Prevalence of the number of pre-gestational diagnoses and trends in the United States in 2006 and 2016

A Latent Class Analysis of Pre-Pregnancy Multimorbidity Patterns in a Delivery Cohort at a Safety-Net Hospital

Background: Multimorbidity affects approximately 1 in 3 adults and is associated with adverse health outcomes. However, there is a paucity of information describing patterns of multimorbidity among the birthing population. The objective of this study was to describe the clustering of pre-pregnancy chronic conditions in the birthing population by age, race and ethnicity, insurance status, and parity using latent class analysis (LCA). Study design: We conducted a retrospective cohort study of deliveries using medical record data between 2015 and 2019. Multimorbidity was defined as having at least two chronic conditions before the start of the index pregnancy, using adapted versions of obstetric comorbidity indices. The final LCA model was selected based on clinical interpretability and statistical fit. We also compared the distribution of sociodemographic factors across classes. Results: Of 6,455 deliveries, 1,870 (29%) deliveries were to patients with multimorbidity. LCA resulted in a 3-class model: Class 1 (45% of individuals with multimorbidity) was characterized by mood/anxiety and substance use disorders; class 2 (39%) was defined by body mass index ≥30 kg/m2 and chronic hypertension; and class 3 (16%) was characterized by reproductive conditions and infertility. Individuals who were <25 years or non-Hispanic White were more frequently in class 1; individuals who were ≥35 years or non-Hispanic Black were disproportionately in class 2. Nulliparas and individuals with private insurance were more frequently in class 3. Conclusion: Multimorbidity is prevalent in pregnancy and distinct chronic condition clusters vary across sociodemographic sub-groups, demonstrating the need for integrative approaches to periconceptional care for birthing individuals with multimorbidity.

Pregnancy with multiple high-risk factors: a systematic review and meta-analysis

Background

A wide spectrum of high-risk factors in pregnancy can lead to adverse pregnancy outcomes or short- or long-term health effects. Despite this, there has been no synthesis of findings on the measurement, potential causes, and health outcomes of multiple high-risk factors in pregnancy (MHFP). We aimed to address this gap by summarising the existing research on this topic.

Methods

We retrieved studies published up to 3 June 2024 through systematic database searches and used a narrative synthesis approach to summarise the measurement, patterns, causes, and outcomes of MHFP. We also estimated the pooled MHFP prevalence through meta-analysis with a random effects model and performed subgroup analyses and meta-regression to examine potential sources of between-study heterogeneity.

Results

We included 83 observational studies published between 2010 and 2024, of which 72% were from high-income countries. These studied factors can be grouped into four categories: physical conditions, mental conditions, sociobehavioural problems, and pregnancy history. We identified 16 MHFP patterns, among which co-existing multiple physical conditions were the most common pattern. The overall pooled prevalence of MHFP was 12% (95% confidence interval (CI) = 12-13), with an increasing trend and relatively higher levels in low- and middle-income countries (LMICs). We observed heterogeneity in the measurement of MHFP across the studies, possibly due to the number of risk factors in the definition of MHFP. About 78% of included studies investigated MHFP-associated health outcomes for women and offspring, with only two studies examining long-term maternal or offspring outcomes later in life.

Conclusions

Research into MHFP has been emerging over the past decade, but is far from complete. The burden of MHFP is increasing worldwide, particularly LMICs. Maternal healthcare systems must shift to a multidisciplinary and integrated framework so as to better design and implement prevention and intervention programmes and sustain the healthy development of the next generation.

Registration

PROSPERO: CRD42022358889.

The development of a core outcome set for studies of pregnant women with multimorbidity

BACKGROUND

Heterogeneity in reported outcomes can limit the synthesis of research evidence. A core outcome set informs what outcomes are important and should be measured as a minimum in all future studies. We report the development of a core outcome set applicable to observational and interventional studies of pregnant women with multimorbidity.

METHODS

We developed the core outcome set in four stages: (i) a systematic literature search, (ii) three focus groups with UK stakeholders, (iii) two rounds of Delphi surveys with international stakeholders and (iv) two international virtual consensus meetings. Stakeholders included women with multimorbidity and experience of pregnancy in the last 5 years, or are planning a pregnancy, their partners, health or social care professionals and researchers. Study adverts were shared through stakeholder charities and organisations.

