A Major Public Health Issue: The High Incidence of Falls during Pregnancy

Kari Dunning; Grace LeMasters; Amit Bhattacharya

Disclosures

Maternal and Child Health Journal. 2010;14(5):720-725. 

In This Article

Discussion

Even though physicians presumably advise women on inevitable instability during pregnancy due to changes in center of gravity and loosening of joints, one in four fall, and one in ten fall two or more times over just a 9 month gestation. Further, these falls caused 10.0% to seek obtain medical attention which further increases obstetrical costs. These are astounding numbers as this public health problem is completely preventable. Most falls were associated with slippery floors, wearing inappropriate shoes and using insufficient safety measures such as holding on to stair hand rails. Further, carrying additional loads was a factor in 28.7% of falls as pregnancy in itself already compromises vision of the feet and floors. The fact that most of these falls occurred during the last trimester supports this concern. Two recent longitudinal studies showed increases in postural sway during second and third trimesters, indicating additional instability.[19,20]

These findings regarding falls agree with previous research showing younger women are at higher risk for injury due to trauma during pregnancy.[1,21–23] Younger women may be more likely to be active than those over 35 years, which would contribute to the higher incidence of falls.

Our data show that fall rates for pregnant women are similar to those of elderly persons living in the community, estimated at 25% for those 70 years of age and 35% for those over 75.[24] Fracture rates of 5% among those who fell also are similar in our sample compared to the elderly.[25] This comparison is important as seldom is it recognized that pregnant women should receive the same cautionary warnings e.g. wearing flat rubber soled shoes that the elderly receive.

Rates of reported emergency department visits due to a fall in our participants aged 20–24 years were 4826 per 100,000 compared with 2337 per 100,000 for age matched women.[26] Hospital admission rates due to a fall are 9–28 times larger (depending on age) during pregnancy compared to all women aged 20–39 in the same county.[26] This observed difference may be due to a higher rate of serious falls in pregnant women or a tendency to admit them in order to evaluate fetal status; nonetheless, these events increase medical care costs.

Falls due to reported physical violence were minimal; of the 1070 women who fell, only eight (0.7%) women reported their fall was associated with being ''purposefully pushed or struck''. Prevalence of violence during pregnancy has been shown to range from 0.9 to 20%.[27] The survey used in this study only asked about violence associated with the fall, therefore cannot be compared to direct rates of overall violence during pregnancy. There are no studies that have investigated falls due to violence during pregnancy. One explanation for this lower reporting of violence may be that women who were physically assaulted were more likely to be non respondents or did not report the violence.

Although obvious strengths of this study include the population based study design and relatively large sample size, there are limitations such as possible recall or participation bias. To minimize recall bias, women were contacted within 8 weeks of giving birth. We believe participation bias is also minimal because the fall rate among women who did not complete the full survey but did complete the non participant postcard survey was 30.8% vs. 26.8% among participants. Further, fall rates did not decrease from the early responders (phone and internet) to the later responders (first and second mailing). Because subjects were identified through birth certificates, falls resulting in fatalities to mother or child, estimated at 0.1 per 100,000 live births[22] are not available but are rare events. Authorization to review medical records for validation of medical attention was limited, but this has been shown to occur even in long term prospective studies due to privacy concerns.[28] Finally, it is possible that medical attention sought due to a fall was dependent on insurance but this information was not collected.

In conclusion, the public health importance of loss of balance and falls during pregnancy is obvious as one in four women fell during pregnancy. This study should be used as a basis for developing in-depth intervention for pregnancy regarding risk factors for falls and good fall prevention strategies. Based on this study, specific tips that may help decrease falls during pregnancy include: avoid slippery floors; when walking on stairs, hold on to the railand do not carry items or children; wear shoes that are flat, rubber soled and not loose; try not to hurry; be careful when carrying children, walking on unlevel surfaces (e.g. grass) or when performing any activity that obstructs your view. A pamphlet in the physician waiting area with fall prevention tips may be beneficial. Physicians may want to target higher risk women including those <30 years old and women with gestational diabetes.

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