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Bernstein SL, Picciolo M, Grills E, Catchpole K. A Qualitative Study of Systems-Level Factors That Affect Rural Obstetric Nurses' Work During Clinical Emergencies. Jt Comm J Qual Patient Saf 2024; 50:507-515. [PMID: 38220586 DOI: 10.1016/j.jcjq.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Maternal morbidity and mortality is rising in the United States. Previous studies focus on patient attributes, and most of the national data are based on research performed at urban tertiary care centers. Although it is well understood that nurses affect patient outcomes, there is scant evidence to understand the nurse work system, and no studies have specifically studied rural nurses. The authors sought to understand the systems-level factors affecting rural obstetric nurses when their patients experience clinical deterioration. METHODS The research team used a qualitative descriptive approach, including a modified critical incident technique, in interviews with bedside nurses (n = 7) and physicians (n = 4) to understand what happens when patients experience clinical deterioration. Physicians were included to better understand the systems in which nurses work. Clinicians were interviewed at three rural hospitals in New England, with a mean births per year of 190. FINDINGS Six systems-level factors/themes were identified: (1) shortages of resources; (2) need for teamwork; (3) physicians' multiple conflicting and simultaneous responsibilities, such as seeing patients in the office while women labor on the hospital floor; (4) need for all team members to be at the top of their game; (5) process issues during high-acuity patient transfer, including difficulty finding available beds at tertiary care centers; and (6) insufficient policies that take low-resource contexts into account, such as requiring two registered nurses to remove emergency medications from the medication cabinet. CONCLUSION Rural nurses need policies and protocols that are written with their hospital context in mind. Hospitals may need outside support for content expertise, but policies should be co-created with clinicians with rural practice experience.
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Osei-Poku GK, Prentice JC, Easter SR, Diop H. Delivery at an inadequate level of maternal care is associated with severe maternal morbidity. Am J Obstet Gynecol 2024:S0002-9378(24)00421-6. [PMID: 38432412 DOI: 10.1016/j.ajog.2024.02.308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Implementing levels of maternal care is one strategy proposed to reduce maternal morbidity and mortality. The levels of maternal care framework outline individual medical and obstetrical comorbidities, along with hospital resources required for individuals with these different comorbidities to deliver safely. The overall goal is to match individuals to hospitals so that all birthing people get appropriate resources and personnel during delivery to reduce maternal morbidity. OBJECTIVE This study examined the association between delivery in a hospital with an inappropriate level of maternal care and the risk of experiencing severe maternal morbidity. STUDY DESIGN The 40 birthing hospitals in Massachusetts were surveyed using the Centers for Disease Control and Prevention's Levels of Care Assessment Tool. We linked individual delivery hospitalizations from the Massachusetts Pregnancy to Early Life Longitudinal Data System to hospital-level data from the Levels of Care Assessment Tool surveys. Level of maternal care guidelines were used to outline 16 high-risk conditions warranting delivery at hospitals with resources beyond those considered basic (level I) obstetrical care. We then used the Levels of Care Assessment Tool assigned levels to determine if delivery occurred at a hospital that had the resources to meet an individual's needs (ie, if a patient received risk-appropriate care). We conducted our analyses in 2 stages. First, multivariable logistic regression models predicted if an individual delivered in a hospital that did not have the resources for their risk condition. The main explanatory variable of interest was if the hospital self-assessed their level of maternal care to be higher than the Levels of Care Assessment Tool assigned level. We then used logistic regression to examine the association between delivery at an inappropriate level hospital and the presence of severe maternal morbidity at delivery. RESULTS Among 64,441 deliveries in Massachusetts from January 1 to December 31, 2019, 33.2% (21,415/64,441) had 1 or more of the 16 high-risk conditions that require delivery at a center designated as a level I or higher. Of the 21,415 individuals with a high-risk condition, 13% (2793/21,415), equating to 4% (2793/64,441) of the entire sample, delivered at an inappropriate level of maternal care. Birthing individuals with high-risk conditions who delivered at a hospital with an inappropriate level had elevated odds (adjusted odds ratio, 3.34; 95% confidence interval, 2.24-4.96) of experiencing severe maternal morbidity after adjusting for patient comorbidities, demographics, average hospital severe maternal morbidity rate, hospital level of maternal care, and geographic region. CONCLUSION Birthing people who delivered in a hospital with risk-inappropriate resources were substantially more likely to experience severe maternal morbidity. Delivery in a hospital with a discrepancy in their self-assessment and the Levels of Care Assessment Tool assigned level substantially predicted delivery in a hospital with an inappropriate level of maternal care, suggesting inadequate knowledge of hospitals' resources and capabilities. Our data demonstrate the potential for the levels of maternal care paradigm to decrease severe maternal morbidity while highlighting the need for robust implementation and education to ensure everyone receives risk-appropriate care.
