Trend and risk Factors for Severe Peripartum Maternal morbidity - a population-based Cohort Study

OBJECTIVES

While the rates of maternal mortality in developed countries have remained low in recent years, rates of severe maternal morbidity (SMM) are still increasing in high income countries. As a result, SMM is currently used as a measure of maternity care level. The aim of this study was to investigate the prevalence and risk factors of SMM surrounding childbirth.

METHODS

A nested case-control study was performed between the years 2013-2018. SMM was defined as peripartum hospitalization involving intensive care unit (ICU). A comparison was conducted between parturient with SMM to those without, randomly matched for delivery mode and date of birth in a 1:1 ratio. Multivariable logistic regression models were used to evaluate the independent association between SMM and different maternal and pregnancy characteristics.

RESULTS

During the study period, 96,017 live births took place, of which 144 (1.5 per 1,000 live births-0.15%) involved SMM with ICU admissions. Parturient with SMM were more likely to have a history of 2 or more pregnancy losses (18.2% vs. 8.3%, p = 0.004), deliver preterm (48.9% vs. 8.8%, p < 0.001), and suffer from placenta previa (11.9% vs. 1.5%, p < 0.001), and/or placenta accreta (9.7% vs. 1.5%, p = 0.003). Several significant and independent risk factors for SMM were noted in the multivariable regression models: preterm delivery, history of ≥ 2 pregnancy losses, grand-multiparity, Jewish ethnicity, and abnormal placentation (previa or accreta).

CONCLUSIONS FOR PRACTICE

SMM rates in our cohort were lower than reported in developed countries. An independent association exists between peripartum maternal ICU admissions and several demographic and clinical risk factors, including preterm birth and abnormal placentation.

The maternal health of American Indian and Alaska Native people: A scoping review

Indigenous people in the United States experience disadvantage in multiple domains of health. Yet, their maternal health receives limited research attention. With a focus on empirical research findings, we conduct a scoping review to address two questions: 1) what does the literature tell us about the patterns and prevalence of maternal mortality and morbidity of American Indian and Alaska Native (AI/AN) people? and 2) how do existing studies explain these patterns? A search of CINAHL, Embase and Medline yielded 4757 English-language articles, with 66 eligible for close review. Of these, few focused specifically on AI/AN people's maternal health. AI/AN people experience higher levels of maternal mortality and morbidity than non-Hispanic White people, with estimates that vary substantially across samples and geography. Explanations for the maternal health of AI/AN people focused on individual factors such as poverty, cultural beliefs, and access to healthcare (e.g. lack of insurance). Studies rarely addressed the varied historical and structural contexts of AI/AN tribal nations, such as harms associated with colonization and economic marginalization. Research for and by Indigenous communities and nations is needed to redress the effective erasure of AI/AN people's maternal health experiences and to advance solutions that will promote their health and well-being.

Investigating the impact of structural racism on black birthing people - associations between racialized economic segregation, incarceration inequality, and severe maternal morbidity

Black birthing people are twice as likely to experience severe maternal morbidity (SMM) as their white counterparts. Structural racism provides a framework for understanding root causes of perinatal health disparities. Our objective was to investigate associations between measures of structural racism and severe maternal morbidity (SMM) among Black birthing people in the US. We linked delivery hospitalizations for Black birthing people in the National Inpatient Sample (2008-2011) with data from the American Community Survey 5-year estimates and the Vera Institute of Justice Incarceration Trends datasets (2008-2011). Structural racism measures included the Index of Concentration at the Extremes for race and income (i.e., racialized economic segregation) and Black-white incarceration inequality, assessed as quintiles by hospital county. Multilevel logistic regression assessed the relationship between these county-level indicators of structural racism and SMM. Black birthing people delivering in quintiles 5 (concentrated deprivation; OR = 1.45, 95% CI = 1.16-1.81) and 3 (OR = 1.27, 95% CI = 1.04-1.56) experienced increased odds of SMM compared to those in quintile 1 (concentrated privilege). After adjusting for individual characteristics, obstetric comorbidities, and hospital characteristics the odds of SMM remained elevated for Black birthing people delivering in quintiles 5 (aOR = 1.32, 95% CI = 1.02-1.71) and 3 (aOR = 1.24, 95% CI = 1.02-1.51). Delivering in the quintile with the highest incarceration inequality (Q5) was not significantly associated with SMM (aOR = 0.95, 95% CI = 0.72-1.25) compared to those delivering in counties with the lowest incarceration inequality (Q1). In this national-level study, racialized economic segregation was associated with SMM among Black birthing people. Our findings highlight the need to promote maternal and perinatal health equity through actionable policies that prioritize investment in communities experiencing deprivation.

