Trends and inequities in severe maternal morbidity in Massachusetts: A closer look at the last two decades.

It is estimated that 50,000-60,000 pregnant people in the United States (US) experience severe maternal morbidity (SMM). SMM includes life-threatening conditions, such as acute myocardial infarction, acute renal failure, amniotic fluid embolism, disseminated intravascular coagulation, or sepsis. Prior research has identified both rising rates through 2014 and wide racial disparities in SMM. While reducing maternal death and SMM has been a global goal for the past several decades, limited progress has been made in the US in achieving this goal. Our objectives were to examine SMM trends from 1998-2018 to identify factors contributing to the persistent and rising rates of SMM by race/ethnicity and describe the Black non-Hispanic/White non-Hispanic rate ratio for each SMM condition. We used a population-based data system that links delivery records to their corresponding hospital discharge records to identify SMM rates (excluding transfusion) per 10, 000 deliveries and examined the trends by race/ethnicity. We then conducted stratified analyses separately for Black and White birthing people. While the rates of SMM during the same periods steadily increased for all racial/ethnic groups, Black birthing people experienced the greatest absolute increase compared to any other race/ethnic group going from 69.4 in 1998-2000 to 173.7 per 10,000 deliveries in 2016-2018. In addition, we found that Black birthing people had higher rates for every individual condition compared to White birthing people, with rate ratios ranging from a low of 1.11 for heart failure during surgery to a high of 102.4 for sickle cell anemia. Obesity was not significantly associated with SMM among Black birthing people but was associated with SMM among White birthing people [aRR 1.18 (95% CI: 1.02, 1.36)]. An unbiased understanding of how SMM has affected different race/ethnicity groups is key to improving maternal health and preventing SMM and mortality among Black birthing people. SMM needs to be addressed as both a medical and public health challenge.

Polycystic ovary syndrome and risk of adverse pregnancy outcomes: a registry linkage study from Massachusetts.

STUDY QUESTION: Do women with polycystic ovary syndrome (PCOS) have a greater risk of adverse pregnancy complications (gestational diabetes, preeclampsia, cesarean section, placental abnormalities) and neonatal outcomes (preterm birth, small for gestational age, prolonged delivery hospitalization) compared to women without a PCOS diagnosis and does this risk vary by BMI, subfertility and fertility treatment utilization? SUMMARY ANSWER: Deliveries to women with a history of PCOS were at greater risk of complications associated with cardiometabolic function, including gestational diabetes and preeclampsia, as well as preterm birth and prolonged length of delivery hospitalization. WHAT IS KNOWN ALREADY: Prior research has suggested that women with PCOS may be at increased risk of adverse pregnancy outcomes. However, findings have been inconsistent possibly due to lack of consistent adjustment for confounding factors, small samples size and other sources of bias. STUDY DESIGN, SIZE, DURATION: Massachusetts deliveries among women ≥18 years old during 2013-2017 from state vital records linked to hospital discharges, observational stays and emergency department visits were linked to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) and the Massachusetts All-Payers Claims Database (APCD). PARTICIPANTS/MATERIALS, SETTING, METHODS: PCOS was identified by ICD9 and ICD10 codes in APCD prior to index delivery. Relative risks (RRs) and 95% CI for pregnancy and delivery complications were modeled using generalized estimating equations with a log link and a Poisson distribution to take multiple cycles into account and were adjusted a priori for maternal age, BMI, race/ethnicity, education, plurality, birth year, chronic hypertension and chronic diabetes. Tests for homogeneity investigated differences between maternal pre-pregnancy BMI categories (<30, ≥30, <25 and ≥25 kg/m2) and between non-infertile deliveries and deliveries that used ART or had a history of subfertility (defined by birth certificates, SART CORS records, APCD or hospital records). MAIN RESULTS AND THE ROLE OF CHANCE: Among 91 825 deliveries, 3.9% had a history of PCOS. Women with a history of PCOS had a 51% greater risk of gestational diabetes (CI: 1.38-1.65) and a 25% greater risk of preeclampsia (CI: 1.15-1.35) compared to women without a diagnosis of PCOS. Neonates born to women with a history of PCOS were more likely to be born preterm (RR: 1.17, CI: 1.06-1.29) and more likely to have a prolonged delivery hospitalization after additionally adjusting for gestational age (RR: 1.23, CI: 1.09-1.40) compared to those of women without a diagnosis of PCOS. The risk for gestational diabetes for women with PCOS was greater among women with a pre-pregnancy BMI <30 kg/m2. LIMITATIONS, REASONS FOR CAUTION: PCOS was defined by ICD documentation prior to delivery so there may be women with undiagnosed PCOS or PCOS diagnosed after delivery included in the unexposed group. The study population is limited to deliveries within Massachusetts among most private insurance payers and inpatient or observational hospitalization in Massachusetts during the follow-up window, therefore there may be diagnoses and or deliveries outside of the state or outside of our sample that were not captured. WIDER IMPLICATIONS OF THE FINDINGS: In this population-based study, women with a history of PCOS were at greater risk of pregnancy complications associated with cardiometabolic function and preterm birth. Obstetricians should be aware of patients' PCOS status and closely monitor for potential pregnancy complications to improve maternal and infant perinatal health outcomes. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by the NIH (R01HD067270). S.A.M. receives grant funding from NIH, AbbVie and the Marriot Family Foundation; payment/honoraria from the University of British Columbia, World Endometriosis Research Foundation and Huilun Shanghai; travel support for attending meetings for ESHRE 2019, IASP 2019, National Endometriosis Network UK meeting 2019; SRI 2022, ESHRE 2022; participates on the data safety monitoring board/advisory board for AbbVie, Roche, Frontiers in Reproductive Health; and has a leadership role in the Society for Women's Health Research, World Endometriosis Research Foundation, World Endometriosis Society, American Society for Reproductive Medicine and ESHRE. The other authors have no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

