Catherine E Varner1, Alison L Park2, Darby Little2, Joel G Ray2. 1. Schwartz/Reisman Emergency Medicine Institute (Varner, Little) and Department of Family and Community Medicine (Varner), University of Toronto; University of Toronto (Varner, Little), Sinai Health System; ICES (Park, Ray); Keenan Research Centre (Ray), Li Ka Shing Knowledge Institute and Department of Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont. catherine.varner@sinaihealthsystem.ca. 2. Schwartz/Reisman Emergency Medicine Institute (Varner, Little) and Department of Family and Community Medicine (Varner), University of Toronto; University of Toronto (Varner, Little), Sinai Health System; ICES (Park, Ray); Keenan Research Centre (Ray), Li Ka Shing Knowledge Institute and Department of Obstetrics and Gynecology (Ray), St. Michael's Hospital, Toronto, Ont.
Abstract
BACKGROUND: Peripregnancy emergency department use may be common, but data specific to health care systems like that in Canada are lacking. As prior research was limited to livebirths, omitting pregnancies ending in miscarriage or induced abortion, the current study quantified and characterized emergency department use among women in Ontario with a recognized pregnancy. METHODS: This retrospective population-based cohort study included all recognized pregnancies among Ontario residents aged 10-55 years with an estimated date of conception between Apr. 1, 2002, and Mar. 31, 2017. We defined peripregnancy emergency department use as any emergency department visit during pregnancy or within 42 days after pregnancy. We used modified Poisson regression with a robust error variance to generate relative risks (RRs) and 95% confidence intervals (CIs) for the outcome of any peripregnancy emergency department use in association with maternal age, parity, residential income quintile, location of residence, immigrant status, antenatal care provider and number of comorbidities within 120 days before the clinical start of the pregnancy (expressed as total number of Aggregated Diagnosis Groups [ADGs] obtained with the Johns Hopkins Adjusted Clinical Group System). All RRs, except for number of comorbidities, were further adjusted for number of ADGs. RESULTS: Peripregnancy emergency department use occurred in 1 075 991 (39.4%) of 2 728 236 recognized pregnancies, including 35.8% of livebirths, 47.3% of stillbirths, 73.7% of miscarriages and 84.8% of threatened abortions. A peripregnancy emergency department visit was more likely among women who were less than 25 years of age (adjusted RR 1.16, 95% CI 1.16-1.17), were nulliparous (adjusted RR 1.13, 95% CI 1.13-1.13), resided in the lowest income quintile area (adjusted RR 1.16, 95% CI 1.15-1.16) or in a rural area (adjusted RR 1.50, 95% CI 1.50-1.51), were Canadian-born (adjusted RR 1.22, 95% CI 1.22-1.23), were not seen by an obstetrician (adjusted RR 1.66, 95% CI 1.54-1.80) or had a greater number of ADGs. Emergency department use peaked in the first trimester and in the first week postpartum. Compared to women residing in urban areas, those residing in rural areas had an odds ratio (OR) of 3.44 (95% CI 3.39-3.49) for 3 or more emergency department visits. Women with 3-4 (OR 1.99, 95% CI 1.97-2.01), 5-6 (OR 3.55, 95% CI 3.49-3.61), or 7 or more (OR 7.59, 95% CI 7.39-7.78) prepregnancy comorbidities were more likely to have 3 or more peripregnancy emergency department visits than were those with 2 or fewer comorbidities. INTERPRETATION: Peripregnancy emergency department use occurred in nearly 40% of pregnancies, notably in the first trimester and early in the postpartum period. Efforts are needed to streamline rapid access to ambulatory obstetric care during these peak periods, when women are susceptible to miscarriage or a complication after a livebirth. Copyright 2020, Joule Inc. or its licensors.