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Affiliation(s)
- Godwin K Osei-Poku
- Division of Research and Analysis, Betsy Lehman Center for Patient Safety, Commonwealth of Massachusetts, Boston, MA.
| | - Julia C Prentice
- Division of Research and Analysis, Betsy Lehman Center for Patient Safety, Commonwealth of Massachusetts, Boston, MA; Department of Psychiatry, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA
| | - Sarah Rae Easter
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Hafsatou Diop
- Commissioners Office, Massachusetts Department of Public Health, Boston, MA
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Rojas-Suarez J, Paruk F. Maternal high-care and intensive care units in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 93:102474. [PMID: 38395025 DOI: 10.1016/j.bpobgyn.2024.102474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
Despite notable advancements in minimizing maternal mortality during recent decades, a pronounced disparity persists between high-income nations and low-to middle-income countries (LMICs), particularly in intensive and high-care for pregnant and postpartum individuals. This divergence is multifactorial and influenced by factors such as the availability and accessibility of community-based maternity healthcare services, the quality of preventive care, timeliness in accessing hospital or critical care, resource availability, and facilities equipped for advanced interventions. Complications from various conditions, including human immunodeficiency virus (HIV), unsafe abortions, puerperal sepsis, and, notably, the COVID-19 pandemic, intensify the complexity of these challenges. In confronting these challenges and deliberating on potential solutions, we hope to contribute to the ongoing discourse around maternal healthcare in LMICs, ultimately striving toward an equitable health landscape where every mother, regardless of geographic location or socioeconomic status, has access to the care they require and deserve. The use of traditional and innovative methods to achieve adequate knowledge, appropriate skills, location of applicable resources, and strong leadership is essential. By implementing and enhancing these strategies, limited-resource settings can optimize the available resources to promptly recognize the severity of illness in obstetric individuals, ensuring timely and appropriate interventions for mothers and children. Additionally, strategies that could significantly improve the situation include increased investment in healthcare infrastructure, effective resource management, enhanced supply chain efficiency, and the development and use of low-cost, high-quality equipment. Through targeted investments, innovations, efficient resource management, and international cooperation, it is possible to ensure that every maternal high-care and ICU unit, regardless of geographical location or socioeconomic status, has access to high-quality critical care to provide life-saving care.
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Affiliation(s)
- José Rojas-Suarez
- Intensive Care and Obstetric Research Group (GRICIO), Universidad de Cartagena, Colombia; GINUMED Research Group, Corporación Universitaria Rafael Núñez, Cartagena, Colombia.
| | - Fathima Paruk
- Department of Critical Care, Steve Biko Academic Hospital and Faculty of Health Science University of Pretoria, South Africa.
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Hall C, Romano CJ, Bukowinski AT, Gumbs GR, Dempsey KN, Poole AT, Conlin AMS, Lamb SV. Severe Maternal Morbidity among Women in the U. S. Military, 2003-2015. Am J Perinatol 2024; 41:150-159. [PMID: 34891195 DOI: 10.1055/s-0041-1740248] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to assess trends and correlates of severe maternal morbidity at delivery among active duty women in the U.S. military, all of whom are guaranteed health care and full employment. STUDY DESIGN Linked military personnel and medical encounter data from the Department of Defense Birth and Infant Health Research program were used to identify a cohort of delivery hospitalizations among active duty military women from January 2003 through August 2015. Cases of severe maternal morbidity were identified by applying 21- and 20-condition algorithms (with and without blood transfusion) developed by the Centers for Disease Control and Prevention. Rates (per 10,000 delivery hospitalizations) were reported overall and by specific condition. Multivariable Poisson regression models estimated associations with demographic, clinical, and military characteristics. RESULTS Overall, 187,063 hospitalizations for live births were included for analyses. The overall 21- and 20-condition severe maternal morbidity rates were 111.7 (n = 2089) and 37.4 (n = 699) per 10,000 delivery hospitalizations, respectively. The 21-condition rate increased by 184% from 2003 to 2015; the 20-condition rate increased by 40%. Compared with non-Hispanic White women, the adjusted 21-condition rate of severe maternal morbidity was higher for Hispanic (adjusted rate ratio [aRR] = 1.28, 95% confidence interval [CI]: 1.13-1.46), non-Hispanic Black (aRR = 1.34, 95% CI: 1.21-1.49), Asian/Pacific Islander (aRR = 1.35, 95% CI: 1.13-1.61), and American Indian/Alaska Native (aRR = 1.39, 95% CI: 1.06-1.82) women. Rates also varied by age, clinical factors, and deployment history. CONCLUSION Active duty U.S. military women experienced an increase in severe maternal morbidity from 2003 to 2015 that followed national trends, despite protective factors such as stable employment and universal health care. Similar to other populations, military women of color were at higher risk for severe maternal morbidity relative to non-Hispanic White military women. Continued surveillance and further investigation into maternal health outcomes are critical for identifying areas of improvement in the Military Health System. KEY POINTS · Cesarean delivery and multiple birth were the strongest correlates of severe maternal morbidity in this population.. · Racial disparities persisted across indicators of severe maternal morbidity.. · Rates of disseminated intravascular coagulation were higher than those reported nationally..
