Trends in Severe Maternal Morbidity in the US Across the Transition to ICD-10-CM/PCS From 2012-2019

Pregnancy with endometriosis: Assessment of national-level trends, characteristics, and maternal morbidity at delivery

OBJECTIVE

To examine pregnancy characteristics and maternal morbidity at delivery among pregnant patients with a diagnosis of endometriosis.

STUDY DESIGN

This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample. Study population was 17,796,365 hospital deliveries from 2016 to 2020, excluded adenomyosis and uterine myoma. The exposure was endometriosis diagnosis. Main outcome measures were clinical and pregnancy characteristics and severe maternal morbidity at delivery related to endometriosis, assessed with multivariable regression model.

RESULTS

Endometriosis was diagnosed in 17,590 patients. The prevalence of endometriosis increased by 24 % from one in 1,191 patients in 2016 to one in 853 patients in 2020 (adjusted-odds ratio [aOR] 1.24, 95% confidence interval [CI] 1.19-1.30). Clinical and pregnancy characteristics that had greater than two-fold association to endometriosis included polycystic ovary syndrome, placenta previa, cesarean delivery, maternal age of ≥30 years, prior pregnancy loss, and anxiety disorder. Pregnant patients with endometriosis were more likely to have the diagnosis of measured severe maternal morbidity during the index hospitalization for delivery (47.8 vs 17.3 per 1,000 deliveries, aOR 1.91, 95%CI 1.78-2.06); these associations were more prominent following vaginal (aOR 2.82, 95%CI 2.41-3.30) compared to cesarean (aOR 1.85, 95%CI 1.71-2.00) deliveries. Among the individual morbidity indicators, endometriosis was most strongly associated with thromboembolism (aOR 5.05, 95%CI 3.70-6.91), followed by sepsis (aOR 2.39, 95%CI 1.85-3.09) and hysterectomy (aOR 2.18, 95%CI 1.85-2.56). When stratified for endometriosis anatomical site, odds of thromboembolism was increased in endometriosis at distant site (aOR 9.10, 95%CI 3.76-22.02) and adnexa (aOR 7.37, 95%CI 4.43-12.28); odds of sepsis was most increased in endometriosis at multi-classifier locations (aOR 7.33, 95%CI 2.93-18.31) followed by pelvic peritoneum (aOR 5.54, 95%CI 2.95-10.40); and odds of hysterectomy exceeded three-fold in endometriosis at adnexa (aOR 3.00, 95%CI 2.30-3.90), distant site (aOR 5.36, 95%CI 3.48-8.24), and multi-classifier location (aOR 4.46, 95%CI 2.11-9.41).

CONCLUSION

The results of this nationwide analysis suggest that pregnancy with endometriosis is uncommon but gradually increasing over time in the United States. The data also suggest that endometriosis during pregnancy is associated with increased risk of severe maternal morbidity at delivery, especially for thromboembolism, sepsis, and hysterectomy. These morbidity risks differed by the anatomical location of endometriosis.

Concept Analysis of Woman-Centered Care: Implications for Postpartum Care

ABSTRACT

Approximately two-thirds of pregnancy-related deaths in the United States occur during the postpartum period, yet there is minimal research focusing on the postpartum hospital stay, a critical point of contact between women and the health care system and an important opportunity for intervention. A new approach to postpartum care is needed. "Woman-centered" postpartum care is recommended to improve maternal outcomes, but the concept of woman-centered care is not well-defined. Using Walker & Avant's method of concept analysis, we identified four defining attributes of woman-centered care in the literature: 1) choice, control, and involvement in decision-making; 2) communication and collaboration in the caregiver-woman relationship; 3) individualized and holistic care; and 4) continuity of care. Using these findings, we offer a conceptual definition of woman-centered care and apply the attributes to the postpartum hospitalization in the model and contrary cases. We discuss the potential of the concept to improve maternal health care during this critical period.

Validation of ICD-10 Codes for Severe Maternal Morbidity at Delivery in a Public Hospital

BACKGROUND

Severe maternal morbidity is a composite measure of serious obstetric complications that is often identified in administrative data using the International Classification of Diseases (ICD) diagnosis and procedure codes for a set of 21 indicators. Prior studies of screen-positive cases have demonstrated low predictive value for ICD codes relative to the medical record. To our knowledge, the validity of ICD-10 codes for identifying severe maternal morbidity has not been fully described.

METHODS

We estimated the sensitivity, specificity, positive predictive value, and negative predictive value of ICD-10 codes for severe maternal morbidity occurring at delivery, compared with medical record abstraction (gold standard), for 1,000 deliveries that took place during 2016-2018 at a large, public hospital.

RESULTS

We identified a total of 67 cases of severe maternal morbidity using the ICD-10 definition and 74 cases in the medical record. The sensitivity was 26% (95% confidence interval [CI] = 16%, 37%), the positive predictive value was 28% (95% CI = 18%, 41%), the specificity was 95% (95% CI = 93%, 96%), and the negative predictive value was 94% (95% CI = 92%, 96%).

CONCLUSIONS

The validity of ICD-10 codes for severe maternal morbidity in our high-burden population was poor, suggesting considerable potential for bias.

Severe maternal morbidity from pregnancy through 1 year postpartum

BACKGROUND

Few recent studies have examined the rate of severe maternal morbidity occurring during the antenatal and/or postpartum period to 42 days after delivery. However, little is known about the rate of severe maternal morbidity occurring beyond 42 days after delivery.

OBJECTIVE

This study aimed to examine the distribution of severe maternal morbidity and its indicators during antenatal, delivery, and postpartum hospitalizations to 365 days after delivery and to estimate the increase in severe maternal morbidity rate and its indicators after accounting for antenatal and postpartum severe maternal morbidity to 365 days after delivery.

STUDY DESIGN

This was a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from Michigan, Oregon, and South Carolina from 2008 to 2020. This study examined the distribution of severe maternal morbidity, nontransfusion severe maternal morbidity, and severe maternal morbidity indicators during antenatal, delivery, and postpartum hospitalizations to 365 days after delivery. Subsequently, this study examined "severe maternal morbidity cases added," which represent cases among unique individuals that are included by considering the antenatal and postpartum periods but that would be missed if only the delivery hospitalization cases were included.

RESULTS

A total of 64,661 (2.5%) individuals experienced severe maternal morbidity, whereas 37,112 (1.4%) individuals experienced nontransfusion severe maternal morbidity during antenatal, delivery, and/or postpartum hospitalization. A total of 31% of severe maternal morbidity cases were added after accounting for severe maternal morbidity occurring during the antenatal or postpartum hospitalization to 365 days after delivery, whereas 49% of nontransfusion severe maternal morbidity cases were added after accounting for nontransfusion severe maternal morbidity occurring during the antenatal or postpartum periods. Severe maternal morbidity occurring between 43 and 365 days after delivery contributed to 12% of all severe maternal morbidity cases, whereas nontransfusion severe maternal morbidity occurring between 43 and 365 days after delivery contributed to 19% of all nontransfusion severe maternal morbidity cases.

