Abstract:

BACKGROUND:Severe maternal morbidity continues to be an issue of national and global concern and is increasing in incidence. The incidence of infertility is also on the rise, and infertile women experience a higher risk of incident chronic medical disease and cancer, suggesting that fertility may serve as a window to a woman's overall health. OBJECTIVE:To investigate the risk of severe maternal morbidity by maternal fertility status. STUDY DESIGN:Retrospective cohort analysis using Optum's de-identifed Clinformatics® Data Mart Database between 2003-2015. Infertile women stratified by infertility diagnosis, testing or treatment were compared to fertile women seeking routine gynecologic care. In both groups, only women who underwent pregnancy and delivery of a singleton during the follow up period were included. Main outcomes were severe maternal morbidity indicators, defined by the CDC, and identified by ICD-10 and CPT codes within 6 weeks of each delivery. Results were adjusted for maternal age, race, education, nulliparity, race, smoking, obesity, delivery mode, preterm birth, number of prenatal visits, and year of delivery. RESULTS:19,658 women comprised the infertile group and 525,695 women comprised the fertile group. The overall incidence of any severe maternal morbidity indicator was 7.0% among women receiving fertility treatment, 6.4% among women receiving a fertility diagnosis, 5.5% among women receiving fertility testing and 4.3% among fertile women.. Overall, infertile women had a significantly higher risk of developing any severe maternal morbidity indicator (AOR 1.22, CI 1.14-1.31, p<0.01) as well as a significantly higher risk of disseminated intravascular coagulation (DIC) (AOR 1.48, CI 1.26 - 1.73, p<0.01), eclampsia (AOR 1.37, CI 1.05 - 1.79, p<0.01), heart failure during procedure or surgery (AOR 1.54, CI 1.21 - 1.97, p<0.01), internal injuries of the thorax, abdomen or pelvis (AOR 1.59, CI 1.12 - 2.26, p<0.01), intracranial injuries (AOR 1.77, CI 1.20- 2.61, p<0.01), pulmonary edema (AOR 2.18, CI 1.54 - 3.10, p<0.01), thrombotic embolism (AOR 1.58, CI 1.14 - 2.17, p<0.01), and blood transfusion (AOR 1.50, CI 1.30 - 1.72, p<0.01) compared to fertile women. Fertile women did not face a significantly higher risk of any maternal morbidity indicator compared to infertile women. In subgroup analysis by maternal race/ethnicity, the likelihood of severe morbidity was significantly higher among fertile Black women compared to fertile Caucasian women. There was no difference between infertile Black and Caucasian women after multivariable adjustment. CONCLUSION:Using an insurance claims database, we report that women diagnosed with infertility and women receiving fertility treatment experience a significantly higher risk of multiple indicators of severe maternal morbidity compared to fertile women. The increased risk of severe maternal morbidity noted among fertile Black women compared to fertile Caucasian women is attenuated among infertile Black women, who face similar risks as infertile Caucasian women.