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Affiliation(s)
- Clinton Hall
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos Inc., San Diego, California
| | - Celeste J Romano
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos Inc., San Diego, California
| | - Anna T Bukowinski
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos Inc., San Diego, California
| | - Gia R Gumbs
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos Inc., San Diego, California
| | - Kaitlyn N Dempsey
- School of Medicine, Uniformed Services University, Bethesda, Maryland
- Department of Obstetrics and Gynecology, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Aaron T Poole
- Department of Obstetrics and Gynecology, Naval Medical Center Portsmouth, Portsmouth, Virginia
- Las Palmas Del Sol Healthcare, El Paso, Texas
| | - Ava Marie S Conlin
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
| | - Shannon V Lamb
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland
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Guglielminotti J, Samari G, Friedman AM, Landau R, Li G. State-Level Indicators of Structural Racism and Severe Adverse Maternal Outcomes During Childbirth. Matern Child Health J 2024; 28:165-176. [PMID: 37938439 DOI: 10.1007/s10995-023-03828-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVES Structural racism (SR) is viewed as a root cause of racial and ethnic disparities in maternal health outcomes. However, evidence linking SR to increased odds of severe adverse maternal outcomes (SAMO) is scant. This study assessed the association between state-level indicators of SR and SAMO during childbirth. METHODS Data for non-Hispanic Black and non-Hispanic white women came from the US Natality file, 2017-2018. The exposures were state-level Black-to-white inequity ratios for lower education level, unemployment, and prison incarceration. The outcome was patient-level SAMO, including eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Adjusted odds ratios (aORs) of SAMO associated with each ratio were estimated using multilevel models adjusting for patient, hospital, and state characteristics. RESULTS A total of 4,804,488 birth certificates were analyzed, with 22.5% for Black women. SAMO incidence was 106.4 per 10,000 (95% CI 104.5, 108.4) for Black women, and 72.7 per 10,000 (95% CI 71.8, 73.6) for white women. Odds of SAMO increased 35% per 1-unit increase in the unemployment ratio for Black women (aOR 1.35; 95% CI 1.04, 1.73), and 16% for white women (aOR 1.16; 95% CI 1.01, 1.33). Odds of SAMO increased 6% per 1-unit increase in the incarceration ratio for Black women (aOR 1.06; 95% CI 1.03, 1.10), and 4% for white women (aOR 1.04; 95% CI 1.02, 1.06). No significant association was observed between SAMO and the lower education level ratio. CONCLUSIONS FOR PRACTICE State-level Black-to-white inequity ratios for unemployment and incarceration are associated with significantly increased odds of SAMO.
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Affiliation(s)
- Jean Guglielminotti
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY, 10032, USA.
