Prevalence of Pregnancy-related Complications among Pregnant Women with Congenital Heart Defects Enrolled in Medicaid during 1999-2013 Open Access

Josias Sejour, Dahanah (2017)

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Purpose: Those with congenital heart defects (CHD) require on-going care and lifelong cardiac surveillance. However, individuals with CHD are often lost to follow up as they transition from childhood to adulthood. While reasons for lapses in medical care vary, studies have found that a change in or a loss of medical insurance are two major causes of lapses in care for individuals with CHD. Due to the increased risk of pregnancy related complications, it is imperative that women with CHD receive adequate medical care prior to and during pregnancy. The current study determined whether prevalence of pregnancy-related complications differed by history of Medicaid enrollment among pregnant women with CHD.

Methods: Medicaid claims were limited to female patients who were coded as having at least one CHD diagnosis in the years 1999-2007 with at least one pregnancy-related diagnosis in 2008-2013. Using multivariable logistic regression, odds ratios were calculated between Medicaid enrollment history and pregnancy-related complications.

Results: The analytic sample retained was 1,799 women. Of those, 557 (31%) were continuously enrolled in Medicaid from 1999-2007, while 1,242 (69.0%) were occasionally enrolled in Medicaid from 1999-2007. With respect to pregnancy-related complications, 206 (11.5%) had cardiovascular complications, 476 (26.5%) experienced neonatal/fetal loss, 1,426 (79.3%) had maternal complications and 419 (23.3%) experienced complications in pregnancy. While history of Medicaid enrollment was not a significant predictor of cardiovascular complications, complications during pregnancy or neonatal/fetal loss, it was a significant predictor of complications during delivery for women aged 19 or older. Pregnant women > 19 with CHD who were only occasionally enrolled in Medicaid were more likely to have complications during delivery than those who were continuously enrolled in Medicaid.

Conclusion: Results suggest an association between history of enrollment in Medicaid and certain pregnancy-related complications among pregnant women with CHD. More research is needed to further examine this relationship, especially with the inclusion of previously uninsured women with CHD who only become eligible for Medicaid because of their pregnancy. Subsequently, to assess this relationship, there is a need for additional data sources that provide more accurate reporting of medical histories for Medicaid patients with CHD. Given that the majority of this CHD sample were occasionally enrolled in Medicaid, and given that there is an ever-growing number of individuals with CHD surviving into adulthood, these findings indicate the need for a re-assessment of Medicaid's eligibility requirement for adult disability status.

Table of Contents

Table of Contents


Congenital Heart Defects (CHD) 1

Social Ecological Model and CHD.. 3

Medicaid and CHIP. 3

Medicaid and S-CHIP in Georgia. 4

Medicaid, SSI and CHD.. 5

Pregnancy and Medicaid. 6

Consequence of Lack of Insurance or Delayed Coverage during Pregnancy. 6

Comorbidities Associated with Pregnancy. 7

Pregnancy-related Complications among CHD Patients. 8

Hypothesis. 9


Study Design and Population. 10

Inclusion and Exclusion Criteria. 11

Data Management and IRB.. 11

Outcome Variable. 11

Cardiovascular complications. 12

Complications at delivery. 12

Complications in pregnancy. 12

Neonatal/Fetal loss. 12

Predictor Variable. 13

Continuous enrollment group: 13

Occasional enrollment group: 13

Pregnancy eligible enrollment group: 13

Directed Acyclic Graph (DAG) 13

Covariates. 13

Age at Pregnancy. 14

Race. 14

Severity of CHD.. 14

Urban-Rural Residence. 14

Maternal Behavioral Risk Factors. 14

Statistical Analysis. 15

Descriptive Statistics. 15

Bivariate Level Analysis. 16

Logistic Regression Models. 16

Cardiovascular Complications. 17

Complications at delivery. 17

Complications in Pregnancy. 17

Neonatal/Fetal Loss. 17

Discussion. 18

Limitations. 19

Conclusion. 20



Table 1. Demographic Characteristics of Pregnant Women with CHD, 1999-2013. 42

Table 2a. Association of Selected Variables with Medicaid Enrollment History. 43

Table 2b. Association of selected variables with Cardiovascular Complications. 44

Table 2c. Association of Selected Variables with Complications at delivery. 45

Table 2d. Association of Selected Variables with Complications in Pregnancy. 46

Table 2e. Association of Selected Variables with Neonatal/Fetal Loss. 47

Table 3a. Crude and Adjusted Odds Ratios of the Relationship between History of Medicaid Enrollment and Cardiovascular Complications 48

Table 3b. Crude and Adjusted Odds Ratios of the Relationship between History of Medicaid Enrollment and Complications at delivery 49

Table 3c. Crude and Adjusted Odds Ratios of the Relationship between History of Medicaid Enrollment and Complications in Pregnancy 50

Table 3d. Crude and Adjusted Odds Ratios and 95% Confidence Intervals for the Relationship between History of Medicaid Enrollment and Neonatal/Fetal Loss. 51


Figure 1. DAG.. 52


Appendix A. Source of Information on Medicaid Variables. 53

Appendix B. Congenital Heart Defect ICD-9-CM Codes and Marelli's* Congenital Heart Defect Severity Ratings 54

Appendix C. Clinical Classifications Software (CCS) for ICD-9-CM Codes Used to Group the Four Pregnancy-related Complication Outcomes 56

Cardiovascular Complications. 56

Complications at delivery. 56

Complications in Pregnancy. 57

Neonatal/Fetal Loss. 57

Appendix D. Clinical Classifications Software (CCS) for ICD-9-CM Codes Used to Group Maternal Behavioral Risk Factors 58

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