Vulnerable groups of birthing individuals have increasingly been the focus of perinatal research because of their increased risk of adverse birth outcomes. In particular, infants born to women of minoritized racial and ethnic groups, those residing in rural locations, and those with certain medical conditions all have increased risk of outcomes including prematurity, low birth weight status, other neonatal morbidities, and mortality.1–3 An additional population at risk, women with disabilities, have been the focus of only limited research. Previous work, albeit limited, has shown that these women are at increased risk of preterm birth and low birth weight.4 However, a comprehensive assessment of the impact of maternal disability status on other adverse neonatal outcomes has been lacking. In this issue of Pediatrics, Brown et al investigate whether different maternal disabilities are associated with increased neonatal complications using a robust population-based dataset. They demonstrate mild-to-moderate elevated risk for neonatal morbidities among infants born to women with disabilities, particularly to those women with intellectual or developmental disability and women with multiple disabilities.5
This is an important analysis using multiple linked data sources that allow for comprehensive and high-quality population-based assessments of multiple maternal characteristics and their association with neonatal outcomes. After controlling for maternal factors, the adjusted risk for neonatal morbidities was 11% to 54% higher and the risk for NICU admission was 9% to 73% higher across all groups of pregnant women with disabilities (physical, sensory, intellectual or developmental, or disabilities in multiple of these categories), compared to those without any documented disability. Notably, the authors also identified additional risk factors of adverse birth outcomes beyond disability; women with all forms of disability had higher rates of both mental illness and smoking in pregnancy, and those with intellectual or developmental and multiple disabilities had higher rates of substance use disorder compared to women without disability.
Although this study provides valuable, population-based information on an understudied cohort, several important factors are not included in the analysis because of lack of data and/or consideration. First, maternal birth status, that is whether women were themselves born preterm or with intrauterine growth restriction, was not included. This important characteristic is known to be associated with an intergenerational risk for adverse birth outcomes.6–8 Second, as noted by the authors, maternal race and ethnicity data were also unavailable and clearly are an important social construct requiring thoughtful consideration when assessing birth outcomes.9,10 Third, the administrative nature of this data set did not allow for inclusion of variables indicating the presence and degree of familial and community support, particularly relationship status. Given the potential need among women with disability for additional support for assistance with activities of daily living during the pre- and postnatal care periods, better understanding of support systems in place during the perinatal period is an important consideration. Fourth, smoking is a significant risk factor for preterm birth and low birth weight,11,12 and although smoking status was known, it was not included in the adjusted models. Lastly, as mentioned by the authors, this study is unable to assess the difference between quantity and quality of prenatal care received by these women. Previous studies have demonstrated inequitable receipt of prenatal care, with women with certain types of disabilities experiencing inadequate or no prenatal care.13,14 Brown et al showed that despite similar timing of initiation of care and number of prenatal visits between women with and without disabilities in this study, the quality and appropriateness of care is unknown, especially for those with limited access to care on the basis of residence location, degree of health literacy, and other contributing factors.
Overall, this study highlights the need for ongoing research to identify the barriers and facilitators to improve birth outcomes among women with disabilities. Moreover, further work is needed to identify and measure the potential additive or exponential impact of disabilities in the birthing population when combined with other known perinatal risk factors. Adapting already existing programs for the perinatal population as well as developing targeted new programs to meet the unique needs of pregnant women with disabilities will likely be needed.
An example of program adaptation worth considering is what we can learn from the “Nurse-Family Partnership” project, which begins maternal home visits early in pregnancy and continues in the postnatal period for women with identified risk factors, including young age, single-parent status, or low socioeconomic status.15,16 Historically, women with disabilities have not been a focus population of such a program and thus represent an opportunity to adapt this model of care and potentially mitigate some of the disparities demonstrated by Brown et al. The development and dissemination of effective interventions, however, will require multidisciplinary efforts from clinical research, perinatal quality improvement collaboratives, and public health initiatives. Brown et al provide an important early step in describing birth outcomes associated with this population, thus laying the groundwork for further analyses and targeted interventions.
COMPANION PAPER: A companion to this article can be found online at www.peds.org/cgi/doi/10.1542/peds.2021-055318.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.