D B Stulberg1, L Cain2, I H Dahlquist2, D S Lauderdale3. 1. Department of Family Medicine, University of Chicago, 5841 S. Maryland Ave., MC 7110, Suite M-156, Chicago, IL 60637, USA Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, USA MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA stulberg@uchicago.edu. 2. Department of Family Medicine, University of Chicago, 5841 S. Maryland Ave., MC 7110, Suite M-156, Chicago, IL 60637, USA. 3. Department of Public Health Sciences, University of Chicago, 5841 S. Maryland Ave. MC 2000, Chicago, IL 60637, USA.
Abstract
STUDY QUESTION: Does the risk of adverse outcomes at the time of ectopic pregnancy vary by race/ethnicity among women receiving Medicaid, the public health insurance program for low-income people in the USA? SUMMARY ANSWER: Among Medicaid beneficiaries with ectopic pregnancy, 11% experienced at least one complication, and women from all racial/ethnic minority groups were significantly more likely than whites to experience complications. WHAT IS KNOWN ALREADY: In this population of Medicaid recipients, African American women are significantly more likely than whites to experience ectopic pregnancy, but the risk of adverse outcomes has not previously been assessed. STUDY DESIGN, SIZE, AND DURATION: We conducted a cross-sectional observational study of all women (n = 19 135 106) ages 15-44 enrolled in Medicaid for any amount of time during 2004-2008 who lived in one of the following 14 US states: Arizona; California; Colorado; Florida; Illinois; Indiana; Iowa; Louisiana; Massachusetts; Michigan; Minnesota; Mississippi; New York; and Texas. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: We analyzed Medicaid claims records for inpatient and outpatient encounters and identified ectopic pregnancies with a principal diagnosis code for ectopic pregnancy from 2004-2008. We calculated the ectopic pregnancy complication rate as the number of ectopic pregnancies with at least one complication (blood transfusion, hysterectomy, any sterilization, or length-of-stay (LOS) > 2 days) divided by the total number of ectopic pregnancies. We used Poisson regression to assess the risk of ectopic pregnancy complication by race/ethnicity. Secondary outcomes were each individual complication, and ectopic pregnancy-related death. We calculated the ectopic pregnancy mortality ratio as the number of deaths divided by live births. MAIN RESULTS AND THE ROLE OF CHANCE: Ectopic pregnancy-associated complications occurred in 11% of cases. Controlling for age and state, the risk of any complication was significantly higher among women who were black (incidence risk ratio [IRR] 1.47, 95% CI 1.43-1.53, P < 0.0001), Hispanic (IRR 1.16, 95% CI 1.12-1.21, P < 0.0001), Asian (IRR 1.34, 95% CI 1.24-1.45, P < 0.0001), American Indian/Alaskan Native (IRR 1.34 95% CI 1.16-1.55, P < 0.0001), and Native Hawaiian/Pacific Islander (IRR 1.61, 95% CI 1.39-1.87, P < 0.0001) compared with white women. The ectopic pregnancy mortality ratio was 0.48 per 100 000 live births, similar to that reported in previous US surveillance. LIMITATIONS, REASONS FOR CAUTION: This is a secondary analysis of insurance claims. WIDER IMPLICATIONS OF THE FINDINGS: Among women at higher baseline risk of pregnancy complications due to their economic status, women from racial/ethnic minority groups face an additional risk of ectopic pregnancy adverse outcomes compared with whites. Systematic changes to reduce racial disparities are an essential part of improving maternal health in the USA. STUDY FUNDING/COMPETING INTERESTS: The Eunice Kennedy Shriver National Institute of Child Health and Human Development (1 K08 HD060663 to D.B.S.). The authors report no conflict of interest. TRIAL REGISTRATION NUMBER: Not applicable.
STUDY QUESTION: Does the risk of adverse outcomes at the time of ectopic pregnancy vary by race/ethnicity among women receiving Medicaid, the public health insurance program for low-income people in the USA? SUMMARY ANSWER: Among Medicaid beneficiaries with ectopic pregnancy, 11% experienced at least one complication, and women from all racial/ethnic minority groups were significantly more likely than whites to experience complications. WHAT IS KNOWN ALREADY: In this population of Medicaid recipients, African American women are significantly more likely than whites to experience ectopic pregnancy, but the risk of adverse outcomes has not previously been assessed. STUDY DESIGN, SIZE, AND DURATION: We conducted a cross-sectional observational study of all women (n = 19 135 106) ages 15-44 enrolled in Medicaid for any amount of time during 2004-2008 who lived in one of the following 14 US states: Arizona; California; Colorado; Florida; Illinois; Indiana; Iowa; Louisiana; Massachusetts; Michigan; Minnesota; Mississippi; New York; and Texas. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: We analyzed Medicaid claims records for inpatient and outpatient encounters and identified ectopic pregnancies with a principal diagnosis code for ectopic pregnancy from 2004-2008. We calculated the ectopic pregnancy complication rate as the number of ectopic pregnancies with at least one complication (blood transfusion, hysterectomy, any sterilization, or length-of-stay (LOS) > 2 days) divided by the total number of ectopic pregnancies. We used Poisson regression to assess the risk of ectopic pregnancy complication by race/ethnicity. Secondary outcomes were each individual complication, and ectopic pregnancy-related death. We calculated the ectopic pregnancy mortality ratio as the number of deaths divided by live births. MAIN RESULTS AND THE ROLE OF CHANCE: Ectopic pregnancy-associated complications occurred in 11% of cases. Controlling for age and state, the risk of any complication was significantly higher among women who were black (incidence risk ratio [IRR] 1.47, 95% CI 1.43-1.53, P < 0.0001), Hispanic (IRR 1.16, 95% CI 1.12-1.21, P < 0.0001), Asian (IRR 1.34, 95% CI 1.24-1.45, P < 0.0001), American Indian/Alaskan Native (IRR 1.34 95% CI 1.16-1.55, P < 0.0001), and Native Hawaiian/Pacific Islander (IRR 1.61, 95% CI 1.39-1.87, P < 0.0001) compared with white women. The ectopic pregnancy mortality ratio was 0.48 per 100 000 live births, similar to that reported in previous US surveillance. LIMITATIONS, REASONS FOR CAUTION: This is a secondary analysis of insurance claims. WIDER IMPLICATIONS OF THE FINDINGS: Among women at higher baseline risk of pregnancy complications due to their economic status, women from racial/ethnic minority groups face an additional risk of ectopic pregnancy adverse outcomes compared with whites. Systematic changes to reduce racial disparities are an essential part of improving maternal health in the USA. STUDY FUNDING/COMPETING INTERESTS: The Eunice Kennedy Shriver National Institute of Child Health and Human Development (1 K08 HD060663 to D.B.S.). The authors report no conflict of interest. TRIAL REGISTRATION NUMBER: Not applicable.
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