CONCLUSION

Our study showed that a total of 31% of severe maternal morbidity and 49% of nontransfusion severe maternal morbidity cases were added after accounting for severe maternal morbidity occurring during the antenatal or postpartum hospitalization to 365 days after delivery. Our findings highlight the importance of expanding the severe maternal morbidity definition beyond the delivery hospitalization to better capture the full period of increased risk, identify contributing factors, and design strategies to mitigate this risk. Only then can we improve outcomes for mothers and subsequently the quality of life of their infants.

Adverse delivery hospitalisation outcomes in 2020 during the COVID-19 pandemic

OBJECTIVE

To evaluate risk for adverse obstetric outcomes associated with the coronavirus disease 2019 (COVID-19) pandemic period and with COVID-19 diagnoses.

DESIGN

Serial cross-sectional study.

SETTING

A national sample of US delivery hospitalisations before (1/2016 to 2/2020) and during the first 10 months of (3/2020 to 12/2020) the COVID-19 pandemic.

POPULATION

All 2016-2020 US delivery hospitalisations in the National Inpatient Sample.

METHODS

Delivery hospitalisations were identified and stratified into pre-pandemic and pandemic periods and the likelihood of adverse obstetric outcomes was compared using logistic regression models with adjusted odds ratios (aOR) with 95% confidence intervals (CI) as measures of association. Risk for adverse outcomes was also analysed specifically for 2020 deliveries with a COVID-19 diagnosis.

MAIN OUTCOME MEASURE

Adverse maternal outcomes including respiratory complications and cardiac morbidity.

RESULTS

Of an estimated 18.2 million deliveries, 2.9 million occurred during the pandemic. The proportion of delivery hospitalisations with a COVID-19 diagnosis increased from 0.1% in March 2020 to 3.1% in December. Comparing the pandemic period to the pre-pandemic period, there were higher adjusted odds of transfusion (aOR 1.12, 95% CI 1.05-1.19), a respiratory complication composite (aOR 1.37, 95% CI 1.29-1.46), cardiac severe maternal morbidity (aOR 1.30, 95% 1.20-1.39), postpartum haemorrhage (aOR 1.19, 95% CI 1.15-1.24), placental abruption/antepartum haemorrhage (OR 1.04, 95% CI 1.00-1.08), and hypertensive disorders of pregnancy (OR 1.23, 95% CI 1.21-1.26). These associations were similar to unadjusted analysis. Risk for these outcomes during the pandemic period was significantly higher in the presence of a COVID-19 diagnosis.

CONCLUSIONS

In a national estimate of delivery hospitalisations, the odds of cardiac and respiratory outcomes were higher in 2020 compared with 2016-2019. COVID-19 diagnoses were specifically associated with a range of serious complications.

Centering Equity and Fostering Stakeholder Collaboration and Trust-Pillars of the Maternal Health Innovation Program in Maryland

Objective

To describe two main pillars of the Maryland Maternal Health Innovation Program (MDMOM): (1) centering equity and (2) fostering broad stakeholder collaboration and trust.

Methods

We summarized MDMOM's key activities and used severe maternal morbidity (SMM) surveillance and program monitoring data to quantify MDMOM's work on the two pillars. We developed measures of hospital engagement with MDMOM (participation in quality improvement [QI] activities, participation in check-in meetings, staff involvement) and with other partners (participation in QI activities, representation in state-level groups). We examined Bonferroni-adjusted correlations between these hospital engagement measures and with key hospital characteristics: level of maternity care, annual delivery volume, and SMM rate.

Results

Over 100 national and state organizations and individual stakeholders contributed to our building the MDMOM program and implementing key activities centering equity: hospital-based SMM surveillance in 20 of Maryland's 32 hospitals; almost 5,000 trainings offered to perinatal health care providers; two telemedicine/telehealth interventions; training of home visitors and community-based organization staff. Birthing hospitals represent MDMOM's main implementation partners. The strength of their participation in MDMOM QI activities is positively correlated to their participation in check-in meetings and with the degree of involvement by physicians in such activities. Higher engagement in MDMOM QI activities is also positively correlated to hospitals' participation in other state-level maternal health initiatives or groups.

Conclusion

Our experience with the MDMOM program demonstrates that an equity focus and broad stakeholder collaboration building strong relationships and providing implementation support can lead to high levels of engagement in innovative maternal health interventions.

Preventing posttraumatic stress disorder following childbirth: a systematic review and meta-analysis

OBJECTIVE

Women can develop posttraumatic stress disorder in response to experienced or perceived traumatic, often medically complicated, childbirth; the prevalence of these events remains high in the United States. Currently, no recommended treatment exists in routine care to prevent or mitigate maternal childbirth-related posttraumatic stress disorder. We conducted a systematic review and meta-analysis of clinical trials that evaluated any therapy to prevent or treat childbirth-related posttraumatic stress disorder.

DATA SOURCES

PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for eligible trials published through September 2023.

STUDY ELIGIBILITY CRITERIA

Trials were included if they were interventional, if they evaluated any therapy for childbirth-related posttraumatic stress disorder for the indication of symptoms or before posttraumatic stress disorder onset, and if they were written in English.

METHODS

Independent coders extracted the sample characteristics and intervention information of the eligible studies and evaluated the trials using the Downs and Black's quality checklist and Cochrane's method for risk of bias evaluation. Meta-analysis was conducted to evaluate pooled effect sizes of secondary and tertiary prevention trials.

RESULTS

A total of 41 studies (32 randomized controlled trials, 9 nonrandomized trials) were reviewed. They evaluated brief psychological therapies including debriefing, trauma-focused therapies (including cognitive behavioral therapy and expressive writing), memory consolidation and reconsolidation blockage, mother-infant-focused therapies, and educational interventions. The trials targeted secondary preventions aimed at buffering childbirth-related posttraumatic stress disorder usually after traumatic childbirth (n=24), tertiary preventions among women with probable childbirth-related posttraumatic stress disorder (n=14), and primary prevention during pregnancy (n=3). A meta-analysis of the combined randomized secondary preventions showed moderate effects in reducing childbirth-related posttraumatic stress disorder symptoms when compared with usual treatment (standardized mean difference, -0.67; 95% confidence interval, -0.92 to -0.42). Single-session therapy within 96 hours of birth was helpful (standardized mean difference, -0.55). Brief, structured, trauma-focused therapies and semi-structured, midwife-led, dialogue-based psychological counseling showed the largest effects (standardized mean difference, -0.95 and -0.91, respectively). Other treatment approaches (eg, the Tetris game, mindfulness, mother-infant-focused treatment) warrant more research. Tertiary preventions produced smaller effects than secondary prevention but are potentially clinically meaningful (standardized mean difference, -0.37; -0.60 to -0.14). Antepartum educational approaches may help, but insufficient empirical evidence exists.

