Pregnancy
Emergency care during pregnancy could signal greater risk for severe maternal morbidity
A new study found that pregnant people in Massachusetts who made multiple unscheduled hospital visits during their pregnancy were 46 per cent more likely to experience severe maternal morbidity than those who sought limited or no emergency care during pregnancy.
Frequent hospital visits during pregnancy could be a sign that a pregnant person will encounter life-threatening complications during or after pregnancy, according to a new study led by Boston University School of Public Health (BUSPH) and Cityblock Health.
Published in JAMA Network Open, the study found that, among nearly 775,000 pregnant people in Massachusetts, 31 per cent of these individuals had at least one unscheduled emergency visit to the hospital, and 3.3 per cent had four or more unscheduled hospital visits.
The latter group was nearly 50 per cent more likely to experience severe maternal morbidity (SMM), which encompasses a range of complications during labour or childbirth that can lead to poor maternal outcomes such as aneurysms, eclampsia, kidney and heart failure, and sepsis.
Importantly, the findings also revealed that nearly half of the pregnant people who sought emergency care four or more times during their pregnancy visited multiple hospitals for evaluation. The resulting lack of consistent treatment to patients from any given hospital makes it difficult for hospital-based pregnancy programs to capture the true burden of prenatal and postpartum challenges that these patients experience.
The analysis is the first US-based assessment of an association between four or more emergency-care visits during pregnancy and risk of SMM. It builds upon a prior study by the researchers which found that 70 per cent of people who had a pregnancy-associated death during postpartum also visited a hospital between the time they gave birth and the time they were hospitalised at death.
As both SMM and maternal morbidity rates in the US remain the highest among wealthy countries, identifying these high-risk pregnant patients and understanding the extent of their prenatal health challenges can spur efforts to connect this population to other preventive care within their communities.
“When there is a poor maternal health outcome, there is a tendency to say, ‘If we only knew earlier,’” said study lead author Dr. Eugene Declercq, professor of community health sciences at BUSPH.
“Those in our study with repeated prenatal emergency visits are showing us clearly they’re at risk. Avoiding severe maternal morbidity isn’t something that only happens at the time of birth—it must start with the early identification of high-risk cases like these, followed by community-based support to avoid catastrophic outcomes for mothers and infants.”
For the study, Dr. Declercq and colleagues utilized data from a statewide database that linked unscheduled hospital visits—including trips to the emergency department as well as observational hospital stays—by 774,092 pregnant patients to births and foetal deaths in Massachusetts between October 2002 and March 2020.
About 18 per cent of patients had one emergency visit to the hospital, nearly 7 per cent had two visits, 3 per cent had 3 visits, and 3.3 had four or more visits. About 44 per cent of patients who sought emergency care four or more times during pregnancy visited more than one hospital. This group was 46 per cent more likely to experience SMM than patients who sought less emergency care and visited fewer hospitals during their pregnancy.
Patients were also more likely to seek emergency care during the first eight weeks and last eight weeks of their pregnancy.
The researchers also observed several racial, economic, and age-related disparities among the patients who used emergency care multiple times during their pregnancy. High utilization of unscheduled hospital care was most associated with women under 25 years old, Hispanic and non-Hispanic Black patients, and those who were born in the US, unmarried, or who had an additional health condition or opioid-related hospitalization in the year prior to their pregnancy. Some of these individuals have visited up to six different Massachusetts hospitals for emergency care, the researchers say.
“Our study shows for the first time that those who use the emergency room more during pregnancy are more likely to be people of colour who are at significantly higher risk of experiencing a potentially life-altering morbidity event around the time of childbirth,” said study senior author Dr. Pooja Mehta, adjunct assistant professor of obstetrics & gynecology at BU’s Chobanian & Avedisian School of Medicine and vice president of population health at Cityblock Health.
“We need to do much more than provide these individuals a follow-up prenatal visit; our actions have to be timely and address root causes and fragmentation in the system to impact the layers of structural racism that we already know contribute to maternal morbidity.”