BACKGROUND: Peripregnancy emergency department use may be common, but data specific to health care systems like that in Canada are lacking. As prior research was limited to livebirths, omitting pregnancies ending in miscarriage or induced abortion, the current study quantified and characterized emergency department use among women in Ontario with a recognized pregnancy. METHODS: This retrospective population-based cohort study included all recognized pregnancies among Ontario residents aged 10-55 years with an estimated date of conception between Apr. 1, 2002, and Mar. 31, 2017. We defined peripregnancy emergency department use as any emergency department visit during pregnancy or within 42 days after pregnancy. We used modified Poisson regression with a robust error variance to generate relative risks (RRs) and 95% confidence intervals (CIs) for the outcome of any peripregnancy emergency department use in association with maternal age, parity, residential income quintile, location of residence, immigrant status, antenatal care provider and number of comorbidities within 120 days before the clinical start of the pregnancy (expressed as total number of Aggregated Diagnosis Groups [ADGs] obtained with the Johns Hopkins Adjusted Clinical Group System). All RRs, except for number of comorbidities, were further adjusted for number of ADGs. RESULTS: Peripregnancy emergency department use occurred in 1 075 991 (39.4%) of 2 728 236 recognized pregnancies, including 35.8% of livebirths, 47.3% of stillbirths, 73.7% of miscarriages and 84.8% of threatened abortions. A peripregnancy emergency department visit was more likely among women who were less than 25 years of age (adjusted RR 1.16, 95% CI 1.16-1.17), were nulliparous (adjusted RR 1.13, 95% CI 1.13-1.13), resided in the lowest income quintile area (adjusted RR 1.16, 95% CI 1.15-1.16) or in a rural area (adjusted RR 1.50, 95% CI 1.50-1.51), were Canadian-born (adjusted RR 1.22, 95% CI 1.22-1.23), were not seen by an obstetrician (adjusted RR 1.66, 95% CI 1.54-1.80) or had a greater number of ADGs. Emergency department use peaked in the first trimester and in the first week postpartum. Compared to women residing in urban areas, those residing in rural areas had an odds ratio (OR) of 3.44 (95% CI 3.39-3.49) for 3 or more emergency department visits. Women with 3-4 (OR 1.99, 95% CI 1.97-2.01), 5-6 (OR 3.55, 95% CI 3.49-3.61), or 7 or more (OR 7.59, 95% CI 7.39-7.78) prepregnancy comorbidities were more likely to have 3 or more peripregnancy emergency department visits than were those with 2 or fewer comorbidities. INTERPRETATION: Peripregnancy emergency department use occurred in nearly 40% of pregnancies, notably in the first trimester and early in the postpartum period. Efforts are needed to streamline rapid access to ambulatory obstetric care during these peak periods, when women are susceptible to miscarriage or a complication after a livebirth. Copyright 2020, Joule Inc. or its licensors.