CONCLUSION

Brief trauma-focused and non-trauma-focused psychological therapies delivered early in the period following traumatic childbirth offer a critical and feasible opportunity to buffer the symptoms of childbirth-related posttraumatic stress disorder. Future research that integrates diagnostic and biological measures can inform treatment use and the mechanisms at work.

Assessing the impact of transitioning to 11th revision of the International Classification of Diseases (ICD-11) on comorbidity indices

OBJECTIVES

This study aimed to support the implementation of the 11th Revision of the International Classification of Diseases (ICD-11). We used common comorbidity indices as a case study for proactively assessing the impact of transitioning to ICD-11 for mortality and morbidity statistics (ICD-11-MMS) on real-world data analyses.

MATERIALS AND METHODS

Using the MIMIC IV database and a table of mappings between the clinical modification of previous versions of ICD and ICD-11-MMS, we assembled a population whose diagnosis can be represented in ICD-11-MMS. We assessed the impact of ICD version on cross-sectional analyses by comparing the populations' distribution of Charlson and Elixhauser comorbidity indices (CCI, ECI) across different ICD versions, along with the adjustment in comorbidity weighting.

RESULTS

We found that ICD versioning could lead to (1) alterations in the population distribution and (2) changes in the weight that can be assigned to a comorbidity category in a reweighting initiative. In addition, this study allowed the creation of the corresponding ICD-11-MMS codes list for each component of the CCI and the ECI.

DISCUSSION

In common with the implementations of previous versions of ICD, implementation of ICD-11-MMS potentially hinders comparability of comorbidity burden on health outcomes in research and clinical settings.

CONCLUSION

Further research is essential to enhance ICD-11-MMS usability, while mitigating, after identification, its adverse effects on comparability of analyses.

Neighborhood Deprivation and Severe Maternal Morbidity in a Medicaid Population

INTRODUCTION

Few studies have examined whether neighborhood deprivation is associated with severe maternal morbidity (SMM) in already socioeconomically disadvantaged populations. Little is known about to what extent neighborhood deprivation accounts for Black-White disparities in SMM. This study investigated these questions among a statewide Medicaid-insured population, a low-income population with heightened risk of SMM.

METHODS

Data were from Michigan statewide linked birth records and Medicaid claims between 01/01/2016 and 12/31/2019, and were analyzed between 2022 and 2023. Neighborhood deprivation was measured with the Area Deprivation Index at census block group and categorized as low, medium, or high deprivation. Multilevel logistic models were used to examine the association between neighborhood deprivation and SMM. Fairlie nonlinear decomposition was conducted to quantify the contribution of neighborhood deprivation to SMM racial disparity.

RESULTS

People in the most deprived neighborhoods had higher odds of SMM than those in the least deprived neighborhoods (aOR [95% CI]: 1.27 [1.15, 1.40]). Such association was observed in Black (aOR [95% CI]: 1.34 [1.07, 1.67]) and White (aOR [95% CI]: 1.26 [1.12, 1.42]) racial subgroups. Decomposition showed that of 57.5 (cases per 10,000) explained disparity in SMM, neighborhood deprivation accounted for 23.1 (cases per 10,000; 95% CI: 16.3, 30.0) or two-fifths (40.2%) of the Black-White disparity. Analysis on SMM excluding blood transfusion showed consistent but weaker results.

CONCLUSIONS

Neighborhood deprivation may be used as an effective tool to identify at-risk individuals within a low-income population. Community-engaged interventions aiming at improving neighborhood conditions may be helpful to reduce both SMM prevalence and racial inequity in SMM.

Severe maternal morbidity surveillance, temporal trends and regional variation: A population-based cohort study

OBJECTIVE

To quantify temporal trends and regional variation in severe maternal morbidity (SMM) in Sweden.

DESIGN

Cohort study.

POPULATION

Live birth and stillbirth deliveries in Sweden, 1999-2019.

METHODS

Types and subtypes of SMM were identified, based on a standard list (modified for Swedish clinical setting after considering the frequency and validity of each indicator) using diagnoses and procedure codes, among all deliveries at ≥22 weeks of gestation (including complications within 42 days of delivery). Contrasts between regions were quantified using rate ratios (RRs) and 95% confidence intervals (95% CIs). Temporal changes in SMM types and subtypes were described.

MAIN OUTCOME MEASURES

Types and subtypes of SMM.

RESULTS

There were 59 789 SMM cases among 2 212 576 deliveries, corresponding to 270.2 (95% CI 268.1-272.4) per 10 000 deliveries. Composite SMM rates increased from 236.6 per 10 000 deliveries in 1999 to 307.3 per 10 000 deliveries in 2006, before declining to 253.8 per 10 000 deliveries in 2019. Changes in composite SMM corresponded with temporal changes in severe haemorrhage rates, which increased from 94.9 per 10 000 deliveries in 1999 to 169.3 per 10 000 deliveries in 2006, before declining to 111.2 per 10 000 deliveries in 2019. Severe pre-eclampsia, eclampsia and HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome (103.8 per 10 000 deliveries), severe haemorrhage (133.7 per 10 000 deliveries), sepsis, embolism, disseminated intravascular coagulation, shock and severe mental health disorders were the most common SMM types. Rates of embolism, disseminated intravascular coagulation and shock, acute renal failure, cardiac complications, sepsis and assisted ventilation increased, whereas rates of surgical complications, severe uterine rupture and anaesthesia complications declined.

CONCLUSIONS

The observed spatiotemporal variations in composite SMM and SMM types provide substantive insights and highlight regional priorities for improving maternal health.

Trends and Disparities in Severe Maternal Morbidity Indicator Categories during Childbirth Hospitalization in California from 1997 to 2017

OBJECTIVE

 Severe maternal morbidity (SMM) is increasing and characterized by substantial racial and ethnic disparities. Analyzing trends and disparities across time by etiologic or organ system groups instead of an aggregated index may inform specific, actionable pathways to equitable care. We explored trends and racial and ethnic disparities in seven SMM categories at childbirth hospitalization.

STUDY DESIGN

 We analyzed California birth cohort data on all live and stillbirths ≥ 20 weeks' gestation from 1997 to 2017 (n = 10,580,096) using the Centers for Disease Control and Prevention's SMM index. Cases were categorized into seven nonmutually exclusive indicator categories (cardiac, renal, respiratory, hemorrhage, sepsis, other obstetric, and other medical SMM). We compared prevalence and trends in SMM indicator categories overall and by racial and ethnic group using logistic and linear regression.

RESULTS

 SMM occurred in 1.16% of births and nontransfusion SMM in 0.54%. Hemorrhage SMM occurred most frequently (27 per 10,000 births), followed by other obstetric (11), respiratory (7), and sepsis, cardiac, and renal SMM (5). Hemorrhage, renal, respiratory, and sepsis SMM increased over time for all racial and ethnic groups. The largest disparities were for Black individuals, including over 3-fold increased odds of other medical SMM. Renal and sepsis morbidity had the largest relative increases over time (717 and 544%). Sepsis and hemorrhage SMM had the largest absolute changes over time (17 per 10,000 increase). Disparities increased over time for respiratory SMM among Black, U.S.-born Hispanic, and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals. Disparities decreased over time for sepsis SMM among Black individuals yet remained substantial.

