A Scary Self-Fulfilling Prophecy for Pregnancies

Regular visits to the emergency department can signal danger for those who become pregnant. What does it mean, and who's most at risk?


During pregnancy, women face a myriad of potential health concerns. Although prenatal care is often provided by either a primary care physician or an OB/GYN, many women find themselves in positions where this is not available to them. In this case, or in the case of emergencies, it is not unusual for pregnant patients to have to visit the emergency department, or ED.

However, the emergency department can be a stressful environment. Depending on the hospital, it can often be understaffed, underfunded and overcrowded. Although studies have looked at correlations between pregnancy-related healthcare and pregnancy outcomes, there is little understanding on the association between ED visitation and pregnancy outcomes.

A 2022 study out of the University of Toronto and St. Michael’s Hospital aimed to study the association between ED use during prepregnancy and pregnancy outcomes. This study was led by Dr. Catherine E. Varner, a clinician investigator at the Schwartz/Reisman Emergency Medicine Institute at Mount Sinai Hospital, and published in JAMA Network Open.

ED visitation is associated with poor pregnancy outcomes

This study was a population-based study, and looked retroactively at data from all live births and stillbirths in Ontario between 2003 and 2020. Overall, this included over 2.2 million births.

A total of 9.7% of the births included in the final cohort were from women who had visited the ED within 90 days before becoming pregnant (which is what the authors define as prepregnancy). These women were more likely to be young, low-income, or rural. Their ED visits could likely be attributed to the fact that these groups are all less likely to have primary care physicians.

Those who did visit the ED prepregnancy were more likely to experience maternal morbidity — short- and long-term health problems that come from being pregnant. In fact, the researchers observed that the risk of maternal morbidity increased based on ED visitation. This means that not all those who had prepregnancy ED visits were equal, but instead that someone who visited the ED three times during prepregnancy had a greater risk of maternal morbidity than someone who visited once.

Furthermore, not only was prepregnancy ED visitation associated with higher risk of maternal morbidity, but so was an ED visit within the first trimester. Additionally, prepregnancy ED visits were associated with increased neonatal death.

Socially disadvantaged patients more likely to visit the ED

ED utilization is closely associated with several socioeconomic factors including age, income, food security, education, and housing status. As a result, ED visitation is most common in patients who are already socially disadvantaged. Thus the findings that ED visits prepregnancy are associated with both maternal and neonatal death are quite important.

These findings become increasingly complicated when considering the impacts of race and ethnicity on one’s health. For example, the study found that 19% of prepregnancy ED visits were for pregnancy-related conditions. This includes issues with infertility and recurrent miscarriages, both associated with endometriosis and polycystic ovarian syndrome — conditions which are more common in racialized, particularly Black, women.

Thus a sort of self-fulfilling prophecy occurs, where women who are already more likely to be mistreated by the healthcare system find themselves utilizing the ED more often prepregnancy than their counterparts. In turn, this increases their likelihood of maternal and neonatal death.

Can this data be used to inform healthcare?

The findings of this study were especially interesting because even after adjusting for socioeconomic factors such as age and income, the researchers still found that ED visitation was associated with worse health outcomes for both the mother and fetus.

Thus although ED utilization does not necessarily cause maternal or neonatal death, it is an important indication of a lack of stable prenatal care. There is an opportunity here to take a collectivistic view rather than an individualistic view. According to the researchers, the frequency of ED use should serve as a red flag to ensure that the most vulnerable patients in our healthcare system do not slip between the cracks.

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Salma is a PhD student in the Department of Immunology at the University of Toronto, where she also completed her MSc and HBSc. She is passionate about equity, accessibility and transparency in science, and is excited about helping highlight Canadian research!