Could you believe that all through my pregnancy so far they don't know how much weight I've gained, because they don't have a wheelchair or sitting scale or nothing. They don't monitor my weight at all. [33-year-old woman with cerebral palsy]
Special concerns during pregnancy vary for women with different types of disabilities. We know from this study that women with disabilities are less likely to become pregnant than women in general; therefore, it is difficult to find enough women with a particular type of disability to participate in a survey, even one as large as this, so that we can draw valid conclusions. We chose to examine the pregnancy experiences of the 120 women with spinal cord injury who participated in this study because it was the largest subgroup in the sample.
Few clinicians are informed about the pregnancy outcomes of women with spinal cord injury, or SCI. Yet the majority of women who acquire a SCI are of childbearing age. Recent ten-year hospital studies indicate an increasing number of births among women with traumatic spinal cord injury. However, few clinicians have experience managing pregnancy, labor, and delivery in women with SCI. Therefore, clinical guidelines for this population are often based on case reports or small case series, which tend to report the most unusual and serious problems rather than uncomplicated cases. Unfounded assumptions of poor outcomes may influence clinicians to behave as though risks are greater than they actually are for most women with SCI and practice defensive medicine. If the chance for a positive pregnancy outcome is considered slim, or threat to the mother's life too high, clinicians may encourage women who want to have their babies to have unnecessary or undesired therapeutic abortions.
In these analyses, we examined whether women with SCI are at higher risk of specific pregnancy-related complications than are women without disabilities.
Results
Thirty-seven percent of the women with disabilities had natural children compared to half of the able-bodied comparison group. No significant difference was found between the groups in the rate of miscarriages, abortions, or stillbirths.
Among 120 women with spinal cord injury, 52 (43 percent) had been pregnant, and 21 had pregnancies diagnosed after onset of injury. Pregnancy was impossible for 31 percent due to tubal ligation (11percent) or hysterectomy (15 percent). Significantly more women without disabilities (50 percent) had live births compared to 18 percent of women after spinal cord injury, a frequency that is consistent with the 10-20 percent rate of births found in other studies. Fewer women with SCI had miscarriages (11 percent) compared with 17 percent of women without disabilities, whereas the number of reported induced abortions and stillbirths was about equal in both groups.
Certain prenatal complications were more prevalent among women with SCI than among women without disabilities. Ten percent of women with SCI, and 5.47 percent of women without disabilities, had gestational diabetes, but this difference was not significant. Significantly more women with SCI had bladder and kidney infections during pregnancy, with 52 percent and 29 percent of SCI women having had bladder and kidney infections, respectively, compared to 17 percent and 8 percent of non-disabled women.
Both autonomic hyperreflexia (32 percent) and preeclampsia (38 percent) were found at relatively high rates among women with SCI; only 13 percent of women without disabilities had preeclampsia. Yet there was no significant difference between the two groups for frequency of pre-term labor (33 percent versus 22 percent); pre-term delivery (29 percent versus 18 percent); or low birth weight (14 percent versus 15 percent), despite a typical increased risk of these complications in association with autonomic hyperreflexia and preeclampsia. Frequency of failure to progress during labor was also similar between the two groups (24 percent versus 18 percent).
Other studies have found a higher prevalence of these complications among women with spinal cord injury. The lack of significant differences in complication frequency between our two groups may reflect limitations in the research design. The sample size of women with SCI who had been pregnant after injury is extremely small (21) compared to the size of the group of women without disabilities who had been pregnant (220). Objective hospital data to corroborate self-report data were not available with our written questionnaire method. Also, women who gave birth many years ago may not recall some details of their pregnancy and birth experience.
Conclusion
Physicians and women with spinal cord injuries themselves often operate under the misconception that pregnancy following spinal cord injury should be avoided. Consequently, women with disabilities report difficulty in finding obstetricians or midwives willing to assist them with their "high risk" pregnancies. However, the results of our study confirm findings from other studies that normal labor and delivery are possible, even routine, and generally pose little or no added risk to the mother or baby. Physicians do need to be alerted to possible complications associated with spinal cord injury such as severe autonomic hyperreflexia in women with lesions at or above the T6 level, respiratory compromise, skin breakdown, increased risk of urinary tract infections, increased spasticity, and medications commonly used in SCI that could be toxic to the fetus.