CONCLUSION

 Our research further supports the critical need to address SMM and disparities as a significant public health priority in the United States and suggests that examining SMM subgroups may reveal helpful nuance for understanding trends, disparities, and potential needs for intervention.

KEY POINTS

· By SMM subgroup, trends and racial and ethnic disparities varied yet Black individuals consistently had highest rates.. · Hemorrhage, renal, respiratory, and sepsis SMM significantly increased over time.. · Disparities increased for respiratory SMM among Black, U.S.-born Hispanic and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals..

"Black Women Should Not Die Giving Life": The lived experiences of Black women diagnosed with severe maternal morbidity in the United States

OBJECTIVE

We sought to understand the lived experiences of Black women diagnosed with severe maternal morbidity (SMM) in communities with high maternal mortality to inform practices that reduce obstetric racism and improve patient outcomes.

METHODS

From August 2022 through December 2022, we conducted a phenomenological, qualitative study among Black women who experienced SMM. Participants were recruited via social media and met inclusion criteria if they self-identified as Black cisgender women, were 18-40 years old, had SMM diagnosed, and lived within zip codes in the United States that have the top-five highest maternal mortality rates. Family members participated on behalf of women who were deceased but otherwise met all other criteria. We conducted in-depth interviews (IDIs), and transcripts were analyzed using inductive and deductive methods to explore birth story experiences.

RESULTS

Overall, 12 participants completed IDIs; 10 were women who experienced SMM and 2 were mothers of women who died due to SMM. The mean age for women who experienced SMM was 31 years (range 26-36 years) at the time of the IDI or death. Most participants had graduate-level education, and the average annual household income was 123,750 USD. Women were especially interested in study participation because of their high-income status as they did not fit the stereotypical profile of Black women who experience racial discrimination. The average time since SMM diagnosis was 2 years. Participants highlighted concrete examples of communication failures, stereotyping by providers, differential treatment, and medical errors which patients experienced as manifestations of racism. Medical personnel dismissing and ignoring concerns during emergent situations, even when raised through strong self-advocacy, was a key factor in racism experienced during childbirth.

CONCLUSIONS

Future interventions to reduce racism and improve maternal health outcomes should center on the experiences of Black women and focus on improving patient-provider communication, as well as the quality and effectiveness of responses during emergent situations. Précis statement: This study underscores the need to center Black women's experiences, enhance patient-provider communication, and address emergent concerns to mitigate obstetric racism and enhance maternal health outcomes.

Association between stillbirth and severe maternal morbidity

BACKGROUND

Severe maternal morbidity has been increasing in the past few decades. Few studies have examined the risk of severe maternal morbidity among individuals with stillbirths vs individuals with live-birth deliveries.

OBJECTIVE

This study aimed to examine the prevalence and risk of severe maternal morbidity among individuals with stillbirths vs individuals with live-birth deliveries during delivery hospitalization as a primary outcome and during the postpartum period as a secondary outcome.

STUDY DESIGN

This was a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from California (2008-2018), Michigan (2008-2020), Missouri (2008-2014), Pennsylvania (2008-2014), and South Carolina (2008-2020). Relative risk regression analysis was used to examine the crude and adjusted relative risks of severe maternal morbidity along with 95% confidence intervals among individuals with stillbirths vs individuals with live-birth deliveries, adjusting for birth year, state of residence, maternal sociodemographic characteristics, and the obstetric comorbidity index.

RESULTS

Of the 8,694,912 deliveries, 35,012 (0.40%) were stillbirths. Compared with individuals with live-birth deliveries, those with stillbirths were more likely to be non-Hispanic Black (10.8% vs 20.5%); have Medicaid (46.5% vs 52.0%); have pregnancy complications, including preexisting diabetes mellitus (1.1% vs 4.3%), preexisting hypertension (2.3% vs 6.2%), and preeclampsia (4.4% vs 8.4%); have multiple pregnancies (1.6% vs 6.2%); and reside in South Carolina (7.4% vs 11.6%). During delivery hospitalization, the prevalence rates of severe maternal morbidity were 791 cases per 10,000 deliveries for stillbirths and 154 cases per 10,000 deliveries for live-birth deliveries, whereas the prevalence rates for nontransfusion severe maternal morbidity were 502 cases per 10,000 deliveries for stillbirths and 68 cases per 10,000 deliveries for live-birth deliveries. The crude relative risk for severe maternal morbidity was 5.1 (95% confidence interval, 4.9-5.3), whereas the adjusted relative risk was 1.6 (95% confidence interval, 1.5-1.8). For nontransfusion severe maternal morbidity among stillbirths vs live-birth deliveries, the crude relative risk was 7.4 (95% confidence interval, 7.0-7.7), whereas the adjusted relative risk was 2.0 (95% confidence interval, 1.8-2.3). This risk was not only elevated among individuals with stillbirth during the delivery hospitalization but also through 1 year after delivery (severe maternal morbidity adjusted relative risk, 1.3; 95% confidence interval, 1.1-1.4; nontransfusion severe maternal morbidity adjusted relative risk, 1.2; 95% confidence interval, 1.1-1.3).

CONCLUSION

Stillbirth was found to be an important contributor to severe maternal morbidity.

Age-Stratified Sex Differences in Heart Failure With Preserved Ejection Fraction Among Adult Hospitalizations

BACKGROUND

There is evidence that heart failure with preserved ejection fraction (HFpEF)-related hospitalizations are increasing in the United States. However, there is a lack of knowledge about HFpEF-related hospitalizations among younger adults.

OBJECTIVE

The aims of this study were to perform a retrospective analysis using the Nationwide Inpatient Sample and to examine age-stratified sex differences in the prevalence, correlates, and outcomes of HFpEF-related hospitalization across the adult life span.

METHOD

Using the Nationwide Inpatient Sample (2002-2014), patient and hospital characteristics were determined. Joinpoint regression was used to describe age-stratified sex differences in the annual average percent change of hospitalizations with HFpEF. Survey logistic regression was used to estimate adjusted odds ratios representing the association of sex with HFpEF-related hospitalization and in-hospital mortality.

RESULTS

There were 8 599 717 HFpEF-related hospitalizations (2.43% of all hospitalizations). Women represented the majority (5 459 422 [63.48%]) of HFpEF-related adult hospitalizations, compared with men (3 140 295 [36.52%]). Compared with men younger than 50 years, women within the same age group were 6% to 28% less likely to experience HFpEF-related hospitalization. Comorbidities such as hypertensive heart disease, renal disease, hypertension, obstructive sleep apnea, atrial fibrillation, obesity, anemia, and pulmonary edema explained a greater proportion of the risk of HFpEF-related hospitalization in adults younger than 50 years than in adults 50 years or older.

CONCLUSION

Before the age of 50 years, women exhibit lower HFpEF-related hospitalization than men, a pattern that reverses with advancing age. Understanding and addressing the factors contributing to these sex-specific differences can have several potential implications for improving women's cardiovascular health.