Neighborhood deprivation and severe maternal morbidity in a medicaid-Insured population in Georgia

BACKGROUND

Despite growing acceptance of the role of context in shaping perinatal risk, data on how neighborhood factors may identify high-risk obstetric patients is limited. In this study, we evaluated the effect of neighborhood deprivation and neighborhood racial composition on severe maternal morbidity (SMM) among persons delivered in a large public health system in Atlanta, Georgia.

METHODS

We conducted a population cohort study using electronic medical record data on all deliveries at Grady Memorial Hospital during 2011-2020. Using residential zip codes, we calculated neighborhood deprivation index based on data from the US Census. We used log-binomial regression with generalized estimating equations to estimate crude and adjusted relative risks (aRR) and 95% confidence intervals (CI) for the association between tertile of neighborhood deprivation and SMM, adjusting for demographic, clinical, and neighborhood-level (racial composition, food desert, and transit access) covariates.

RESULTS

Among 25,257 deliveries, 6.2% (1566) experienced SMM. Approximately 24.0%, 32.0%, and 44.0% of women lived in the lowest, middle, and highest tertile of neighborhood deprivation, respectively and 64.9% lived in a neighborhood with majority non-Hispanic Black residents. After adjustment, there was no association between neighborhood deprivation and SMM (aRR: 1.0 (0.8, 1.1)) or residence in a majority Black neighborhood and SMM (aRR:1.0 (0.9, 1.2)).

CONCLUSION

In this safety-net hospital, residence in a high deprivation or majority Black neighborhood did not predict SMM at or following delivery. Individual-level social determinants may better explain variation in risk, particularly in high-burden populations.

Comparison of global indicators for severe maternal morbidity among South Korean women who delivered from 2003 to 2018: a population-based retrospective cohort study

Background

Even though several severe maternal morbidity (SMM) indicators exist globally, indicators that can serve as international standards are needed. Therefore, this study aimed to compare the SMM risk assessment using four international indicators and identify the factors underlying the differences among the risk assessments obtained by the various indicators.

Methods

This study used the National Health Insurance delivery cohort in South Korea from 2003 to 2018. SMM was estimated using four indicators: the United States Centers for Disease Control and Prevention (US-CDC) SMM algorithm, the American College of Obstetricians and Gynecologists (ACOG) gold standard guidelines, Zwart et al.’s indicators for the Netherlands, and the European Network on Severe Acute Maternal Morbidity (EURONET-SAMM) index. Generalized estimating equations models were used to identify the relationships between SMM indicators and risk factors.

Results

The SMM incidence rates in 6,421,091 deliveries, were 2.36%, 3.12%, 0.31%, and 1.36% using the US-CDC, ACOG, Zwart et al.’s, and EURONET SAMM indicators, respectively. In sub indicators, hemorrhage-related codes constituted the highest proportion of all SMM indicators. Advanced maternal age was related to high risk in all four SMM indicators (US-CDC: 40–44 years, RR 1.67, 95% CI 1.63–1.71; ACOG’s guidelines: 40–44 years, RR 1.52, 95% CI 1.49–1.56; Zwart’s indicators: RR 2.72, 95% CI 2.55–2.90; EURONET-SAMM: RR 2.04, 95% CI 1.97–2.11) compared to those aged 25–29 years. In residential area, women who lived in rural area had approximately 1.2- to 1.5-fold higher risk of SMM compared to those who lived in Seoul. Additionally, inadequate prenatal care was associated with a 1.1- to 1.4-fold higher risk of SMM compared to adequate prenatal care.

Conclusions

SMM was associated with maternal age, socioeconomic status, and adverse obstetric factors using various international SMM indicators. Further studies are needed to further determine risk and preventable factors for SMM and to identify more specific causes associated with the frequent sub-indicators of SMM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01482-y.

There are several indicators of severe maternal morbidity (SMM) globally, but indicators that can serve as international standards are not exist yet. This study compared the SMM risk assessment using four international indicators such as US-CDC’s SMM, ACOG’s gold standard guidelines, Zwart et al.’s SMM, and EURONET-SAMM, and identify the factors underlying the differences among the risk assessments obtained by the various indicators.

This study extracted women who were aged 15–49 years, those who had childbirth in the healthcare institute during 2003 to 2018 in South Korea using the National Health Insurance database.

Of the 6,421,091 childbirth cases, the incidence of each SMM indicators were as follow: the US-CDC’s SMM: 2.4%; the ACOG’s gold standard guidelines: 3.1%; Zwart et al.’s SMM: 0.3%; the EURONET-SAMM: 1.4% indicators. In addition, the highest incidence of each sub-indicators was blood transfusion or obstetric hemorrhage which recorded more than 70% of total SMM cases. In particular, the risk factor on SMM were: advanced maternal age; living rural area; inadequate prenatal care.

