Treating high-risk pregnancies in the community EMS environment

In the U.S., 23 women die during or as a result of childbirth for every 100,000 live births, making the country 55th in the world for maternal mortality rates. While most U.S. births are not considered high risk, the number of high-risk pregnancies in the country has risen in recent years, with pregnancy and childbirth complications increasing by 9% among women of all ages between 2018-2020.

High risk pregnancies include complications due to:

• Trauma, such as falls, motor vehicle crashes and domestic violence
• Poverty, leading to inadequate nutrition and substandard housing
• Low education levels
• Lack of community and family support
• Inadequate access to healthcare

Community paramedicine (CP) or mobile integrated healthcare (MIH) programs present unique opportunities to mitigate the impact from factors related to the social determinants of health. By making appropriate referrals to community resources, community EMS providers can help fill the gap for women who do not have access to the appropriate services. This could result in improved health outcomes for both the mother and fetus.

Healthcare inequity among pregnant women

One disturbing aspect of complicated pregnancies is the inequity of care among the child-birthing population.

The leading causes of maternal deaths in the U.S. – accounting for nearly one-third of all maternal fatalities – include [2]:

• Hemorrhage
• Pregnancy-induced hypertension
• Embolism
• Infection
• Chronic medical conditions
• Cardiovascular diseases
• Other pre-existing medical conditions

Race and socioeconomic status also factor into maternal mortality rates. A 2018 study of national vital statistics data found that Black women are more than twice as likely to die in childbirth than white women [2]. Additionally, women who are unmarried, have little-to-no education and live in rural areas are associated with 50% to 114% higher maternal mortality risks. Similar disparities are found when it comes to infant mortality, as well [3].

Treating adolescent mothers

Pregnancies in adolescents present a higher risk due to the physical immaturity of the patient as well as contributing SDOH factors. A review of 31 studies of adolescent pregnancies found that Black adolescent mothers had an increased chance of preterm birth and of low fetal birth weight compared to white adolescent mothers. Lower maternal socioeconomic status and decreased literacy levels were also found to increase the risk of adolescent maternal mortality and low birthweight in infants [7].

Community paramedics’ role in treating high-risk pregnancies

Community EMS providers can provide support to expectant mothers through the prevention of negative outcomes.

Step 1: Identify risk factors. Providers should conduct a risk assessment with patients to identify potential factors that may be impacting their pregnancy. The CDC’s Pregnancy Risk Assessment Monitoring System is a project with the goal of improving the health of mothers and infants by reducing adverse outcomes, targeting specific categories, including [4]:

• Nutrition
• Pre-pregnancy weight
• Substance use
• Intimate-partner violence
• Depression
• Healthcare services
• Pregnancy intention
• Postpartum family planning
• Oral health
• Health insurance status one month before pregnancy
• Health insurance status for prenatal care
• Health insurance status postpartum
• Infant sleeping practices
• Breastfeeding practices

A review of PRAMS reports on the CDC website will show the risk indicators’ status in each state. Providers can incorporate the appropriate specific indicators in each category into their patient risk assessment to identify local education, counseling and community resources.

Injury prevention

Injury prevention is an important topic when educating women who may be at risk of experiencing trauma during pregnancy, particularly among younger women of color. A lack of seatbelt use in pregnancy is associated with increased maternal and fetal morbidity and mortality.

Domestic violence has also been identified as a risk factor for pregnant women who suffer from [5]:

• A substance use disorder
• Mental illness
• Intimate partner violence
• Low socioeconomic status
• Limited education
• A history of violence in relationships

An analysis of 83 studies examining the impact of SDOH factors on adverse maternal outcomes – including pregnancy-related death, severe maternal morbidity and emergency hospitalizations or readmissions – was conducted. The data revealed associations between minority race and ethnicity; government-provided or a lack of insurance coverage; and lower education levels with increased incidence of maternal death and severe maternal morbidity [6].

Step 2: Connect the patient to resources. Once the specific risks to a pregnant patient have been identified, the next step is to make the appropriate referrals to community resources. Many communities publish local directories which can be helpful in identifying services. Most locations in the U.S. are served by 211, which provides information and referral services for a wide range of health and human services, including [8]:

• Food availability
• Mental health services
• Labor support
• School district programs
• Suicide prevention
• Other services

In addition to voice services, state 211 websites are searchable. Common search terms for maternal and infant health include “pregnancy counseling,” “prenatal care,” “WIC,” and “breastfeeding support programs.” When making a referral, consider eligibility requirements. The 211 database may refer you to the organization’s website for more information on eligibility and how to make a referral.

Also, take into consideration the needs and beliefs of the patient when accessing resources. Some organizations that provide pregnancy counseling and related services may be religiously based and/or take a strong stance on certain pregnancy-related choices. It’s important to consult with the patient and give her a full understanding of her options.

Step 3: Check on your patient. Conduct a follow-up visit to ensure the patient was able to connect with the available resources and that their maternal healthcare remains on track.

Is your community paramedicine program working with expectant mothers in your area? Let us know unique ways your agency is addressing patients and utilizing local resources – send an email to editor@ems1.com.

References

1. Central Intelligence Agency. “The World Factbook,” Washington, 2021.
2. Singh GK. “Trends and Social Inequalities in Maternal Mortality in the United States, 1969-2018,” International Journal of Maternal and Child Health and AIDS, vol. 10, no. 1, pp. 29-42, 30 Dec 2020.
3. Singh GK, Yu SM, “Infant Mortality in the United States, 1915-2017: Large Social Inequalities have Persisted for Over a Century,” International Journal of Maternal and Child Health and AIDS, vol. 8, no. 1, pp. 19-31, 2019.
4. Centers for Disease Control and Prevention. “What is PRAMS?,” U.S. Department of Health & Human Services, 2021.
5. Lucia A, Dantoni SE. “Trauma Management of the Pregnant Patient,” Critical Care Clinics, vol. 32, no. 1, pp. 109-117, Jan 2016.
6. Wang E, Glazer KB, Howell EA, Janevic TM. “Social Determinants of Pregnancy-Related Mortality and Morbidity in the United States: A Systematic Review,” Obstetrics & Gynecology, vol. 135, no. 4, pp. 896-915, Apr 2020.
7. Amjad S, MacDonald I, Chambers T, Osornio-Vargas A, et al. “Social determinants of health and adverse maternal and birth outcomes in adolescent pregnancies: A systematic review and meta-analysis,” Paediatric and Perinatal Epidemiology, vol. 33, no. 1, pp. 88-99, 5 Dec 2018.
8. United Way. “Help starts here,” 2022. [Online]. Available: https://www.211.org/.