RESULTS

Twenty-six studies were included in the systematic literature search (2017 to 2021) reporting 185 outcomes. Thematic analysis of the focus groups added a further 28 outcomes. Two hundred and nine stakeholders completed the first Delphi survey. One hundred and sixteen stakeholders completed the second Delphi survey where 45 outcomes reached Consensus In (≥70% of all participants rating an outcome as Critically Important). Thirteen stakeholders reviewed 15 Borderline outcomes in the first consensus meeting and included seven additional outcomes. Seventeen stakeholders reviewed these 52 outcomes in a second consensus meeting, the threshold was ≥80% of all participants voting for inclusion. The final core outcome set included 11 outcomes. The five maternal outcomes were as follows: maternal death, severe maternal morbidity, change in existing long-term conditions (physical and mental), quality and experience of care and development of new mental health conditions. The six child outcomes were as follows: survival of baby, gestational age at birth, neurodevelopmental conditions/impairment, quality of life, birth weight and separation of baby from mother for health care needs.

CONCLUSIONS

Multimorbidity in pregnancy is a new and complex clinical research area. Following a rigorous process, this complexity was meaningfully reduced to a core outcome set that balances the views of a diverse stakeholder group.

Key outcomes for reporting in studies of pregnant women with multiple long-term conditions: a qualitative study

BACKGROUND

Maternal multiple long-term conditions are associated with adverse outcomes for mother and child. We conducted a qualitative study to inform a core outcome set for studies of pregnant women with multiple long-term conditions.

METHODS

Women with two or more pre-existing long-term physical or mental health conditions, who had been pregnant in the last five years or planning a pregnancy, their partners and health care professionals were eligible. Recruitment was through social media, patients and health care professionals' organisations and personal contacts. Participants who contacted the study team were purposively sampled for maximum variation. Three virtual focus groups were conducted from December 2021 to March 2022 in the United Kingdom: (i) health care professionals (n = 8), (ii) women with multiple long-term conditions (n = 6), and (iii) women with multiple long-term conditions (n = 6) and partners (n = 2). There was representation from women with 20 different physical health conditions and four mental health conditions; health care professionals from obstetrics, obstetric/maternal medicine, midwifery, neonatology, perinatal psychiatry, and general practice. Participants were asked what outcomes should be reported in all studies of pregnant women with multiple long-term conditions. Inductive thematic analysis was conducted. Outcomes identified in the focus groups were mapped to those identified in a systematic literature search in the core outcome set development.

RESULTS

The focus groups identified 63 outcomes, including maternal (n = 43), children's (n = 16) and health care utilisation (n = 4) outcomes. Twenty-eight outcomes were new when mapped to the systematic literature search. Outcomes considered important were generally similar across stakeholder groups. Women emphasised outcomes related to care processes, such as information sharing when transitioning between health care teams and stages of pregnancy (continuity of care). Both women and partners wanted to be involved in care decisions and to feel informed of the risks to the pregnancy and baby. Health care professionals additionally prioritised non-clinical outcomes, including quality of life and financial implications for the women; and longer-term outcomes, such as children's developmental outcomes.

CONCLUSIONS

The findings will inform the design of a core outcome set. Participants' experiences provided useful insights of how maternity care for pregnant women with multiple long-term conditions can be improved.

Common Combinations of Pregestational Diagnosis and Pregnancy Complications

Objective Single pregestational diagnoses have been demonstrated to be associated with pregnancy-related complications. But, the effect of multiple diagnoses is understudied. The objective of this study is to determine the most common combinations of pregestational diagnoses and to determine if specific combinations increase the risk of pregnancy-related complications. Study design We performed a cross-sectional study of the 2016 Healthcare Cost and Utilization Project's National Inpatient Sample (HCUP NIS) database. Inclusion criteria were: Diagnosis-related groups assumed to be associated with delivery, and three or fewer International Classification of Diseases, Tenth Revision (ICD-10), clinical modification codes with a prevalence greater than or equal to 0.5%, or clinically important risk factors in Bateman's co-morbidity index. Chi-squared analysis of combinations of pregestational diagnoses was performed to assess the relative risk of pregnancy-related complications. Results The 2016 database included 255,233 delivered pregnancies. The most common combinations of pregestational diagnoses involved advanced maternal age, prior cesarean delivery, obesity, and tobacco use. Most combinations did not demonstrate an increased risk for complications greater than the risk with a single diagnosis. In those with statistically significant risk, all were 3-fold or less except we noted a 4.4-fold higher risk (95% CI: 3.16-6.15) of preeclampsia in obese patients of advanced maternal age compared to patients who were only of advanced maternal age. Conclusion Our results revealed that common combinations of pregestational diagnoses, in general, do not increase the risk for common pregnancy-related complications greater than the risk with a single diagnosis. This is reassuring, given that women entering pregnancy with multiple co-morbidities are becoming more common.