Length of Stay Among Infants with Neonatal Abstinence Syndrome and Risk of Hospital Readmission.

OBJECTIVES: To assess whether a shorter length of stay (LOS) is associated with a higher risk of readmission among newborns with neonatal abstinence syndrome (NAS) and examine the risk, causes, and characteristics associated with readmissions among newborns with NAS, using a longitudinally linked population-based database. METHODS: Our study sample included full-term singletons with NAS (n = 4,547) and without NAS (n = 327,836), born in Massachusetts during 2011-2017. We used log-binomial regression models to estimate the crude risk ratios (cRRs) and adjusted RRs with 95% confidence intervals (CI) of the association between LOS and readmissions, controlling for maternal age, race/ethnicity, education, marital status, insurance, method of delivery, birthweight, adequacy of prenatal care, smoking, and abnormal conditions of newborn. RESULTS: Compared with infants without NAS, infants with NAS had a non-significantly higher risk of readmission within 2-42 days (2.8% vs. 2.5%; p = 0.17) and a significantly higher risk of readmission within 43-182 days (2.7% vs. 1.8%; p < 0.001). The risk of readmission within 2-42 days was significantly higher among infants with NAS with a LOS of 0-6 days compared to a LOS of 14-20 days (reference group) (aRR: 2.1; 95% CI: 1.2-3.5). No significant differences in readmission rates between 43 and 182 days were observed across LOS categories. CONCLUSIONS: Among infants with NAS, a LOS of 0-6 days was associated with a significantly higher risk of readmission within 2-42 days of discharge compared to a longer LOS.

Assisted reproductive technology treatment increases obstetric and neonatal risks over that of the underlying infertility diagnosis.

OBJECTIVE: To determine whether assisted reproductive technology (ART) treatment adds obstetric and neonatal risks over and above that of underlying infertility-related diagnoses. DESIGN: Retrospective study of linked ART, birth certificate, hospital discharge data, and outpatient insurance claims data in Massachusetts (2013-2017). SETTING: Database. PATIENT(S): Singleton deliveries in women with and without diagnoses of tubal disease, polycystic ovarian syndrome (PCOS), other ovulatory conditions, or endometriosis, identified from the insurance claims and ART data. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): ART and non-ART pregnancy and delivery outcomes were compared with each other and with women with no history of infertility or usage of fertility treatment (fertile group). Generalizing estimating equations with Poisson distribution and exchangeable correlation structure were used to obtain adjusted relative risk ratios (aRRs) and 95% confidence intervals (CIs). RESULT(S): Infertility-related diagnoses significantly increased the risks of pregnancy hypertension (PCOS: aRR, 1.13, 95% CI 1.00-1.27), preeclampsia/eclampsia (tubal: aRR 1.28, 95% CI 1.02-1.61; PCOS: aRR 1.23, 95% CI 1.06-1.43; other ovulatory: aRR 1.11, 95% CI 1.02-1.20), gestational diabetes (tubal: aRR 1.28, 95% CI 1.08-1.50; PCOS: aRR 1.58, 95% CI 1.42-1.75; other ovulatory: aRR 1.19, 95% CI 1.12-1.26), and placental problems (tubal aRR 1.47, 95% CI 1.11-1.94), as well as low birthweight and prematurity, compared with deliveries from the fertile group. Within each diagnosis, the use of ART consistently increased the risk of placental problems (aRR 1.49-2.86) but varied for other conditions. CONCLUSION(S): Our study demonstrated that compared with the fertile group, risk was elevated in pregnancies and deliveries from women with tubal, PCOS, other ovulatory, and endometriosis diagnoses who did/did not undergo ART treatment. Placental abnormalities were particularly elevated in ART compared to non-ART deliveries having the same diagnosis.