The team hopes these findings bring attention to the high rates of emergency care visits driven by unmet needs—a public health issue that is not well documented—and encourage researchers, healthcare providers, policymakers, and reproductive health advocates to envision ways to strengthen or compensate for traditional prenatal care that falls short of meeting pregnant patients’ health needs.
Fertility
France urges 29-year-olds to start families now
France is urging 29-year-olds to have children as part of a 16-point plan to boost fertility and raise birth rates.
Health officials say the aim is to prevent men and women facing fertility problems later in life and thinking “if only I had known”.
The strategy comes as the country, like many western nations including the UK, faces tumbling birth rates.
The trend is creating concerns about how governments can fund pensions and healthcare for ageing populations with fewer younger working people paying taxes.
But policies to raise fertility rates globally have produced limited results, and critics of the scheme suggest better housing and maternity provision could be more effective.
The government will send out “targeted, balanced, and scientifically sound information” to young people on issues including sexual health and contraception.
The material “will also reiterate that fertility is a shared responsibility between women and men,” the country’s health ministry said.
The plan includes efforts to increase the number of egg-freezing centres from 40 to 70. The process involves extracting and storing a woman’s eggs for potential future use.
The country’s health system already provides free egg-freezing for people aged 29 to 37, a service that costs about £5,000 per round in the UK.
The country’s fertility rate of 1.56 children per woman is below the 2.1 needed to maintain a stable population.
However, it is higher than rates in China, Japan and South Korea, and the UK, where the latest figures show it dropped to a record low of 1.41 in England and Wales by 2024.
Professor François Gemenne, who specialises in sustainability and migration at HEC Paris Business School, told Sky News: “This is something that demographers had known for a long time, but the fact that there were more deaths than births in France last year created a shock effect.”
He said the country’s “demographic worry” is exacerbated by the design of its pensions system and its “obsession with immigration and the fear of being ‘replaced'”.
The plan also includes a new national communication campaign, a “My Fertility” website advising on the effects of smoking, weight and lifestyle, and school lessons for children about reproductive health.
The health ministry has acknowledged its maternal and infant mortality rates are higher than neighbouring countries and is beginning a review of perinatal care to address the “concerning” situation.
Channa Jayasena, professor in reproductive endocrinology at Imperial College London, told Sky News: “On the female side, societal changes leading to older age of motherhood are certainly important.
He said obesity was also a problem as it increased women’s risk of polycystic ovary syndrome and endometriosis.
Allan Pacey, professor of andrology (male reproductive health) at Manchester University, said for most people globally, deciding to have children was “down to [non-medical] factors such as better access to education, career opportunities, taxation, housing, mortgages, finance, etc.”
“Medicine can’t help with those things,” Pacey added.
Insight
Pregnancy and breastfeeding linked to higher cognitive ability in postmenopausal women
Pregnancy and breastfeeding are linked to stronger cognition in postmenopausal women, a long-term study suggests.
Greater cumulative time spent pregnant and time spent breastfeeding correlated with higher overall scores in the study, including verbal and visual memory, in later life.
Researchers analysed annual assessments of more than 7,000 women aged about 70 for up to 13 years using data from the Women’s Health Initiative Memory Study and the Women’s Health Initiative Study of Cognitive Aging.
On average, those who were pregnant for around 30.5 months were expected to have a 0.31 per cent higher global cognition score than those who had never been pregnant.
A lifetime average of 11.6 months of breastfeeding was linked to a 0.12 per cent higher global score.
Each additional month spent pregnant was associated with a 0.01-point rise in overall ability.
Each extra month of breastfeeding showed the same increase, and a 0.02-point gain in verbal and visual memory. Although small, these effects are similar to known protective factors such as not smoking and high physical activity.
The work was led by Molly Fox, an anthropology professor at the University of California, Los Angeles.
Fox said: “Any ways in which we can focus public health outreach or clinical interventions towards higher-risk populations leads to more effective and efficient efforts.”
Participants who had ever been pregnant scored, on average, 0.60 points higher than those who had never been pregnant.
