Abstract
Background
Severe maternal morbidity has been linked to maternal mortality and several perinatal complications, but the evidence on associations with children’s neurodevelopmental disorders is still unclear.
Objective
To assess associations between severe maternal morbidity and cerebral palsy in children, overall and by major severe maternal morbidity subtypes.
Study design
Longitudinal cohort study of all live births in the province of Ontario, Canada, between 2003 and 2019 followed up through 2020 (n=2,136,816), under a single-payer healthcare system. Severe maternal morbidity (n=41,396) was identified from inpatient or emergency department diagnoses during the index pregnancy or postpartum (20 weeks gestation to 42 days postpartum) based on validated algorithms according to diagnostic and procedure codes. Severe maternal morbidity was categorized into severe hypertensive disorders of pregnancy (severe preeclampsia, Hemolysis, Elevated Liver enzymes, and Low Platelets syndrome, and eclampsia combined), severe hemorrhage (eg, antepartum or postpartum hemorrhage with coagulation defect, red cell transfusion, procedures to the uterus, or hysterectomy), sepsis (puerperal sepsis or septicemia during labor), and other severe maternal morbidities (eg, admission to intensive care, shock). Cerebral palsy in offspring was defined as a single inpatient or 2 or more outpatient diagnoses at least 2 weeks apart between birth and the end of follow-up (age, 1–17 years). Associations were estimated using Poisson regression models.
Results
Of 2,136,816 children included in this study (mean [standard deviation] gestational age, 38.9 [1.8] weeks; 1,074,548 males [51.3%]), 41,396 (2.0%) were exposed to severe maternal morbidity. In a median follow-up of 9.5 years (interquartile range, 5.2–13.7), 5352 children were diagnosed with cerebral palsy (0.3%), of which 272 cerebral palsy cases (0.7%) were exposed to severe maternal morbidity. The average annual cerebral palsy incidence rate was 7.5 per 10,000 child-years in those exposed to severe maternal morbidity and 2.5 per 10,000 in those unexposed. Children of mothers with severe maternal morbidity had an increased risk of cerebral palsy (rate ratio, 2.71; 95% confidence interval, 2.39–3.06) after adjusting for maternal sociodemographic and clinical characteristics. All severe maternal morbidity subtypes considered were associated with increased risks of cerebral palsy, with the strongest associations observed for severe hypertension disorders (adjusted rate ratio, 3.29 [2.44–4.33]). Other severe maternal morbidity subtypes also showed similarly increased risks (adjusted rate ratio for sepsis, 2.45 [1.86, 3.15]), severe hemorrhage 2.44 (1.89, 3.09), and other severe maternal morbidity subtypes (2.81 [2.30–3.39]).
Conclusion
In this population-based study of more than 2 million births, severe maternal morbidity was associated with an increased risk of cerebral palsy. This risk was observed across major severe morbidity subtypes, including hypertensive disorders, hemorrhage, and sepsis. These findings highlight the potential benefits of optimizing maternal health and illustrate potential long-term adverse consequences of severe maternal morbidity in offspring. Children of mothers who experience severe or life-threatening events during the perinatal period may benefit from enhanced surveillance for early cerebral palsy symptoms.