Pregnancy outcomes among women with endometriosis and fibroids: registry linkage study in Massachusetts.

BACKGROUND: Endometriosis and uterine fibroids are common gynecologic conditions associated with a greater risk for infertility. Previous research has suggested that these conditions are associated with adverse pregnancy outcomes, potentially because of increased utilization of fertility treatments. OBJECTIVE: Our objective was to investigate whether women with a history of endometriosis or fibroids had a greater risk for adverse pregnancy outcomes and whether this risk varied by infertility history and fertility treatment utilization. STUDY DESIGN: Deliveries (2013-2017) recorded in Massachusetts' vital records were linked to assisted reproductive technology data, hospital stays, and all-payer claims database. We identified endometriosis and fibroids diagnoses via the all-payer claims database before index delivery. Adjusted relative risks for pregnancy complications were modeled using generalized estimating equations with a log link and Poisson distribution. The influence of subfertility or infertility and assisted reproductive technology was also investigated. RESULTS: Among 91,825 deliveries, 1560 women had endometriosis and 4212 had fibroids. Approximately 30% of women with endometriosis and 26% of women with fibroids experienced subfertility or infertility without utilizing assisted reproductive technology, and 34% of women with endometriosis and 21% of women with fibroids utilized assisted reproductive technology for the index delivery. Women with a history of endometriosis or fibroids were at a greater risk for pregnancy-induced hypertension, preeclampsia, or eclampsia (endometriosis relative risk, 1.17; fibroids relative risk, 1.08), placental abnormalities (endometriosis relative risk, 1.65; fibroids relative risk, 1.38), and cesarean delivery (endometriosis relative risk, 1.22; fibroids relative risk, 1.17) than women with no history of those conditions. Neonates born to women with a history of endometriosis or fibroids were also at a greater risk for preterm birth (endometriosis relative risk, 1.24; fibroids relative risk, 1.17). Associations between fibroids and low birthweight varied by fertility status or assisted reproductive technology (P homogeneity=.01) and were stronger among noninfertile women. CONCLUSION: Endometriosis or fibroids increased the risk for adverse pregnancy outcomes, possibly warranting differential screening or treatment.

Hospitalizations up to 8 years following delivery in assisted reproductive technology-treated and subfertile women.

OBJECTIVE: To investigate hospitalizations up to 8 years after live birth among women who used assisted reproductive technology (ART) or who were subfertile compared with women who conceived naturally. DESIGN: Retrospective cohort. SETTING: Deliveries among privately insured women aged ≥18 years between 2004 and 2017 from Massachusetts state vital records were linked to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System and hospital observational/inpatient stays. PATIENT(S): We compared patients with ART, medically assisted reproduction (MAR), and unassisted subfertile (USF) delivery with those with fertile delivery. INTERVENTION(S): NA. MAIN OUTCOME MEASURE(S): Postdelivery hospitalization information was derived from the International Classification of Diseases codes for discharges and combined by type. The relative risks and 95% confidence intervals (CIs) of hospitalization for up to the first 8 years postdelivery were modeled. RESULT(S): Among 492,515 deliveries, 5.6% used ART, 1.6% used MAR, and 1.8% were USF. Compared with fertile deliveries, deliveries that used ART or MAR or were USF were more likely to have hospital utilization (inpatient or observational stay) for any reason for up to 8 years of follow-up (USF, adjusted relative risk [aRR], 1.18 [95% CI, 1.12-1.25]; MAR, aRR, 1.20 [1.13-1.27]; and ART, aRR, 1.29 [1.25-1.34]). Assisted reproductive technology deliveries had an increased risk of hospitalization for conditions of the cardiovascular system (aRR, 1.31 [95% CI, 1.20-1.41]), overweight/obesity (aRR, 1.30 [1.17-1.44]), diabetes (aRR, 1.25 [1.05-1.49]), reproductive tract (aRR, 1.62 [1.47-1.79]), digestive tract (aRR, 1.39 [1.30-1.49]), thyroid (aRR, 2.02 [1.80-2.26]), respiratory system (aRR, 1.13 [1.03-1.24]), and cancer (aRR, 1.40 [1.18-1.65]) up to 8 years after delivery. Deliveries with MAR and subfertility had similar patterns of hospitalization as ART deliveries. CONCLUSION(S): Women who conceived through fertility treatment or experienced subfertility were at increased risk of subsequent hospitalization resulting from a variety of chronic and acute conditions.