In conclusion, SMM was associated with maternal age, socioeconomic status, and adverse obstetric factors using various global SMM indicators. Therefore, further studies are needed to identify more specific causes associated with the frequent sub-indicators of SMM and to determine risk and preventable factors for SMM.

Prevalence and management of severe intrapartum hypertension in patients with preeclampsia at an urban tertiary care medical center

OBJECTIVES

Data on management of severe intrapartum hypertension is lacking. The aim of this study is to explore the proportion of timely interventions in severe, persistent intrapartum hypertension treatment by exploring the prevalence and management of intrapartum hypertension trends.

STUDY DESIGN

This was a retrospective case-control study of pregnant women who delivered at the University of Chicago between January 2015 and March 2017. Patients with severe preeclampsia who underwent labor (either induced or spontaneous) were stratified into two groups: severe intrapartum hypertension and no severe intrapartum hypertension.

MAIN OUTCOME MEASURES

Type of treatment and timing to treatment of severe hypertensive episodes were explored as well as prevalence of maternal adverse outcomes.

RESULTS

A total of 95 patients with severe preeclampsia in labor were identified. In patients with persistent severe intrapartum hypertension (n = 52), 15 (28.9%) received treatment. Patients experiencing greater than three episodes of blood pressure elevation were more likely to receive treatment as compared to those with fewer episodes. There was no significant difference in severe maternal morbidity (SMM) between those treated within 60 min compared to those untreated or treated after 60 min (16.7% vs 27.5%; p = 0.71).

CONCLUSIONS

Management protocols of intrapartum hypertensive episodes are variable or not universally implemented. Inadequately treated episodes of severe intrapartum hypertension trend towards higher rates of SMM.

Severe maternal morbidity: admission shift from intensive care unit to obstetric high-dependency unit

Background

To study temporal trends of intensive care unit (ICU) admission in obstetric population after the introduction of obstetric high-dependency unit (HDU).

Methods

This is a retrospective study of consecutive obstetric patients admitted to the ICU/HDU in a provincial referral center in China from January 2014 to December 2019. The collected information included maternal demographic characteristics, indications for ICU and HDU admission, the length of ICU stay, the total length of in-hospital stay and APACHE II score. Chi-square and ANOVA tests were used to determine statistical significance. The temporal changes were assessed with chi-square test for linear trend.

Results

A total of 40,412 women delivered and 447 (1.11%) women were admitted to ICU in this 6-year period. The rate of ICU admission peaked at 1.59% in 2016 and then dropped to 0.67% in 2019 with the introduction of obstetric HDU. The average APACHE II score increased significantly from 6.8 to 12.3 (P < 0.001) and the average length of ICU stay increased from 1.7 to 7.1 days (P < 0.001). The main indications for maternal ICU admissions were hypertensive disorders in pregnancy (39.8%), cardiac diseases (24.8%), and other medical disorders (21.5%); while the most common reasons for referring to HDU were hypertensive disorders of pregnancy (46.5%) and obstetric hemorrhage (43.0%). The establishment of HDU led to 20% reduction in ICU admission, which was mainly related to obstetric indications.

Conclusions

The introduction of HDU helps to reduce ICU utilization in obstetric population.

An Exploratory Spatiotemporal Analysis of Socio-Environmental Patterns in Severe Maternal Morbidity

OBJECTIVES

Severe Maternal Morbidity (SMM) is a group of pregnancy complications in which a woman nearly dies. Despite its increasing prevalence, little research has evaluated geographic patterns of SMM and the underlying social determinants that influence excess risk. This study examined the spatial clustering of SMM across South Carolina, US, and its associations with place-based social and environmental factors.

METHODS

Hospitalized deliveries from 2012 to 2017 were analyzed using Kulldorff's spatial scan statistic to locate areas with abnormally high rates of SMM. SMM patients inside and outside risk clusters were compared using Generalized Estimating Equations (GEE) to determine underlying individual and community-level risk factors.

RESULTS

GEE models revealed that the odds of living in a high-risk SMM21 (SMM including blood transfusions) cluster was 2.49 times higher among Black patients (p < .001) compared to those outside of a high-risk cluster. Women residing in a high-risk SMM20 (SMM excluding blood transfusions) cluster were 1.38 times more likely to experience the most number of extremely hot days and 1.70 times more likely to present with obesity than women in a low-risk SMM cluster (p < .001).