Authors: Nicholas J Kassebaum; Amelia Bertozzi-Villa; Megan S Coggeshall; Katya A Shackelford; Caitlyn Steiner; Kyle R Heuton; Diego Gonzalez-Medina; Ryan Barber; Chantal Huynh; Daniel Dicker; Tara Templin; Timothy M Wolock; Ayse Abbasoglu Ozgoren; Foad Abd-Allah; Semaw Ferede Abera; Ibrahim Abubakar; Tom Achoki; Ademola Adelekan; Zanfina Ademi; Arsène Kouablan Adou; José C Adsuar; Emilie E Agardh; Dickens Akena; Deena Alasfoor; Zewdie Aderaw Alemu; Rafael Alfonso-Cristancho; Samia Alhabib; Raghib Ali; Mazin J Al Kahbouri; François Alla; Peter J Allen; Mohammad A AlMazroa; Ubai Alsharif; Elena Alvarez; Nelson Alvis-Guzmán; Adansi A Amankwaa; Azmeraw T Amare; Hassan Amini; Walid Ammar; Carl A T Antonio; Palwasha Anwari; Johan Arnlöv; Valentina S Arsic Arsenijevic; Ali Artaman; Majed Masoud Asad; Rana J Asghar; Reza Assadi; Lydia S Atkins; Alaa Badawi; Kalpana Balakrishnan; Arindam Basu; Sanjay Basu; Justin Beardsley; Neeraj Bedi; Tolesa Bekele; Michelle L Bell; Eduardo Bernabe; Tariku J Beyene; Zulfiqar Bhutta; Aref Bin Abdulhak; Jed D Blore; Berrak Bora Basara; Dipan Bose; Nicholas Breitborde; Rosario Cárdenas; Carlos A Castañeda-Orjuela; Ruben Estanislao Castro; Ferrán Catalá-López; Alanur Cavlin; Jung-Chen Chang; Xuan Che; Costas A Christophi; Sumeet S Chugh; Massimo Cirillo; Samantha M Colquhoun; Leslie Trumbull Cooper; Cyrus Cooper; Iuri da Costa Leite; Lalit Dandona; Rakhi Dandona; Adrian Davis; Anand Dayama; Louisa Degenhardt; Diego De Leo; Borja del Pozo-Cruz; Kebede Deribe; Muluken Dessalegn; Gabrielle A deVeber; Samath D Dharmaratne; Uğur Dilmen; Eric L Ding; Rob E Dorrington; Tim R Driscoll; Sergei Petrovich Ermakov; Alireza Esteghamati; Emerito Jose A Faraon; Farshad Farzadfar; Manuela Mendonca Felicio; Seyed-Mohammad Fereshtehnejad; Graça Maria Ferreira de Lima; Mohammad H Forouzanfar; Elisabeth B França; Lynne Gaffikin; Ketevan Gambashidze; Fortuné Gbètoho Gankpé; Ana C Garcia; Johanna M Geleijnse; Katherine B Gibney; Maurice Giroud; Elizabeth L Glaser; Ketevan Goginashvili; Philimon Gona; Dinorah González-Castell; Atsushi Goto; Hebe N Gouda; Harish Chander Gugnani; Rahul Gupta; Rajeev Gupta; Nima Hafezi-Nejad; Randah Ribhi Hamadeh; Mouhanad Hammami; Graeme J Hankey; Hilda L Harb; Rasmus Havmoeller; Simon I Hay; Ileana B Heredia Pi; Hans W Hoek; H Dean Hosgood; Damian G Hoy; Abdullatif Husseini; Bulat T Idrisov; Kaire Innos; Manami Inoue; Kathryn H Jacobsen; Eiman Jahangir; Sun Ha Jee; Paul N Jensen; Vivekanand Jha; Guohong Jiang; Jost B Jonas; Knud Juel; Edmond Kato Kabagambe; Haidong Kan; Nadim E Karam; André Karch; Corine Kakizi Karema; Anil Kaul; Norito Kawakami; Konstantin Kazanjan; Dhruv S Kazi; Andrew H Kemp; Andre Pascal Kengne; Maia Kereselidze; Yousef Saleh Khader; Shams Eldin Ali Hassan Khalifa; Ejaz Ahmed Khan; Young-Ho Khang; Luke Knibbs; Yoshihiro Kokubo; Soewarta Kosen; Barthelemy Kuate Defo; Chanda Kulkarni; Veena S Kulkarni; G Anil Kumar; Kaushalendra Kumar; Ravi B Kumar; Gene Kwan; Taavi Lai; Ratilal Lalloo; Hilton Lam; Van C Lansingh; Anders Larsson; Jong-Tae Lee; James Leigh; Mall