Influence of subfertility and assisted reproductive technology treatment on mortality of women after delivery.

OBJECTIVE: To compare incidence, risk factors, and etiology of women's deaths in fertile, subfertile, and undergoing assisted reproductive technology (ART) in the years after delivery. DESIGN: Retrospective cohort. SETTING: University hospital. PATIENT(S): Women who had delivered in Massachusetts. INTERVENTION(S): This study used data from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System linked to vital records, hospital stays, and the Massachusetts death file. Mortality of patients delivered from 2004-2013 was evaluated through 2015. The exposure groups, determined on the basis of the last delivery, were ART-treated (linked to Society for Assisted Reproductive Technology Clinic Outcome Reporting System), subfertile (no ART but with indicators of subfertility including birth certificate checkbox for fertility treatment, prior hospitalization for infertility [International Classification of Disease codes 9 628 or V23], and/or prior delivery with checkbox or ART), or fertile (neither ART nor subfertile). Numbers (per 100,000 women-years) and causes of death were obtained from the Massachusetts death file. MAIN OUTCOME MEASURE(S): Mortality of women after delivery in each of the three fertility groups and the most common etiology of death in each. RESULT(S): We included 483,547 women: 16,429 ART, 11,696 subfertile, and 455,422 fertile among whom there were 1,280 deaths with 21.1, 25.5, and 44.7 deaths, respectively, per 100,000 women-years. External causes (violence, accidents, and poisonings) were the most common reasons for death in the fertile group. Deaths occurred on average 46 months after delivery. When external causes of death were removed, there were 19.1, 17.0, and 25.6 deaths per 100,000 women-years and leading causes of death in all groups were cancer and circulatory problems. CONCLUSION(S): The study presents reassuring data that death rates within 5 years of delivery in ART-treated and subfertile women do not differ from those in fertile women.

The Association of Concomitant Maternal Marijuana Use on Health Outcomes for Opioid Exposed Newborns in Massachusetts, 2003-2009.

This population-based study showed that maternal opioid plus marijuana use during pregnancy was associated with increased odds of prematurity and low birth weight but lower odds of neonatal abstinence syndrome and prolonged hospitalization compared with opioid exposure without marijuana use. Further research should evaluate the biologic mechanisms responsible for these outcomes.

Factors associated with increased odds of cesarean delivery in ART pregnancies.

OBJECTIVE: To quantify the effect of medical and obstetrical factors on the odds of cesarean delivery, comparing assisted reproductive technology (ART)-treated women and women with subfertility not treated with ART versus fertile women. DESIGN: Retrospective cohort. SETTING: Not applicable. PATIENT(S): Singleton deliveries to primiparous women; with the source of this data being the Massachusetts vital and hospital records linked to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System data (2004-2010). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Mode of delivery. RESULT(S): The 173,130 deliveries included 5,768 ART-treated, 2,657 subfertile (1,627 non-ART medically assisted reproduction [MAR] and 1,030 unassisted infertile), and 164,705 fertile pregnancies and 117,743 vaginal and 55,387 cesarean deliveries. ART-treated women were older, more often white and non-Hispanic, and with more private insurance, previous uterine surgery, gestational diabetes, pregnancy hypertension, bleeding, and placental complications than fertile women. Overall rates of cesarean delivery were 45.7%, 43.3%, and 31.1% for ART-treated, subfertile, and fertile women and 41.7% and 45.9% for MAR and unassisted infertile deliveries. When adjusted for demographics, underlying medical factors, previous uterine surgery, and placental and delivery complications, adjusted odds ratios (ORs) compared with fertile women were 1.27 for ART-treated and 1.15 for subfertile women, with greater odds among unassisted infertile (OR 1.26) but not MAR (OR 1.09) women. The strongest confounders of odds of cesarean delivery were age and previous uterine surgery. CONCLUSION(S): ART and unassisted infertility were associated with greater odds of cesarean compared with fertile women. Underlying medical and obstetrical risks had strong confounding effects strongly attenuating the odds for cesarean delivery.