Risk Factors for Severe Maternal Morbidity Among Women Enrolled in Mississippi Medicaid

Importance

Mississippi has one of the highest rates of severe maternal morbidity (SMM) in the US, and SMMs have been reported to be more frequent among Medicaid-insured women. A substantial proportion of pregnant women in Mississippi are covered by Medicaid; hence, there is a need to identify potential risk factors for SMM in this population.

Objective

To examine the associations of health care access and clinical and sociodemographic characteristics with SMM events among Mississippi Medicaid-enrolled women who had a live birth.

Design, Setting, and Participants

A nested case-control study was conducted using 2018 to 2021 Mississippi Medicaid administrative claims database. The study included Medicaid beneficiaries aged 12 to 55 years who had a live birth and were continuously enrolled throughout their pregnancy period and 12 months after delivery. Individuals in the case group had SMM events and were matched to controls on their delivery date using incidence density sampling. Data analysis was performed from June to September 2022.

Exposure

Risk factors examined in the study included sociodemographic factors (age and race), health care access (distance from delivery center, social vulnerability index, and level of maternity care), and clinical factors (maternal comorbidity index, first-trimester pregnancy-related visits, and postpartum care).

Main Outcomes and Measures

The main outcome of the study was an SMM event. Adjusted odds ratio (aORs) and 95% CIs were calculated using conditional logistic regression.

Results

Among 13 485 Mississippi Medicaid-enrolled women (mean [SD] age, 25.0 [5.6] years; 8601 [63.8%] Black; 4419 [32.8%] White; 465 [3.4%] other race [American Indian, Asian, Hispanic, multiracial, and unknown]) who had a live birth, 410 (3.0%) were in the case group (mean [SD] age, 26.8 [6.4] years; 289 [70.5%] Black; 112 [27.3%] White; 9 [2.2%] other race) and 820 were in the matched control group (mean [SD] age, 24.9 [5.7] years; 518 [63.2%] Black; 282 [34.4%] White; 20 [2.4%] other race). Black individuals (aOR, 1.44; 95% CI, 1.08-1.93) and those with higher maternal comorbidity index (aOR, 1.27; 95% CI, 1.16-1.40) had higher odds of experiencing SMM compared with White individuals and those with lower maternal comorbidity index, respectively. Likewise, an increase of 100 miles (160 km) in distance between beneficiaries' residence to the delivery center was associated with higher odds of experiencing SMM (aOR, 1.14; 95% CI, 1.07-1.20).

Conclusions and Relevance

The study findings hold substantial implications for identifying high-risk individuals within Medicaid programs and call for the development of targeted multicomponent, multilevel interventions for improving maternal health outcomes in this highly vulnerable population.

Global burden of potentially life-threatening maternal conditions: a systematic review and meta-analysis

BACKGROUND

Potentially life-threatening maternal conditions (PLTCs) is an important proxy indicator of maternal mortality and the quality of maternal health services. It is helpful to monitor the rates of severe maternal morbidity to evaluate the quality of maternal care, particularly in low- and lower-middle-income countries. This study aims to systematically identify and synthesize available evidence on PLTCs.

METHODS

We searched studies in English from 2009‒2023 in PubMed, the National Library of Medicine (NLM) Gateway, the POPLINE database, and the Science Direct website. The study team independently reviewed the illegibility criteria of the articles. Two reviewers independently appraised the included articles using the Joanna Briggs Instrument for observational studies. Disputes between the reviewers were resolved by consensus with a third reviewer. Meta-analysis was conducted in Stata version 16. The pooled proportion of PLTCs was calculated using the random effects model. The heterogeneity test was performed using the Cochrane Q test, and its level was determined using the I2 statistical result. Using Egger's test, the publication bias was assessed.

RESULT

Thirty-two cross-sectional, five case-control, and seven cohort studies published from 2009 to 2023 were included in the meta-analysis. The highest proportion of PLTC was 17.55% (95% CI: 15.51, 19.79) in Ethiopia, and the lowest was 0.83% (95% CI: 0.73, 0.95) in Iraq. The pooled proportion of PLTC was 6.98% (95% CI: 5.98-7.98). In the subgroup analysis, the pooled prevalence varied based on country income level: in low-income 13.44% (95% CI: 11.88-15.00) I2 = 89.90%, low-middle income 7.42% (95% CI: 5.99-8.86) I2 = 99.71%, upper-middle income 6.35% (95% CI: 4.21-8.50) I2 = 99.92%, and high-income 2.67% (95% CI: 2.34-2.99) I2 = 99.57%. Similarly, it varied based on the diagnosis criteria; WHO diagnosis criteria used 7.77% (95% CI: 6.10-9.44) I2 = 99.96% at P = 0.00, while the Centers for Disease Controls (CDC) diagnosis criteria used 2.19% (95% CI: 1.89-2.50) I2 = 99.41% at P = 0.00.

CONCLUSION

The pooled prevalence of PLTC is high globally, predominantly in low-income countries. The large disparity of potentially life-threatening conditions among different areas needs targeted intervention, particularly for women residing in low-income countries. The WHO diagnosis criteria minimize the underreporting of severe maternal morbidity.

TRIAL REGISTRATION

CRD42023409229.

Postpartum healthcare expenditures for commercially insured deliveries with and without severe maternal morbidity

BACKGROUND

Although severe maternal morbidity is associated with adverse health outcomes in the year after delivery, patterns of healthcare use beyond the 6-week postpartum period have not been well documented.

OBJECTIVE

This study aimed to estimate healthcare utilization and expenditures for deliveries with and without severe maternal morbidity in the 12 months following delivery among commercially insured patients.

STUDY DESIGN

Using data from the 2016 to 2018 IBM Marketscan Commercial Claims and Encounters Research Databases, we identified deliveries to individuals 15 to 49 years of age who were continuously enrolled in noncapitated health plans for 12 months after delivery discharge. We used multivariable generalized linear models to estimate adjusted mean 12-month medical expenditures and 95% confidence intervals for deliveries with and without severe maternal morbidity, accounting for region, health plan type, delivery method, and obstetrical comorbidities. We estimated expenditures associated with inpatient admissions, nonemergency outpatient visits, outpatient emergency department visits, and outpatient pharmaceutical claims.

RESULTS

We identified 366,282 deliveries without severe maternal morbidity and 3976 deliveries (10.7 per 1000) with severe maternal morbidity. Adjusted mean total medical expenditures for deliveries with severe maternal morbidity were 43% higher in the 12 months after discharge than deliveries without severe maternal morbidity ($5320 vs $3041; difference $2278; 95% confidence interval, $1591-$2965). Adjusted mean expenditures for readmissions and nonemergency outpatient visits during the 12-month postpartum period were 61% and 39% higher, respectively, for deliveries with severe maternal morbidity compared with deliveries without severe maternal morbidity. Among deliveries with severe maternal morbidity, adjusted mean total costs were highest for patients living in the western region ($7831; 95% confidence interval, $5518-$10,144) and those having a primary cesarean ($7647; 95% confidence interval, $6323-$8970).