CONCLUSIONS

This study is the first to characterize the geographic clustering of SMM risk in the US. Our geospatial approach contributes a novel understanding to factors which influence SMM beyond patient-level characteristics and identifies the impact of hot ambient temperature on maternal morbidity. Findings address an important literature gap surrounding place-based risk factors by explaining the contextual social and built environmental factors that drive SMM risk.

Risk Factors for Dual Burden of Severe Maternal Morbidity and Preterm Birth by Insurance Type in California

Objectives

Among childbearing women, insurance coverage determines degree of access to preventive and emergency care for maternal and infant health. Maternal-infant dyads with dual burden of severe maternal morbidity and preterm birth experience high physical and psychological morbidity, and the risk of dual burden varies by insurance type. We examined whether sociodemographic and perinatal risk factors of dual burden differed by insurance type.

Methods

We estimated relative risks of dual burden by maternal sociodemographic and perinatal characteristics in the 2007–2012 California birth cohort dataset stratified by insurance type and compared effects across insurance types using Wald Z-statistics.

Results

Dual burden ranged from 0.36% of privately insured births to 0.41% of uninsured births. Obstetric comorbidities, multiple gestation, parity, and birth mode conferred the largest risks across all insurance types, but effect magnitude differed. The adjusted relative risk of dual burden associated with preeclampsia superimposed on preexisting hypertension ranged from 9.1 (95% CI 7.6–10.9) for privately insured to 15.9 (95% CI 9.1–27.6) among uninsured. The adjusted relative risk of dual burden associated with cesarean birth ranged from 3.1 (95% CI 2.7–3.5) for women with Medi-Cal to 5.4 (95% CI 3.5–8.2) for women with other insurance among primiparas, and 7.0 (95% CI 6.0–8.3) to 19.4 (95% CI 10.3–36.3), respectively, among multiparas.

Conclusions

Risk factors of dual burden differed by insurance type across sociodemographic and perinatal factors, suggesting that care quality may differ by insurance type. Attention to peripartum care access and care quality provided by insurance type is needed to improve maternal and neonatal health.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-021-03313-1.

Escalating Care on Labor and Delivery

Maternal morbidity and mortality are rising due in part to the rising prevalence of chronic illness, socioeconomic and racial disparities, and advanced maternal age. Prevention of maternal adverse outcomes requires prompt escalation of care to facilities with appropriate capabilities including intensive care services. The development of obstetrical-specific risk assessment tools and protocolized care for the most common causes of maternal intensive care unit (ICU) admission has helped to reduce preventable complications. However, significant work remains to address barriers to the escalation of maternal care and minimize delays in appropriate management.

Development and validation of a risk prediction index for severe maternal morbidity based on preconception comorbidities among infertile patients

OBJECTIVE

To develop and validate a preconception risk prediction index for severe maternal morbidity (SMM), defined by the Centers for Disease Control and Prevention as indicators of a life-threatening complication, among infertile patients.

DESIGN

Retrospective analysis of live births and stillbirths from 2007 to 2017 among infertile women.

SETTING

National commercial claims database.

PATIENT(S)

Infertile women identified on the basis of diagnosis, testing, or treatment codes.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome was SMM, identified as any indicator from the Centers for Disease Control and Prevention Index except blood transfusion alone, which was found to overestimate cases. Twenty preconception comorbidities associated with a risk of SMM were selected from prior literature. Targeted ensemble learning methods were used to rank the importance of comorbidities as potential risk factors for SMM. The independent strength of the association between each comorbidity and SMM was then used to define each comorbidity's risk score.

RESULT(S)

Among 94,097 infertile women with a delivery, 2.3% (n = 2,181) experienced an SMM event. The highest risk of SMM was conferred by pulmonary hypertension, hematologic disorders, renal disease, and cardiac disease. Associated significant risks were lowest for substance abuse disorders, prior cesarean section, age ≥40 years, gastrointestinal disease, anemia, mental health disorders, and asthma. The receiver operating characteristic area under the curve for the developed comorbidity score was 0.66. Calibration plots showed good concordance between the predicted and actual risk of SMM.

CONCLUSION(S)

We developed and validated an index to predict the probability of SMM on the basis of preconception comorbidities in patients with infertility. This tool may inform preconception counseling of infertile women and support maternal health research initiatives.

Racial/Ethnic Inequities in Pregnancy-Related Morbidity and Mortality

Racism in America has deep roots that impact maternal health, particularly through pervasive inequities among Black women as compared with White, although other racial and ethnic groups also suffer. Health care providers caring for pregnant women are optimally positioned to maintain vigilance for these disparities in maternal care, and to intervene with their diverse skillsets and knowledge. By increasing awareness of how structural racism drives inequities in health, these providers can encourage hospitals and practices to develop and implement national bundles for patient safety, and use bias training and team-based training practices aimed at improving care for racially diverse mothers.

