff contributed to the design of the study and interpretation of the data and critically revised the manuscript for important intellectual content; Dr Lunsky contributed to the conception and design of the study, the interpretation of the data, and critically revised the manuscript for important intellectual content; and all of the authors approve the final version to be published and agree to be accountable for all aspects of the work.

FUNDING: This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award 5R01HD092326. This research was undertaken, in part, thanks to funding from the Canada Research Chairs Program to Dr Hilary K. Brown. The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding; no endorsement is intended or should be inferred. The funding source had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest to disclose.

COMPANION PAPER: A Companion to this article can be found online at: www.pediatrics.org/cgi/doi/10.1542/peds.2022-058043.

     
  • CI

    confidence interval

  •  
  • pOR

    pooled unadjusted odds ratio

  •  
  • RR

    relative risk

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Supplementary data