CONCLUSION

Severe maternal morbidity at delivery is associated with increased healthcare use and expenditures in the year after delivery. These estimates can inform planning of severe maternal morbidity prevention efforts.

Decomposing the Black-White Racial Disparity in Severe Maternal Morbidity Risk: The Role of Hypertensive Disorders of Pregnancy

BACKGROUND

To our knowledge, no studies have explicitly studied the role of hypertensive disorders of pregnancy (HDP) in racial disparities in severe maternal morbidity (SMM).

METHODS

Using causal mediation models, we estimated the proportion of the non-Hispanic (NH) Black-White racial disparity in risk of SMM that is explained through the pathway of HDP. We linked 2006-2019 Georgia hospital discharge records with vital statistics birth and fetal death records for NH Black and NH White birthing persons. We used G-estimation of a structural nested mean model to decompose the absolute racial disparity in the incidence of SMM into pathways operating through HDP.

RESULTS

NH Black birthing people experienced an excess 56 SMM events (95% confidence interval [CI] = 52, 59) per 10,000 delivery hospitalizations compared with NH White birthing people. If counterfactual disparity measure estimation assumptions hold, the estimated absolute disparity remaining after blocking the causal pathways through HDP was 41 SMM events per 10,000 deliveries (95% CI = 38, 44), suggesting that 26% (95% CI = 12, 40) of the absolute racial disparity would be eliminated if there was no contribution of HDP to SMM risk.

CONCLUSION

Our results are consistent with the hypothesis that intervening to prevent HDP is an important (yet incomplete) pathway for reducing the excess risk among NH Black pregnancies compared with NH White pregnancies.

Characteristics and Outcomes of Patients With Pregnancy-Related End-Stage Kidney Disease

Importance

The incidence of pregnancy-related acute kidney injury is increasing and is associated with significant maternal morbidity including progression to end-stage kidney disease (ESKD). Little is known about characteristics and long-term outcomes of patients who develop pregnancy-related ESKD.

Objectives

To examine the characteristics and clinical outcomes of patients with pregnancy-related ESKD and to investigate associations between pre-ESKD nephrology care and outcomes.

Design, Setting, and Participants

This was a cohort study of 183 640 reproductive-aged women with incident ESKD between January 1, 2000, and November 20, 2020, from the US Renal Data System and maternal data from births captured in the US Centers for Disease Control and Prevention publicly available natality data. Data were analyzed from December 2022 to June 2023.

Exposure

Pregnancy-related primary cause of ESKD, per International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes reported at ESKD onset by the primary nephrologist on Centers for Medicare and Medicaid Services form 2728.

Main Outcomes Measures

Multivariable Cox proportional hazards and competing risk models were constructed to examine time to (1) mortality, (2) access to kidney transplant (joining the waiting list or receiving a live donor transplant), and (3) receipt of transplant after joining the waitlist.

Results

A total of 341 patients with a pregnancy-related primary cause of ESKD were identified (mean [SD] age 30.2 [7.3]). Compared with the general US birthing population, Black patients were overrepresented among those with pregnancy-related ESKD (109 patients [31.9%] vs 585 268 patients [16.2%]). In adjusted analyses, patients with pregnancy-related ESKD had similar or lower hazards of mortality compared with those with glomerulonephritis or cystic kidney disease (adjusted hazard ratio [aHR], 0.96; 95% CI, 0.76-1.19), diabetes or hypertension (aHR, 0.49; 95% CI, 0.39-0.61), or other or unknown primary causes of ESKD (aHR, 0.60; 95% CI, 0.48-0.75). Despite this, patients with pregnancy-related ESKD had significantly lower access to kidney transplant compared with those with other causes of ESKD, including (1) glomerulonephritis or cystic kidney disease (adjusted subhazard ratio [aSHR], 0.51; 95% CI, 0.43-0.66), (2) diabetes or hypertension (aSHR, 0.81; 95% CI, 0.67-0.98), and (3) other or unkown cause (aSHR, 0.82; 95% CI, 0.67-0.99). Those with pregnancy-related ESKD were less likely to have nephrology care or have a graft or arteriovenous fistula placed before ESKD onset (nephrology care: adjusted relative risk [aRR], 0.47; 95% CI, 0.40-0.56; graft or arteriovenous fistula placed: aRR, 0.31; 95% CI, 0.17-0.57).

Conclusion and Relevance

In this study, those with pregnancy-related ESKD had reduced access to transplant and nephrology care, which could exacerbate existing disparities in a disproportionately Black population. Increased access to care could improve quality of life and health outcomes among these young adults with high potential for long-term survival.

Pregnancy and Emergency Department Utilization in North Carolina, 2016-2021: A Population-Based Surveillance Study

Introduction

Pregnancy-associated complaints are a common reason for emergency department visits for women of reproductive age. Emergency department utilization during pregnancy is associated with worse birth outcomes for both mothers and infants. We used statewide North Carolina emergency department surveillance data between 2016 and 2021 to describe the sociodemographic factors associated with the use of emergency department for pregnancy-associated problems and subsequent hospital admission.

Methods

North Carolina Disease Event Tracking and Epidemiologic Collection Tool is a syndromic surveillance system that includes all emergency department encounters at civilian acute-care facilities in North Carolina. We analyzed all emergency department visits between January 1, 2016 and December 31, 2021 for female patients aged 15-44 years residing in North Carolina with at least 1 ICD-10-CM code (analysis occurred in July 2021-October 2022). Each emergency department visit was categorized as pregnancy-associated if assigned ICD-10-CM code(s) indicated pregnancy. We stratified visits by age, race, ethnicity, county of residence, and insurance and compared them with estimated pregnant population proportions using 1-sample t-tests. We used multivariable logistic regression to determine whether pregnancy-associated visits were more likely to be associated with hospital admission and then to determine sociodemographic predictors of admission among pregnancy-associated emergency department visits.

Results

More than 6.4 million emergency department visits were included (N=6,471,197); 10.1% (n=655,476) were pregnancy-associated, significantly higher than the proportion of women estimated to be pregnant at any given time in North Carolina (4.6%, p<0.0001) and increased over time (8.6% in 2016 vs 11.1% in 2021, p<0.0001). Pregnancy-associated visits were lower than expected for ages 25-44 years and higher than expected for those aged 15-24 years, for those of Black race, and for patients residing in rural or suburban areas. The proportion admitted was higher for pregnancy-associated emergency department visits than for nonpregnancy associated (15.6% vs 7.0%, AOR=3.06 [95% CI=3.03, 3.09]). Pregnancy-associated emergency department visits for patients of Black race had 0.58 times (95% CI=0.57, 0.59) the odds of admission compared with White patients.