Prevalence of neonatal near miss and associated factors in Nepal: a cross-sectional study

BACKGROUND

The rate of neonatal mortality has declined but lesser than the infant mortality rate and remains a major public health challenge in low- and middle-income countries. There is an urgent need to focus on newborn care, especially during the first 24 h after birth and the early neonatal period. Neonatal near miss (NNM) is an emerging concept similar to that of maternal near miss. NNM events occur three to eight times more often than neonatal deaths. The objective of this study was to establish the prevalence of NNM and identify its associated factors.

METHODS

A hospital-based cross-sectional study was conducted in Koshi Hospital, Morang district, Nepal. Neonates and their mothers of unspecified maternal age and gestational age were enrolled. Key inclusion criteria were pragmatic and management markers of NNM and admission of newborn infants to the neonatal intensive care unit (NICU) in Koshi Hospital. Non-Nepali citizens were excluded. Consecutive sampling was used until the required sample size of 1,000 newborn infants was reached. Simple and multiple logistic regression was performed using SPSS® version 24.0.

RESULTS

One thousand respondents were recruited. The prevalence of NNM was 79 per 1,000 live births. Severe maternal morbidity (adjusted odds ratio (aOR) 4.52; 95% confidence interval (CI) 2.07-9.84) and no formal education (aOR 2.16; 95% CI 1.12-4.14) had a positive association with NNM, while multiparity (aOR 0.52; 95% CI 0.32-0.86) and caesarean section (aOR 0.44; 95% CI 0.19-0.99) had negative associations with NNM.

CONCLUSIONS

Maternal characteristics and complications were associated with NNM. Healthcare providers should be aware of the impact of obstetric factors on newborn health and provide earlier interventions to pregnant women, thus increasing survival chances of newborns.

Provider Attitudes on Regionalization of Maternity Care: A National Survey

OBJECTIVES

To explore provider perspectives surrounding national guidelines proposing regionalization of maternal care.

METHODS

An 18-item survey focused on provider attitudes and practices surrounding regionalized maternity care was administered to a national sample of practicing obstetricians. We classified respondants reporting less than 500 annual deliveries at their hospital as low-volume providers and those practicing at hospitals performing 500 or more annual deliveries as high-volume providers. We compared responses according to hospital delivery volume using univariate analysis.

RESULTS

Of the 497 physicians surveyed, 278 people responded (56%) with 229 currently practicing obstetrics. The median annual delivery volume amongst respondents was 200 (interquartile range 100-1900) with 146 (63.7%) practicing in low-volume delivery centers. The need for medical or surgical expertise was the most commonly reported indication for maternal transfer (19.7%) and independent of practice setting. Ninety-six percent of providers agreed with the concept of regionalization, but respondents in high-volume centers reported higher familiarity with the levels of maternal care paradigm compared to their low-volume counterparts (81.9% v. 62.3%, p < 0.01). Financial factors (60.3%), geography (48.9%), and access to care (43.2%) were the most cited major barriers to regionalization. High-volume providers endorsed geography as a major barrier more often than low-volume providers (57.8% v. 43.8%, p = 0.04).

CONCLUSIONS FOR PRACTICE

Obstetricians may agree with the concept of regionalized maternity care but also identify significant barriers to its implementation. Early and frequent engagement of providers reflecting the diversity of delivery centers in a region is a simple but necessary step in any attempts to designate levels of maternal care.

Severe maternal morbidity in preterm cesarean delivery: A systematic review and meta-analysis

OBJECTIVE

More than half of extremely preterm infants are delivered by cesarean section. Few data are available about severe maternal morbidity (SMM) of these extremely preterm cesarean. The objective was to determine whether gestational age under 26 weeks of gestation (weeks) was associated with an increased risk of SMM compared with gestational age between 26 and 34 weeks in women having a cesarean delivery.

MATERIAL AND METHODS

We searched MEDLINE, ISI Web of Science, the Cochrane Database, PROSPERO, and ClinicalTrials.gov on January 31, 2020. The search strategy clustered terms describing SMM and preterm cesarean delivery. No restrictions on language, publication status, and study design were applied. Abstracts were included if there was sufficient information to assess study quality. The authors of all identified studies were contacted to request for aggregated data. Relative risks (RR) were calculated using the inverse variance method. The primary outcome was SMM as defined in each study. We analyzed data on preterm cesarean deliveries between 22 and 34 weeks. The protocol was registered in PROSPERO (registration: CRD42019128644).

