Connection to Perinatal Care for the Management of Maternal Inflammatory Bowel Disease in Pregnancy

Abstract

Background: Inflammatory bowel disease (IBD) poses a public health concern, particularly in pregnant individuals, where it has been linked to adverse maternal and fetal outcomes. Routine and specialist consultation is recommended pre-conception, during pregnancy, and postpartum, yet many pregnant Canadians do not receive adequate prenatal care. Addressing these gaps requires a focus on clinical and social determinants of health, but limited data exists on prenatal care utilization, pregnancy outcomes, and inequities affecting access to care for this population. Methods: We performed a population-level retrospective cohort study of pregnant Ontario residents who delivered a live or stillborn infant (>20 weeks gestation) at an Ontario hospital between April 1, 2012 and September 15, 2019. Our three study groups of interest included an IBD, multimorbidity, and healthy control group. Frequencies and proportions were used to report adequacy of prenatal care levels derived from the Revised-Graduated Prenatal Care Utilization Index as well as obstetrical and newborn outcomes in our study groups. Specialty visits for the IBD groups were identified 6 months pre-conception, during pregnancy, and 6 months postpartum. Adequacy of prenatal care among the study groups and social inequities affecting adequacy of care were investigated using multivariable logistic regression to compute unadjusted and adjusted odds ratios (aOR). Social inequities were derived from the Ontario Marginalization Index (ON-Marg). Results: We identified 373,101 pregnancies that met our study criteria, with 3,451 pregnancies in the IBD group, 6,280 in the multimorbidity group, and 363,370 in the healthy control group. Compared to the healthy control group, the IBD (aOR: 1.55; 95% CI, 1.53-1.57) and multimorbidity (aOR: 2.10; 95% CI, 2.08-2.12) groups were at higher odds of receiving adequate prenatal care. For IBD patients, the prevalence of visits with a general practitioner was high in all three trimesters of pregnancy, with a range of 75-93%, while visits with gastroenterology ranged from 44-57%. Obstetrical and neonatal outcomes such as caesarean sections, preterm birth, and low birth weight were higher in the IBD and multimorbidity groups, compared to the healthy control group. For the IBD group, those living in neighborhoods with the highest racialized populations (0.78 [0.72-0.85]), least access to material needs (0.67 [0.62-0.73]), and least residential stability (0.93 [0.87-0.99]) were associated with having lower odds of adequate prenatal care compared to individuals living in the least marginalized neighborhoods. Conclusion: The findings of this study suggest that despite higher odds of receiving adequate care, those with IBD and multimorbidity may have higher rates of adverse obstetrical and newborn outcomes. Social inequities at the neighborhood level had mixed effects on adequacy of care, with some study groups more likely to receive inadequate care, depending on the social inequity dimension. These results highlight the need to address both clinical and social factors to improve prenatal care access and outcomes for individuals with IBD and other chronic conditions in Ontario.