A recent study investigated the critical impact of social and geographical factors on the outcome of pregnancies diagnosed with major congenital heart disease (mCHD). Researchers examined the relationship between socioeconomic status (SES), remoteness of residence (RoR) from a tertiary fetal cardiology center, and the rate of termination of pregnancy (TOP). Therefore, this analysis specifically highlighted the role of delayed Prenatal CHD Diagnosis as a mediating factor.
The retrospective population-based cohort study included 1091 pregnancies with mCHD in Alberta, Canada, spanning from 2008 to 2021. The team used structural equation modeling and mediation analysis to test the direct and indirect links between RoR, SES, and the rate of TOP. Furthermore, the analysis adjusted for maternal age, parity, and the presence of a syndromic diagnosis. This robust methodology helps explain the complex interplay of factors influencing difficult pregnancy decisions.
Out of the included pregnancies, 18.6% (203 cases) ended in TOP. Notably, a lower rate of TOP occurred when the diagnosis was made at or after 22 weeks of gestation (8.8%) compared to earlier diagnosis (27.2%). Consequently, lower SES and increased remoteness were both independently associated with a later diagnosis of mCHD. This finding suggests that access to specialized care directly influences the timing of diagnosis.
Understanding Delayed Prenatal CHD Diagnosis
The mediation analysis revealed that the gestational age (GA) at diagnosis significantly mediated the relationship between both RoR and SES with the TOP rate. In fact, RoR and SES impacted TOP primarily through their effect on the timing of the diagnosis. Therefore, policies aiming to improve outcomes must target timely access to specialized fetal cardiology services.
These results align with global evidence indicating that socioeconomic barriers limit access to optimal prenatal care and screening, especially in developing nations. Studies in India show a significant urban-rural divide where newborns in rural areas frequently face a delayed diagnosis of critical heart defects, leading to higher mortality rates. Moreover, prenatal detection rates for critical congenital heart defects (CCHD) vary widely worldwide, from as low as 13% to over 85%, emphasizing systemic access issues. Low household income and a lack of private insurance often correlate with a lower rate of prenatal diagnosis in international cohorts. Consequently, improving early screening access serves as a crucial intervention point.
Implications for Clinical Practice in India
Delayed diagnosis presents a major challenge in clinical settings across India. While the total number of trained pediatric cardiologists is increasing, there remains a need for more specialists, particularly in rural and district-level hospitals. Furthermore, limited data from Indian centers suggest that high rates of TOP following a prenatal diagnosis may indicate sub-optimal utilization of fetal echocardiography services. Because a planned delivery at a tertiary cardiac center improves neonatal survival and surgical outcomes for prenatally diagnosed CHD, timely and equitable access to specialized care is paramount.
In summary, the study underscores that social determinants of health—remoteness and SES—have a powerful, indirect influence on pregnancy outcomes via the timing of diagnosis. Thus, improving equitable access to tertiary fetal cardiology centers, enhancing provider training in remote areas, and addressing financial barriers are essential steps. These interventions can facilitate earlier Prenatal CHD Diagnosis and ensure comprehensive counseling for parents facing complex decisions.
Frequently Asked Questions
Q1: How does socioeconomic status (SES) influence the termination of pregnancy (TOP) rate for mCHD?
Lower SES and increased remoteness of residence indirectly lead to a lower rate of TOP. This happens because these factors cause a delay in the diagnosis of mCHD, pushing the diagnosis past the second trimester (22 weeks), which is strongly associated with a lower rate of termination.
Q2: What is the main finding regarding the timing of diagnosis and pregnancy outcome?
The gestational age at which mCHD is diagnosed acts as a mediator. A diagnosis made at 22 weeks’ gestation or later is significantly associated with a lower likelihood of the pregnancy ending in TOP compared to an earlier diagnosis.
Q3: Why is earlier prenatal diagnosis of mCHD critical in a country like India?
Earlier diagnosis is critical because it allows for timely referral and a planned delivery at a tertiary cardiac facility, which is proven to improve neonatal survival and surgical outcomes. Moreover, it provides parents with adequate time for comprehensive counseling and informed decision-making.
References
- Bennett S et al. Impact of socioeconomic status and remoteness of residence on pregnancy outcome in major congenital heart disease: mediation analysis. Ultrasound Obstet Gynecol. 2026 Jan 03. doi: 10.1002/uog.70145. PMID: 41483458.
- Socioeconomic barriers to prenatal diagnosis of critical congenital heart disease. NIH.
- Prenatal diagnosis and prevalence of critical congenital heart defects: an international retrospective cohort study. NIH.
- Outcomes of Infants With Prenatally Diagnosed Congenital Heart Disease Delivered in a Tertiary-care Pediatric Cardiac Facility. NIH.
- Fetal cardiology in India – At the crossroads. PMC – NIH.
- Impact of Prenatal Diagnosis on the Management and Prognosis of Infants with Congenital Heart Disease- A Retrospective Study. ijnmr.
- Early Diagnosis, Treatment & India’s CHD Reality | Insights by Dr. Vikas Kohli. YouTube.