RESULTS

Six studies involving 45,572 women (3,440 delivering < 26 weeks; 42,132 delivering between 26 and 34 weeks) were included. SMM occurred in 607 women (17.6 %) < 26 weeks and 4,483 women (10.6 %) between 26 and 34 weeks. Gestational age < 26 weeks was associated with an increased risk of SMM (RR, 1.65; 95 % CI [Confidence Interval], 1.52-1.78; I² = 40 %). Gestational age < 26 weeks remained associated with SMM in the subgroup analyses depending on the type of the study (prospective or retrospective), country of the study (European or non-European), and high quality of the study. A sensitivity analysis showed that gestational age < 25 weeks was also associated with SMM in preterm cesarean delivery (RR, 1.66; 95 % CI, 1.50-1.83; I² = 3%).

CONCLUSIONS

Gestational age < 26 weeks was associated with an increased risk of SMM in women having a preterm cesarean delivery. Obstetricians and neonatologists should be aware of the increased risk of SMM in cesarean.

Severe maternal morbidity and Black-white differences in Washington State

OBJECTIVE

Rates of severe maternal morbidity (SMM) are significantly higher among Black women and some data suggests further worsening of these rates among hospitals with the highest proportion of Black deliveries. In this study, we sought to examine whether Black women have higher SMM in Washington State and whether this varied by hospital.

METHODS

We conducted a retrospective cohort study using linked birth-hospital discharge data from Washington State. We compared Non-Hispanic Black women with Non-Hispanic white women and excluded observations with missing hospital information. SMM was defined using an already published algorithm. We ranked hospitals into low-, medium- and high Black-serving hospitals by using proportions of deliveries to Black women among all deliveries. Multivariable logistic regression models were used to examine the association of Black women with SMM adjusted for demographics, co-morbidities and clustering within hospital.

RESULTS

In the cohort of 407,808 women, 4556 (1.12%) had SMM. High Black-serving hospitals had the highest rate of SMM (1.94%) as compared to medium Black-serving hospitals (1.16%) and low Black-serving hospitals (1.06%) (p < .01). Odds of SMM was higher in Black women (OR = 1.58, 95% CI: 1.39-1.78) and remained elevated after adjusting for demographics and the level of Black-serving hospital (aOR= 1.29, 95% CI: 1.11-1.49).

CONCLUSION

We found that the risk of SMM was higher among Black women. Hospital level performance and health outcomes stratified by maternal race and ethnicity in hospitals and hospital systems should be addressed to further reduce disparities and optimize outcomes.

Racial Differences in Pregnancy-Related Morbidity and Mortality

Racism in the United States has deep roots that affect maternal health, particularly through pervasive inequalities among black women compared with white. Anesthesiologists are optimally positioned to maintain vigilance for these disparities in maternal care, and to intervene with their unique acute critical care skills and knowledge. As leaders in patient safety, anesthesiologists should drive hospitals and practices to develop and implement national bundles for patient safety, as well as using team-based training practices designed to improve hospitals that care for racially diverse mothers.

A scoping review of severe maternal morbidity: describing risk factors and methodological approaches to inform population-based surveillance

Background

Current interest in using severe maternal morbidity (SMM) as a quality indicator for maternal healthcare will require the development of a standardized method for estimating hospital or regional SMM rates that includes adjustment and/or stratification for risk factors.

Objective

To perform a scoping review to identify methodological considerations and potential covariates for risk adjustment for delivery-associated SMM.

Search methods

Following the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews, systematic searches were conducted with the entire PubMed and EMBASE electronic databases to identify publications using the key term “severe maternal morbidity.”

Selection criteria

Included studies required population-based cohort data and testing or adjustment of risk factors for SMM occurring during the delivery admission. Descriptive studies and those using surveillance-based data collection methods were excluded.

Data collection and analysis

Information was extracted into a pre-defined database. Study design and eligibility, overall quality and results, SMM definitions, and patient-, hospital-, and community-level risk factors and their definitions were assessed.

Main results

Eligibility criteria were met by 81 studies. Methodological approaches were heterogeneous and study results could not be combined quantitatively because of wide variability in data sources, study designs, eligibility criteria, definitions of SMM, and risk-factor selection and definitions. Of the 180 potential risk factors identified, 41 were categorized as pre-existing conditions (e.g., chronic hypertension), 22 as obstetrical conditions (e.g., multiple gestation), 22 as intrapartum conditions (e.g., delivery route), 15 as non-clinical variables (e.g., insurance type), 58 as hospital-level variables (e.g., delivery volume), and 22 as community-level variables (e.g., neighborhood poverty).