Leinsalu; Ricky Leung; Xiaohong Li; Yichong Li; Yongmei Li; Juan Liang; Xiaofeng Liang; Stephen S Lim; Hsien-Ho Lin; Steven E Lipshultz; Shiwei Liu; Yang Liu; Belinda K Lloyd; Stephanie J London; Paulo A Lotufo; Jixiang Ma; Stefan Ma; Vasco Manuel Pedro Machado; Nana Kwaku Mainoo; Marek Majdan; Christopher Chabila Mapoma; Wagner Marcenes; Melvin Barrientos Marzan; Amanda J Mason-Jones; Man Mohan Mehndiratta; Fabiola Mejia-Rodriguez; Ziad A Memish; Walter Mendoza; Ted R Miller; Edward J Mills; Ali H Mokdad; Glen Liddell Mola; Lorenzo Monasta; Jonathan de la Cruz Monis; Julio Cesar Montañez Hernandez; Ami R Moore; Maziar Moradi-Lakeh; Rintaro Mori; Ulrich O Mueller; Mitsuru Mukaigawara; Aliya Naheed; Kovin S Naidoo; Devina Nand; Vinay Nangia; Denis Nash; Chakib Nejjari; Robert G Nelson; Sudan Prasad Neupane; Charles R Newton; Marie Ng; Mark J Nieuwenhuijsen; Muhammad Imran Nisar; Sandra Nolte; Ole F Norheim; Luke Nyakarahuka; In-Hwan Oh; Takayoshi Ohkubo; Bolajoko O Olusanya; Saad B Omer; John Nelson Opio; Orish Ebere Orisakwe; Jeyaraj D Pandian; Christina Papachristou; Jae-Hyun Park; Angel J Paternina Caicedo; Scott B Patten; Vinod K Paul; Boris Igor Pavlin; Neil Pearce; David M Pereira; Konrad Pesudovs; Max Petzold; Dan Poenaru; Guilherme V Polanczyk; Suzanne Polinder; Dan Pope; Farshad Pourmalek; Dima Qato; D Alex Quistberg; Anwar Rafay; Kazem Rahimi; Vafa Rahimi-Movaghar; Sajjad ur Rahman; Murugesan Raju; Saleem M Rana; Amany Refaat; Luca Ronfani; Nobhojit Roy; Tania Georgina Sánchez Pimienta; Mohammad Ali Sahraian; Joshua A Salomon; Uchechukwu Sampson; Itamar S Santos; Monika Sawhney; Felix Sayinzoga; Ione J C Schneider; Austin Schumacher; David C Schwebel; Soraya Seedat; Sadaf G Sepanlou; Edson E Servan-Mori; Marina Shakh-Nazarova; Sara Sheikhbahaei; Kenji Shibuya; Hwashin Hyun Shin; Ivy Shiue; Inga Dora Sigfusdottir; Donald H Silberberg; Andrea P Silva; Jasvinder A Singh; Vegard Skirbekk; Karen Sliwa; Sergey S Soshnikov; Luciano A Sposato; Chandrashekhar T Sreeramareddy; Konstantinos Stroumpoulis; Lela Sturua; Bryan L Sykes; Karen M Tabb; Roberto Tchio Talongwa; Feng Tan; Carolina Maria Teixeira; Eric Yeboah Tenkorang; Abdullah Sulieman Terkawi; Andrew L Thorne-Lyman; David L Tirschwell; Jeffrey A Towbin; Bach X Tran; Miltiadis Tsilimbaris; Uche S Uchendu; Kingsley N Ukwaja; Eduardo A Undurraga; Selen Begüm Uzun; Andrew J Vallely; Coen H van Gool; Tommi J Vasankari; Monica S Vavilala; N Venketasubramanian; Salvador Villalpando; Francesco S Violante; Vasiliy Victorovich Vlassov; Theo Vos; Stephen Waller; Haidong Wang; Linhong Wang; XiaoRong Wang; Yanping Wang; Scott Weichenthal; Elisabete Weiderpass; Robert G Weintraub; Ronny Westerman; James D Wilkinson; Solomon Meseret Woldeyohannes; John Q Wong; Muluemebet Abera Wordofa; Gelin Xu; Yang C Yang; Yuichiro Yano; Gokalp Kadri Yentur; Paul Yip; Naohiro Yonemoto; Seok-Jun Yoon; Mustafa Z Younis; Chuanhua Yu; Kim Yun Jin; Maysaa El Sayed Zaki; Yong Zhao; Yingfeng Zheng; Maigeng Zhou; 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