Conclusions

Emergency department utilization during pregnancy is common. The proportion of pregnancy-associated emergency department visits among reproductive-age women is increasing, as are inpatient admissions from the emergency department for pregnancy-associated diagnoses. Use of public health surveillance databases such as the North Carolina Disease Event Tracking and Epidemiologic Collection Tool may help identify opportunities for improving disparities in maternal health care, especially related to access to care.

Association of the Mental Health Parity and Addiction Equity Act and the Affordable Care Act on severe maternal morbidity

OBJECTIVE

This study aimed to characterize the association between Mental Health Parity and the Affordable Care Act and rates of severe maternal morbidity among a population of commercially insured individuals, including individuals with and without perinatal mood and anxiety disorders.

METHODS

We conducted a serial, cross-sectional analysis of individuals with an inpatient delivery in Optum's Clinformatics® Data Mart Database from 2008 to 2021. We applied an interrupted time series model with autoregressive integrated moving average to evaluate changes in quarterly severe maternal morbidity rates.

RESULTS

Adjusted severe maternal morbidity rates declined from 167.2 (95%CI: [152.6, 181.9]) per 10,000 deliveries in the first quarter of 2008 to 98.2 (95%CI: [83.5, 112.8]) per 10,000 deliveries in the last quarter of 2021. Severe maternal morbidity rates remained higher, but declined to a greater degree, among those with perinatal mood and anxiety disorders (435.6, 95%CI: [379.9, 491.3], to 165.0, 95%CI: [109.3, 220.8] per 10,000 deliveries) compared to those without (153.0, 95%CI: [140.7, 165.3] to 81.8, 95%CI: [69.6, 94.1] per 10,000 deliveries).

CONCLUSION

The observed association suggests implementation of Mental Health Parity and Affordable Care Act may have played a role in lowering rates of severe maternal morbidity, particularly among individuals with perinatal mood and anxiety disorders.

Risk of recurrent severe maternal morbidity: a population-based study

BACKGROUND

Severe maternal morbidity is a composite indicator of maternal health and obstetrical care. Little is known about the risk of recurrent severe maternal morbidity in a subsequent delivery.

OBJECTIVE

This study aimed to estimate the risk of recurrent severe maternal morbidity in the next delivery after a complicated first delivery.

STUDY DESIGN

We analyzed a population-based cohort study of women with at least 2 singleton hospital deliveries between 1989 and 2021 in Quebec, Canada. The exposure was severe maternal morbidity in the first hospital-recorded delivery. The study outcome was severe maternal morbidity at the second delivery. Log-binomial regression models adjusted for maternal and pregnancy characteristics were used to generate relative risks and 95% confidence intervals comparing women with and without severe maternal morbidity at first delivery.

RESULTS

Among 819,375 women, 43,501 (3.2%) experienced severe maternal morbidity in the first delivery. The rate of severe maternal morbidity recurrence at second delivery was 65.2 vs 20.3 per 1000 in women with and without previous severe maternal morbidity (adjusted relative risk, 3.11; 95% confidence interval, 2.96-3.27). The adjusted relative risk for recurrence of severe maternal morbidity was greatest among women who had ≥3 different types of severe maternal morbidity at their first delivery, relative to those with none (adjusted relative risk, 5.50; 95% confidence interval, 4.26-7.10). Women with cardiac complication at first delivery had the highest risk of severe maternal morbidity in the next delivery.

CONCLUSION

Women who experience severe maternal morbidity have a relatively high risk of recurrent morbidity in the subsequent pregnancy. In women with severe maternal morbidity, these study findings have implications for prepregnancy counseling and maternity care in the next pregnancy.

A Prediction Model for Severe Maternal Morbidity and Mortality After Delivery Hospitalization

OBJECTIVE

To develop a risk stratification model for severe maternal morbidity (SMM) or mortality after the delivery hospitalization based on information available at the time of hospital discharge.

METHODS

This population-based cohort study included all pregnancies among Ohio residents with Medicaid insurance from 2012 to 2017. Pregnant individuals were identified using linked live birth and fetal death records and Medicaid claims data. Inclusion was restricted to those with continuous postpartum Medicaid enrollment and delivery at 20 or more weeks of gestation. The primary outcome of the study was SMM or mortality after the delivery hospitalization and was assessed up to 42 days postpartum and up to 1 year postpartum separately. Variables considered for the model included patient-, obstetric health care professional-, and system-level data available in vital records or Medicaid claims data. Parsimonious models were created with logistic regression and were internally validated. Receiver operating characteristic curves were used to evaluate model performance, and model calibration was assessed.

RESULTS

There were 343,842 pregnant individuals who met inclusion criteria with continuous Medicaid enrollment through 42 days postpartum and 287,513 with continuous enrollment through 1 year. After delivery hospitalization discharge, the incidence of SMM or mortality was 140.5 per 10,000 pregnancies through 42 days of delivery and 330.7 per 10,000 pregnancies through 1 year postpartum. The final model predicting SMM or mortality through 42 days postpartum included maternal prepregnancy body mass index, age, gestational age at delivery, mode of delivery, chorioamnionitis, and maternal diagnosis of cardiac disease, preeclampsia or gestational hypertension, or a mental health condition. Similar variables were included in the model predicting SMM or mortality through 365 days with chronic hypertension, pregestational diabetes, and illicit substance use added and chorioamnionitis removed. Both models demonstrated moderate prediction (area under the curve [AUC] 0.77, 95% CI 0.76-0.78 for 42-day model; AUC 0.72, 95% CI 0.71-0.73 for the 1-year model) and good calibration.

CONCLUSION

A prediction model for SMM or mortality up to 1 year postpartum was created and internally validated with information available to health care professionals at the time of hospital discharge. The utility of this model for patient counseling and strategies to optimize postpartum care for high-risk individuals will require further evaluation.

A Systematic Review of Interventions for Prevention and Treatment of Post-Traumatic Stress Disorder Following Childbirth

Objective

Postpartum women can develop post-traumatic stress disorder (PTSD) in response to complicated, traumatic childbirth; prevalence of these events remains high in the U.S. Currently, there is no recommended treatment approach in routine peripartum care for preventing maternal childbirth-related PTSD (CB-PTSD) and lessening its severity. Here, we provide a systematic review of available clinical trials testing interventions for the prevention and indication of CB-PTSD.

Data Sources

We conducted a systematic review of PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, and Scopus through December 2022 to identify clinical trials involving CB-PTSD prevention and treatment.

Study Eligibility Criteria

Trials were included if they were interventional, evaluated CB-PTSD preventive strategies or treatments, and reported outcomes assessing CB-PTSD symptoms. Duplicate studies, case reports, protocols, active clinical trials, and studies of CB-PTSD following stillbirth were excluded.

Study Appraisal and Synthesis Methods

Two independent coders evaluated trials using a modified Downs and Black methodological quality assessment checklist. Sample characteristics and related intervention information were extracted via an Excel-based form.

