Pre-pregnancy emergency department use and risk of severe maternal and neonatal outcomes

Pre-pregnancy emergency department use in Ontario is associated with a higher risk for severe maternal and neonatal morbidity, stillbirth, and neonatal death, according to a new study by researchers at ICES and Mount Sinai Hospital, part of Sinai Health. 

Prior research showed that when women visit the ED during pregnancy, they have worse maternal and baby outcomes, possibly due to a lack of healthcare access to a family physician, midwife or obstetrician.

It was not known whether pre-pregnancy ED use is an important indicator of a woman’s overall health, her ability to access healthcare, or the development of serious adverse events in pregnancy and birth. A new study published in JAMA Network Open included 218,011 female patients in Ontario with an emergency department (ED) visit in the 90 days before the start of a pregnancy, compared to 1,912,234 female patients without a pre-pregnancy ED visit.

“Visiting the ED before pregnancy is associated with worse outcomes for mothers and babies,” says Catherine Varner, emergency physician and scientist at Mount Sinai Hospital’s Schwartz/Reisman Emergency Medicine Institute and associate professor in the Department of Family and Community Medicine at the University of Toronto. “This may be a red flag for women receiving insufficient healthcare, or who are dealing with chronic health conditions.”

From April 2003 to January 2020, the data shows that:

• Among all livebirths and stillbirths, 9.7% had an ED visit within 90 days before pregnancy.
• The rates of severe maternal morbidity, severe neonatal morbidity, neonatal death, and stillbirth were higher among women who had visited the ED compared to those who did not.
• These risks increased as the number of ED visits rose from 1 to 3+.

Notably, 19% of pre-pregnancy visits to the ED were for pregnancy-related conditions, which could be associated with a prior pregnancy, miscarriage, or abortion. Further, ED visits for mental health issues were common, and are consistent with prior research showing an association between ED use for mental health conditions and serious adverse maternal and perinatal outcomes.

Limitations of this study included a lack of detail about the severity of a woman’s health condition within the ED, and the care she received in the ED or immediately thereafter. Further, researchers did not have information about race or ethnicity, which could have influenced the rate of ED utilization, although they adjusted for income level and rural residence.

“Our findings highlight the need for health leaders and practitioners to improve preconception care,” says Joel Ray, senior adjunct scientist at ICES and obstetrical medicine physician at St. Michael’s Hospital in Toronto. “Physicians should take a proactive approach by sensitively asking a woman who visits the ED whether she may be planning a pregnancy, providing advice or care for avoiding pregnancy if so desired, and guidance on how best to take care of their health once they wish to conceive.”

The study, “Prepregnancy emergency department use and risks of severe maternal and neonatal morbidity in Canada,” was published in JAMA Network Open.

Author block: Varner CE, Park AL, Ray JG.

Mount Sinai Hospital, part of Sinai Health, is an internationally recognized acute care academic health science centre affiliated with the University of Toronto. The Hospital is a leader in the clinical areas of women’s and infants’ health, chronic disease management, specialized cancer care, emergency medicine, and geriatrics. Founded in 1923, Mount Sinai is committed to the service of others and its purpose to care, create possibilities and offer hope. Holding Exemplary Standing from Accreditation Canada, Mount Sinai is the first and only hospital in Canada to receive Magnet® recognition for nursing excellence and patient care. The Hospital is also top employer in Canada, receiving multiple awards for our employee-focused and culture centred programs. www.mountsinai.on.ca

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Misty Pratt
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