Inpatient hospitalizations in women with and without assisted reproductive technology live birth.

PURPOSE: The aim of this study is to evaluate frequency of hospitalization before, during, and after assisted reproductive technology (ART) treatment by cycle outcome. METHODS: Six thousand and one hundred thirty women residing in Massachusetts undergoing 17,135 cycles of ART reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SARTCORS) from 2004 to 2011 were linked to hospital discharges and vital records. Women were grouped according to ART treatment cycle outcome as: no pregnancy (n = 1840), one or more pregnancies but no live birth (n = 968), or one or more singleton live births (n = 3322). Hospital delivery discharges during 1998-2011 were categorized as occurring before, during, or after the ART treatment. The most prevalent ICD-9 codes for non-delivery hospital discharges were compared. Groups were compared using chi square test using SAS 9.3 software. RESULTS: The proportion of any hospitalization was 57.0, 58.3, and 91.3% for women with no pregnancy, no live birth, and ART singleton live birth, respectively; the proportion of non-delivery hospitalizations was 30.4, 31.0, and 28.3%, respectively. The non-ART delivery proportion after ART treatment did not differ by group (33.4, 36.2, and 36.9%, respectively, p = 0.17). Most frequent non-delivery diagnoses (including fibroids, obesity, ectopic pregnancy, depression, and endometriosis) also did not differ by group. A secondary analysis limited to only women with no delivery discharges before the first ART cycle showed similar results. CONCLUSIONS: All groups had live birth deliveries during the study period, suggesting an important contribution of non-ART treatment or treatment-independent conception to overall delivery and live births. Hospitalizations not associated with delivery suggested similarity in morbidity for all ART patients regardless of success with ART treatment.

Pregnancy outcomes among women with intellectual and developmental disabilities.

BACKGROUND: There is currently no population-based research on the maternal characteristics or birth outcomes of U.S. women with intellectual and developmental disabilities (IDDs). Findings from small-sample studies among non-U.S. women indicate that women with IDDs and their infants are at higher risk of adverse health outcomes. PURPOSE: To describe the maternal characteristics and outcomes among deliveries to women with IDDs and compare them to women with diabetes and the general obstetric population. METHODS: Data from the 1998-2010 Massachusetts Pregnancy to Early Life Longitudinal database were analyzed between November 2013 and May 2014 to identify in-state deliveries to Massachusetts women with IDDs. RESULTS: Of the 916,032 deliveries in Massachusetts between 1998 and 2009, 703 (<0.1%) were to women with IDDs. Deliveries to women with IDDs were to those who were younger, less educated, more likely to be black and Hispanic, and less likely to be married. They were less likely to identify the father on the infant's birth certificate, more likely to smoke during pregnancy, and less likely to receive prenatal care during the first trimester compared to deliveries to women in the control groups (p<0.01). Deliveries to women with IDDs were associated with an increased risk of adverse outcomes, including preterm delivery, very low and low birth weight babies, and low Apgar scores. CONCLUSIONS: Women with IDDs are at a heightened risk for adverse pregnancy outcomes. These findings highlight the need for a systematic investigation of the pregnancy-related risks, complications, costs, and outcomes of women with IDDs.

Maternal characteristics and pregnancy outcomes after assisted reproductive technology by infertility diagnosis: ovulatory dysfunction versus tubal obstruction.

