Pregnancy outcomes among medically complex populations with high risk of pregnancy mortality in Virginia: a retrospective observational study

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BACKGROUND: Abortion may be medically indicated to avert death or permanent harm of the pregnant person. However, some US states now prevent access to abortion for these patients. To evaluate the population for whom this may cause harm, we aimed to estimate the prevalence of severe chronic conditions and pregnancy complications for which induced abortion is indicated, the odds of pregnancy for patients with severe chronic conditions, and compare pregnancy outcomes including induced abortion for pregnancies where such indications are present with pregnancies where they are not. METHODS: In a retrospective observational study using the Virginia All-Payer Claims Database (2018-2019), we identified 1,502,965 female patients aged 14-55 with ≥ 6 months insurance coverage. Medical codes identified severe chronic conditions and pregnancy complications. Pregnancy outcomes were classified using an established algorithm. RESULTS: Among reproductive-aged people, 2.9% had severe chronic conditions that could threaten life with pregnancy. Among 101,582 people who experienced pregnancy, 5.6% had life-threatening complications before their third trimester. Severe chronic conditions were associated with reduced risk of pregnancy (OR: 0.44 [95% CI: 0.41-0.46]), but sickle cell disease patients had increased odds of pregnancy (OR: 2.42 [95% CI: 2.10-2.78]). Compared to pregnancies with neither early complications or severe conditions present, pregnancies involving severe chronic conditions had fewer live births (68.2% vs. 75.3%), more spontaneous abortions (16.9% vs. 12.2%), and more induced abortions (3.7% vs. 2.2%), while pregnancies with early complications also had fewer live births (61.7%) and more spontaneous abortions (25.2%; p < 0.01 for all comparisons). Abortion ratios (induced abortions per 1000 live births) in these data were 5-6 times lower than in Center for Disease Control abortion surveillance data for Virginia 2018-2019, indicating under-ascertainment of induced abortion. CONCLUSIONS: In a state with some abortion restrictions and some protections, thousands of patients experience severe chronic conditions or pregnancy complications for which induced abortion is indicated.

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