Results

A total of 33 studies, including 25 randomized controlled trials (RCTs) and 8 non-RCTs, were included. Trial quality ranged from Poor to Excellent. Trials tested psychological therapies most often delivered as secondary prevention against CB-PTSD onset (n=21); some examined primary (n=3) and tertiary (n=9) therapies. Positive treatment effects were found for early interventions employing conventional trauma-focused therapies, psychological counseling, and mother-infant dyadic focused strategies. Therapies' utility to aid women with severe acute traumatic stress symptoms or reduce incidence of CB-PTSD diagnosis is unclear, as is whether they are effective as tertiary intervention. Educational birth plan-focused interventions during pregnancy may improve maternal health outcomes, but studies remain scarce.

Conclusions

An array of early psychological therapies delivered in response to traumatic childbirth, rather than universally, in the first postpartum days and weeks, may potentially buffer CB-PTSD development. Rather than one treatment being suitable for all, effective therapy should consider individual-specific factors. As additional RCTs generate critical information and guide recommendations for first-line preventive treatments for CB-PTSD, the psychiatric consequences associated with traumatic childbirth could be lessened.

Role of Maternal Age in Increasing Severe Maternal Morbidity Rates in the United States

OBJECTIVE

To evaluate a commonly proposed explanation for increasing rates of severe maternal morbidity (SMM) in the United States: shifts in the birthing population to older maternal ages, a known risk factor for SMM.

METHODS

We conducted a cross-sectional analysis comparing delivery hospitalizations from two time points (2008-2009 to 2017-2018) using hospital discharge data from the National Inpatient Sample. We used demographic decomposition techniques to evaluate whether increasing rates of SMM and nontransfusion SMM were explained by population-level increases in maternal age or changes in age-specific rates. Analyses were stratified by race and ethnicity.

RESULTS

Rates of SMM and nontransfusion SMM significantly increased in the United States between 2008 and 2018 from 135.6 to 170.5 and 58.8 to 67.9 per 10,000 delivery hospitalizations, respectively, with increases observed for nearly all racial and ethnic groups. Over this same period, the proportion of births to people younger than age 25 years decreased and births to people of advanced maternal age (35 years and older) increased, with the largest increases occurring among people identified as non-Hispanic American Indian/Alaskan Native (9.8-13.0%), non-Hispanic Black (10.7-14.4%), and Hispanic (12.1-17.1%). Decomposition analyses indicated that the changing maternal age distribution had little effect on SMM trends. Rather, increases in SMM and nontransfusion SMM were primarily driven by increases in age-specific SMM rates, including rising rates among younger people. Contributions of maternal age shifts were minimal for all racial and ethnic groups except among non-Hispanic Black people, for which 17-34% of the rise in SMM was due to increasing maternal age.

CONCLUSION

Except among certain racial groups, increases in U.S. population-level SMM rates over the past decade were due to increases in age-specific rates rather than shifts to older maternal age among the birthing population. Increasing SMM rates across the maternal age spectrum could indicate worsening prepregnancy health status of the birthing population.

Severe Maternal Morbidity in Georgia, 2009-2020

BACKGROUND

The increasing focus of population surveillance and research on maternal-and not only fetal and infant-health outcomes is long overdue. The United States maternal mortality rate is higher than any other high-income country, and Georgia is among the highest rates in the country. Severe maternal morbidity (SMM) is conceived of as a "near miss" for maternal mortality, is 50 times more common than maternal death, and efforts to systematically monitor SMM rates in populations have increased in recent years. Much of the current population-based research on SMM has occurred in coastal states or large cities, despite substantial geographical variation with higher maternal and infant health burdens in the Southeast and rural regions.

METHODS

This population-based study uses hospital discharge records linked to vital statistics to describe the epidemiology of SMM in Georgia between 2009 and 2020.

RESULTS

Georgia had a higher SMM rate than the United States overall (189.2 vs. 144 per 10,000 deliveries in Georgia in 2014, the most recent year with US estimates). SMM was higher among racially minoritized pregnant persons and those at the extremes of age, of lower socioeconomic status, and with comorbid chronic conditions. SMM rates were 5 to 6 times greater for pregnant people delivering infants <1500 grams or <32 weeks' gestation as compared with those delivering normal weight or term infants. Since 2015, SMM has increased in Georgia.

CONCLUSION

SMM represents a collection of life-threatening emergencies that are unevenly distributed in the population and require increased attention. This descriptive analysis provides initial guidance for programmatic interventions intending to reduce the burden of SMM and, subsequently, maternal mortality in the US South.

Evaluation of All-Cause and Cause-Specific Mortality by Race and Ethnicity Among Pregnant and Recently Pregnant Women in the US, 2019 to 2020

This cross-sectional study examines all-cause and cause-specific mortality rates among pregnant and recently pregnant US women from 2019 to 2020 and compares mortality rates by race and ethnicity.

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.

Findings From Severe Maternal Morbidity Surveillance and Review in Maryland

Importance

In the US, more than 50 000 women experience severe maternal morbidity (SMM) each year, and the SMM rate more than doubled during the past 25 years. In response, professional organizations called for birthing facilities to routinely identify and review SMM events and identify prevention opportunities.

Objective

To examine SMM levels, primary causes, and factors associated with the preventability of SMM using Maryland's SMM surveillance and review program.

Design, Setting, and Participants

This cross-sectional study included pregnant and postpartum patients at 42 days or less after delivery who were hospitalized at 1 of 6 birthing hospitals in Maryland between August 1, 2020, and November 30, 2021. Hospital-based SMM surveillance was conducted through a detailed review of medical records.

Exposures

Hospitalization during pregnancy or within 42 days post partum.

Main Outcomes and Measures

The main outcomes were admission to an intensive care unit, having at least 4 U of red blood cells transfused, and/or having COVID-19 infection requiring inpatient hospital care.

Results

A total of 192 SMM events were identified and reviewed. Patients with SMM had a mean [SD] age of 31 [6.49] years; 9 [4.7%] were Asian, 27 [14.1%] were Hispanic, 83 [43.2%] were non-Hispanic Black, and 68 [35.4%] were non-Hispanic White. Obstetric hemorrhage was the leading primary cause of SMM (83 [43.2%]), followed by COVID-19 infection (57 [29.7%]) and hypertensive disorders of pregnancy (17 [8.9%]). The SMM rate was highest among Hispanic patients (154.9 per 10 000 deliveries), primarily driven by COVID-19 infection. The rate of SMM among non-Hispanic Black patients was nearly 50% higher than for non-Hispanic White patients (119.9 vs 65.7 per 10 000 deliveries). The SMM outcome assessed could have been prevented in 61 events (31.8%). Clinician-level factors and interventions in the antepartum period were most frequently cited as potentially altering the SMM outcome. Practices that were performed well most often pertained to hospitals' readiness and adequate response to managing pregnancy complications. Recommendations for care improvement focused mainly on timely recognition and rapid response to such.

Conclusions and Relevance

The findings of this cross-sectional study, which used hospital-based SMM surveillance and review beyond the mere exploration of administrative data, offers opportunities for identifying valuable quality improvement strategies to reduce SMM. Immediate strategies to reduce SMM in Maryland should target its most common causes and address factors associated with preventability identified at individual hospitals.