Conclusions

The development of a risk adjustment strategy that will allow for SMM comparisons across hospitals or regions will require harmonization regarding: a) the standardization of the SMM definition; b) the data sources and population used; and c) the selection and definition of risk factors of interest.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40748-020-00123-1.

Clinical Implications of Maternal Disparities Administrative Data Research

Administrative data research on maternal racial disparities supports 2 broad clinical inferences. First, failure to rescue in terms of both death and severe maternal morbidity likely accounts for a significant proportion of maternal disparities. Second, risk for adverse outcomes by race is generally differential with risk for cardiovascular complications particularly high for non-Hispanic black women. These differentials suggest that underlying health conditions may represent an important contributor to overall disparities, and optimal longitudinal care utilization with nonobstetric specialists is required to mitigate risk.

Severe maternal morbidity among migrants with insecure residency status in Sweden 2000-2014: a population-based cohort study

BACKGROUND

Migrants with insecure residency status (i.e., undocumented migrants and asylum-seekers, who are denied or waiting for authorized residency) often experience social and psychosocial adversities and limited access to health care. Nonetheless, they have not been profiled on the risk of severe maternal morbidity (SMM), a sentinel measure of maternal health and maternity care.

METHODS

A cohort study on all births recorded in the Swedish Medical Birth Register from 2000-2014 (N = 1,570,472). Lacking a maternal personal identification number was used as an indicator for insecure residency status (1.3% of all births). We used Poisson regression models to estimate risk ratios of SMM in migrant women with insecure residency status compared to the Swedish-born or migrant women with long-term residency, adjusting for the calendar year of birth, maternal age, and parity.

RESULTS

Overall SMM rate among migrant women with insecure residency status was 21.5/1000 and 14.7/1000 among Swedish-born women. Compared to Swedish-born, migrants with insecure residency status had 50% higher risk of overall SMM (adjusted risk ratio (aRR)=1.54 [1.37-1.74]) and over 80% higher risk of SMM excluding transfusion-only cases (aRR=1.88 [1.37-2.57]). When compared to migrant women with long-term residency, migrant women with insecure residency also had a higher risk of SMM (overall SMM aRR=1.42 [1.26,1.61]; SMM excluding transfusion only cases aRR=1.43 [1.04,1.97]), suggesting that insecure residency conferred additional risks of SMM beyond migration.

CONCLUSION

Migrant women with insecure residency status had increased risk of severe maternal morbidity.

Long-Term Consequences of Severe Maternal Morbidity on Infant Growth and Development

OBJECTIVE

Severe maternal morbidity (SMM) is already known to be associated with adverse neonatal outcomes, however, its association with long-term deficits of weight and height, and impairment in neurodevelopment among children was not yet fully assessed. We aim to evaluate whether SMM has repercussions on the weight and height-for-age and neurodevelopmental status of the child.

METHODS

A retrospective cohort analysis with women who had SMM events in a tertiary referral center in Brazil. They were compared to a control group of women who had not experienced any SMM. Childbirth and perinatal characteristics, weight and height-for-age deficits and neurodevelopmental impairment suspicion by Denver II Test were comparatively assessed in both groups using RR and 95% CI. Multiple regression analysis was used addressing deficit of weight-for-age, height-for-age and an altered Denver Test, estimating their independent adjusted RR and 95% CI.

RESULTS

634 women with perinatal outcomes available (311 with SMM and 323 without) and 571 children were assessed. Among women with SMM, increased rates in perinatal deaths, Apgar lower than 7 at five minutes, shorter breastfeeding period, preterm birth (49.0% × 11.1%), low birthweight (45.8% × 11.5%), deficits of weight-for-age [RR 3.11 (1.60-6.04)] and height-for-age [RR 1.52 (1.06-2.19)] and altered Denver Test [RR 1.5 (1.02-2.36)] were more frequently found than in the control group. SMM was not identified as independently associated with any of the main outcomes.

CONCLUSION

SMM showed to be associated with a negative impact on growth and neurodevelopment aspects of perinatal and infant health. These findings suggest that effective health policies directed towards appropriate care of pregnancy may have an impact on the reduction of maternal, neonatal and infant morbidity and mortality.

Maternal near miss and potentially life-threatening condition determinants in patients with type 1 diabetes mellitus at a university hospital in São Paulo, Brazil: a retrospective study

Background

To date, the rates of potentially life-threatening condition (PTLC), maternal near miss (MNM) and maternal deaths in pregnant patients with type 1 diabetes mellitus (T1DM) and variables associated to it have not been studied.