Those who had breastfed scored 0.19 points higher overall and 0.27 points higher for verbal memory than those who had never breastfed.
Women are disproportionately affected by Alzheimer’s disease, a progressive condition that impairs memory and thinking skills, and this is not fully explained by life expectancy differences.
The authors say biology and social factors may both play roles.
They noted that more adult children could contribute to cognitive health by buffering stress, supporting wellbeing or encouraging healthy behaviour.
“If we can figure out, as a next step, why those reproductive patterns lead to better cognitive outcomes in old age, then we can work towards figuring out how to craft therapies, for example, new drugs, repurposed drugs or social programmes, that mimic the naturally occurring effect we observed,” said Fox.
The study team is now working to identify the mechanisms that link reproductive histories to cognitive resilience.
Pregnancy
Stroke prevention and treatment during and after pregnancy key to women’s health – AHA
Stroke prevention requires aggressive blood pressure control and rapid recognition of symptoms in pregnancy and postpartum, a new scientific statement urges.
The guidance details risk factors for pregnancy-related stroke and offers suggestions for prevention, rapid diagnosis, timely treatment and recovery during pregnancy and postpartum.
A stroke occurs in approximately 20 to 40 of every 100,000 pregnancies and is estimated to account for around four to six per cent of pregnancy-related deaths annually in the US.
The statement was published by the American Heart Association and endorsed by the American College of Obstetricians and Gynecologists.
Eliza Miller is chair of the writing group and associate professor of neurology at the University of Pittsburgh.
She said: “When a stroke occurs during pregnancy or the postpartum period, it can lead to serious complications for both the mother and baby, including neurological deficits, long-term disability, increased risk of future strokes and death.
“Controlling blood pressure and other stroke risks before and after delivery, responding immediately to stroke warning signs and providing timely treatment can help save lives and improve outcomes for mothers and their babies.”
There are two types of stroke: an ischaemic stroke occurs when a blood vessel supplying blood to the brain is blocked by a clot, while a haemorrhagic stroke occurs when a blood vessel ruptures and bleeds into the brain.
Risk factors for pregnancy-associated stroke include chronic hypertension (high blood pressure before pregnancy or diagnosed before 20 weeks), preeclampsia (a dangerous condition causing high blood pressure in pregnancy), advanced maternal age (35 years or older), diabetes, obesity, migraine with aura, infections, heart disease and clotting disorders.
Stroke disproportionately affects people of racial and ethnic minorities. A 2020 meta-analysis found that pregnant Black women are twice as likely to have a stroke compared with pregnant white women, even after adjusting for socioeconomic factors.
The statement authors emphasise that the majority of maternal strokes are preventable with earlier and more aggressive blood pressure control.
“Preeclampsia and eclampsia can occur before, during or after delivery, and the early postpartum period is actually the highest risk time for stroke.
“Very close monitoring of blood pressure is essential,” said Miller.
The statement urges all healthcare professionals who care for pregnant patients, including obstetricians, family medicine practitioners and nurses, to be trained to recognise stroke symptoms so they can promptly start treatment.
“It is crucial for women who are pregnant or have recently given birth and have symptoms of new neurological deficits or severe headache, especially if they also have elevated blood pressure, to be immediately evaluated for possible stroke,” said Miller.
The authors emphasise that pregnancy is not a reason to delay or interfere with recommended treatment for acute stroke.
Various anti-clotting medications are available that are safe for pregnant and lactating women, and mechanical thrombectomy (surgical removal of a blood clot) may be needed for patients with large-vessel blockages.
Survivors of pregnancy-associated stroke face unique challenges such as caring for an infant and require support from a multidisciplinary rehabilitation team.
Mood and sleep disorders are common after stroke and may be intensified by postpartum factors such as hormonal shifts, breastfeeding and disrupted sleep.
Miller said: “Babies depend on their mothers’ well-being, and supporting recovery after stroke, both emotionally and practically, is essential so mothers can heal and families can thrive.”
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