OBJECTIVE: To examine differences in maternal characteristics and pregnancy outcomes between women with ovulatory dysfunction (OD) and women with tubal obstruction (TO) who underwent assisted reproductive technology (ART). DESIGN: Retrospective cohort study. SETTING: Centers for Disease Control and Prevention. PATIENT(S): Exposed and nonexposed groups were selected from the 2000-2006 National ART Surveillance System linked with live-birth certificates from three states: Florida, Massachusetts, and Michigan. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Maternal characteristics and pregnancy outcomes, including newborn's health status right after delivery (Apgar score, <7 vs. ≥ 7) as the study outcome of interest, were assessed among women with OD/polycystic ovary syndrome (PCOS) and TO who used ART. RESULT(S): A significantly higher prevalence of women with OD/PCOS were younger (<35 years of age; 65.7% vs. 48.9%), were white (85.4% vs. 74.4%), had higher education (29.4% vs. 15.6%), and experienced diabetes (8.8% vs. 5.3%) compared with those having TO. The odds of having a lower (<7) Apgar score at 5 minutes were almost twice as high among newborns of women with OD/PCOS compared with those with TO (crude odds ratio, 1.86; 95% confidence interval [CI], 1.31, 2.64; adjusted odds ratio, 1.90; 95% CI, 1.30, 2.77). CONCLUSION(S): Women with OD/PCOS who underwent ART have different characteristics and health issues (higher prevalence of diabetes) and infant outcomes (lower Apgar score) compared with women with TO.

States Monitoring Assisted Reproductive Technology (SMART) Collaborative: data collection, linkage, dissemination, and use.

Assisted reproductive technology (ART) refers to fertility treatments in which both eggs and sperm are handled outside the body. The Centers for Disease Control and Prevention (CDC) oversees the National ART Surveillance System (NASS), which collects data on all ART procedures performed in the United States. The NASS, while a comprehensive source of data on ART patient demographics and clinical procedures, includes limited information on outcomes related to women's and children's health. To examine ART-related health outcomes, CDC and three states (Massachusetts, Florida, and Michigan) established the States Monitoring ART (SMART) Collaborative to evaluate maternal and perinatal outcomes of ART and improve state-based ART surveillance. To date, NASS data have been linked with states' vital records, disease registries, and hospital discharge data with a linkage rate of 90.2%. The probabilistic linkage methodology used in the SMART Collaborative has been validated and found to be both accurate and efficient. A wide breadth of applied research within the Collaborative is planned or ongoing, including examinations of the impact of insurance mandates on ART use as well as the relationships between ART and birth defects and cancer, among others. The SMART Collaborative is working to improve state-based ART surveillance by developing state surveillance plans, establishing partnerships, and conducting data analyses. The SMART Collaborative has been instrumental in creating linked datasets and strengthening epidemiologic and research capacity for improving maternal and infant health programs and evaluating the public health impact of ART.

Smoking among pregnant women with disabilities.

PURPOSE: The purpose of this study was to examine the prevalence of smoking before, during, and after pregnancy among a representative sample of Massachusetts women with and without disabilities. METHODS: Data from the 2007 to 2009 Massachusetts Pregnancy Risk Assessment Monitoring System survey were used to estimate the prevalence of smoking by disability status. MAIN FINDINGS: Disability prevalence was 4.8% (n = 204) among Massachusetts women giving birth during 2007 through 2009. The prevalence of smoking during the 3 months before pregnancy among women with disabilities was 37.3% (95% CI, 28.3-47.2%) compared with 18.3% (95% CI, 16.6-20.1%) among women without disabilities. Similarly, 25.2% (95% CI, 17.3-35.2%) of women with disabilities, compared with 9.4% of women without disabilities (95% CI, 8.1-10.8%), smoked during the last trimester of their pregnancy, and 32.1% of women with disabilities (95% CI, 23.5-42.1%) compared with 12.5% of women without disabilities (95% CI, 11.1-14.1%), smoked after pregnancy. In the multivariate logistic regression models, women with disabilities had significantly higher risks of smoking before, during and after pregnancy than women without disabilities (adjusted relative risk [aRR], 1.7 [95% CI, 1.2-2.2]; aRR, 1.9 [95% CI, 1.3-2.8]; aRR, 1.8 [95% CI, 1.3-2.5], respectively) while adjusting for race/Hispanic ethnicity, marital status, education, age, household poverty status, and infant's birth year. IMPLICATIONS: Women with disabilities are more likely to smoke before, during, and after their pregnancy and less likely to quit smoking during pregnancy. Efforts to integrate and target pregnant women with disabilities in smoking-cessation programs are vital.