Methods

This study was as a cross-sectional retrospective study conducted at São Paulo Hospital of Universidade Federal de São Paulo, a tertiary hospital that provides public medical care through the Brazilian unified health system to high-risk pregnancies. Inclusion criteria were T1DM pregnant women who delivered from January 2005 to December 2015. Three groups were established by the World Heath Organization criteria and associations were assessed using the chi-square test in between MNM and no morbidity or PLTC and no morbidity. A P value < 0.05 was considered statistically significant.

Results

The final sample included 137 patients, 8 MNM cases (5.84%), 51 PLTC (37.23%), no cases of maternal deaths and 78 patients (56.93%) did not present any complication. Moreover, there were 122 live births, resulting in a near miss rate of 65.5 per 1.000 live births in patients with T1DM. Two of the MNM cases were for clinical criteria (uncontrollable fit in both) and laboratory criteria for the other six: one patient with severe acute azotemia (creatinine > 300 μmol/ml), one patient with severe hypoperfusion (lactate > 5 mmol/L) and four of them with loss of consciousness and the presence of glucose and ketoacids in urine. PLTC criteria were studied in MNM and PLTC cases. Prolonged hospital stay was the most prevalent PLTC criteria in both groups (100% of MNM cases and 96% of PLTC), followed by renal failure in 50% of MNM cases and severe preeclampsia in 22% of PLTC cases. This study could not find any association between prenatal factors or sociodemographic characteristics with maternal morbidity.

Conclusions

MNM rate in T1DM was extremely high, and determined by complications of the primary disease or hypertensive disorders. No sociodemographic variables studied were related to maternal morbidity; therefore, we could not predict what increases MNM and PLTC in this specific population.

Substance use disorders and risk of severe maternal morbidity in the United States

BACKGROUND

The contribution of substance use disorders to the burden of severe maternal morbidity in the United States is poorly understood. The objective was to estimate the independent association between substance use disorders during pregnancy and risk of severe maternal morbidity.

METHODS

Retrospective analysis of a weighted 53.4 million delivery hospitalizations from 2003 to 2016 among females aged>18 in the National Inpatient Sample. We constructed measures of substance use disorders using diagnostic codes for cannabis, opioids, and stimulants (amphetamines or cocaine) abuse or dependence during pregnancy. The outcome was the presence of any of the 21 CDC indicators of severe maternal morbidity. Using weighted multivariable logistic regression, we estimated the association between substance use disorders and adjusted risk of severe maternal morbidity. Because older age at delivery is predictive of severe maternal morbidity, we tested for effect modification between substance use and maternal age by age group (18-34 y vs >34 y).

RESULTS

Pregnant women with an opioid use disorder had an increased risk of severe maternal morbidity compared with women without an opioid use disorder (18-34 years: aOR: 1.51; 95 % CI: 1.41,1.61, >34 years: aOR: 1.17; 95 % CI: 1.00,1.38). Compared with their counterparts without stimulant use disorders, pregnant women with a simulant use disorder (amphetamines, cocaine) had an increased risk of severe maternal morbidity (18-34 years: aOR: 1.92; 95 % CI: 1.80,2.0, >34 years: aOR: 1.85; 95 % CI: 1.66,2.06). Cannabis use disorders were not associated with an increased risk of severe maternal morbidity.

CONCLUSION

Substance use disorders during pregnancy, particularly opioids, amphetamines, and cocaine use disorders, may contribute to severe maternal morbidity in the United States.

Severe maternal morbidity among U.S.- and foreign-born Asian and Pacific Islander women in California

PURPOSE

The purpose of the study was to examine the risk of severe maternal morbidity (SMM)-a composite of serious, potentially life-threatening conditions related to childbirth-among subgroups of nulliparous women with Asian and Pacific Islander race/ethnicity.

METHODS

This study used linked hospital discharge and vital record data California to identify nulliparous Asian and Pacific Islander women from 1997 to 2012 (n = 453,525). We examined the risk of SMM for 15 Asian and Pacific Islander subgroups and compared the risk between U.S.- and foreign-born women.

RESULTS

The risk of SMM was higher among Pacific Islander women than that among Asian women (148 and 127 cases per 10,000 births, respectively). Among Asian women, the risk of SMM ranged from 94 (Korean) to 165 (Filipina) cases per 10,000 births, and among Pacific Islander women, the risk ranged from 125 (Hawaiian) to 162 (Other). With the exception of Korean and Filipina women, relative risks of SMM for U.S.- versus foreign-born Asian and Pacific Islander women were similar.

CONCLUSIONS

Differences in the risk of SMM exist between subgroups of the Asian and Pacific Islander community. These differences should be considered when conducting research on racial and ethnic differences of SMM and when counseling Asian and Pacific Islander women regarding their risk of SMM.