| | - Goleen Samari
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA
| | - Alexander M Friedman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, New York, NY, 10032, USA
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY, 10032, USA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY, 10032, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA
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Gao X, Thomas TA, Morello-Frosch R, Allen AM, Snowden JM, Carmichael SL, Mujahid MS. Neighborhood gentrification, displacement, and severe maternal morbidity in California. Soc Sci Med 2023; 334:116196. [PMID: 37678111 PMCID: PMC10959124 DOI: 10.1016/j.socscimed.2023.116196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/29/2023] [Accepted: 08/29/2023] [Indexed: 09/09/2023]
Abstract
Gentrification, a racialized and profit-driven process in which historically disinvested neighborhoods experience an influx of development that contributes to the improvement of physical amenities, increasing housing costs, and the dispossession and displacement of existing communities, may influence the risk of severe maternal morbidity (SMM). Leveraging a racially diverse population-based sample of all live hospital births in California between 2006 and 2017, we examined associations between neighborhood-level gentrification and SMM. SMM was defined as having one of 21 procedures and diagnoses, as described in the SMM index developed by Centers for Disease Control and Prevention. We compared three gentrification measures to determine which operationalization best captures aspects of gentrification most salient to SMM: Freeman, Landis 3-D, and Urban Displacement Project Gentrification and Displacement Typology. Descriptive analysis assessed bivariate associations between gentrification and birthing people's characteristics. Overall and race and ethnicity-stratified mixed-effects logistic models assessed associations between gentrification and SMM, adjusting for individual sociodemographic and pregnancy factors while accounting for clustering by census tract. The study sample included 5,256,905 births, with 72,718 cases of SMM (1.4%). The percentage of individuals living in a gentrifying neighborhood ranged from 5.7% to 11.7% across exposure assessment methods. Net of individual and pregnancy-related factors, neighborhood-level gentrification, as measured by the Freeman method, was protective against SMM (OR = 0.89, 95% CI: 0.86-0.93); in comparison, gentrification, as measured by the Gentrification and Displacement Typology, was associated with greater risk of SMM (OR = 1.18, 95% CI: 1.14-1.23). These associations were significant among non-Hispanic White, non-Hispanic Black, and Hispanic individuals. Findings demonstrate that gentrification plays a role in shaping the risk of SMM among birthing people in California. Differences in how gentrification is conceptualized and measured, such as an emphasis on housing affordability compared to a broader characterization of gentrification's multiple aspects, may explain the heterogeneity in the directions of observed associations.
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Affiliation(s)
- Xing Gao
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Timothy A Thomas
- Urban Displacement Project, Institute of Governmental Studies, University of California Berkeley, Berkeley, CA, USA
| | - Rachel Morello-Frosch
- Department of Environmental Science, Policy and Management, University of California Berkeley, Berkeley, CA, USA; Division of Environmental Health Sciences, School of Public Health, University of California Berkeley, Berkeley, CA, USA; Division of Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Amani M Allen
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA; Division of Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Jonathan M Snowden
- School of Public Health, Oregon Health & Science University-Portland State University, OR, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Division of Neonatal & Developmental Medicine, Stanford University, Stanford, CA, USA; Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Stanford University, Stanford, CA, USA
| | - Mahasin S Mujahid
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA.
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Osei-Poku GK, Prentice JC, Peeler M, Bernstein SN, Iverson RE, Schiff DM. Risk of Severe Maternal Morbidity in Birthing People With Opioid Use Disorder. Womens Health Issues 2023; 33:524-531. [PMID: 37423777 DOI: 10.1016/j.whi.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 05/29/2023] [Accepted: 06/09/2023] [Indexed: 07/11/2023]
Abstract
INTRODUCTION We examined severe maternal morbidity (SMM) among birthing people with opioid use disorder (OUD) and evaluated the extent to which differences in SMM exist by race and ethnicity. METHODS We performed a retrospective cohort study using hospital discharge data for all Massachusetts births between 2016 and 2020. SMM rates for all SMM indicators, except transfusions, were computed for those diagnosed with and without OUD. Multivariable logistic regression was used to examine the association between OUD and SMM after adjusting for patient and hospital characteristics, including race and ethnicity. RESULTS Among 324,012 childbirths, the SMM rate was 148 (95% confidence interval [CI]. 115-189) per 10,000 childbirths among birthing people with OUD compared with 88 (95% CI, 85-91) for those without. In adjusted models, both OUD and race/ethnicity were significantly associated with SMM. Birthing people with OUD had 2.12 (95% CI, 1.64-2.75) times the odds of experiencing an SMM event compared with those without. Non-Hispanic Black and Hispanic birthing people were at 1.85 (95% CI, 1.65-2.07) and 1.26 (95% CI, 1.13-1.41) higher odds of experiencing SMM compared with non-Hispanic White birthing people. Among birthing people with OUD, the odds of SMM were not significantly different between birthing people of color and non-Hispanic White individuals. CONCLUSIONS Birthing people with OUD are at an elevated risk of SMM, underscoring the need for improved access to OUD treatment and increased support. Perinatal quality improvement collaboratives should measure SMM in bundles aimed at improving outcomes for birthing people with OUD.
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Affiliation(s)
- Godwin K Osei-Poku
- Betsy Lehman Center for Patient Safety, Commonwealth of Massachusetts, Boston, Massachusetts.
| | - Julia C Prentice
- Betsy Lehman Center for Patient Safety, Commonwealth of Massachusetts, Boston, Massachusetts; Boston University School of Medicine, Boston, Massachusetts
| | - Mary Peeler
- Department of Gynecology and Obstetrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Sarah N Bernstein
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ronald E Iverson
- Boston University School of Medicine, Boston, Massachusetts; Department of Obstetrics and Gynecology, Boston Medical Center, Boston, Massachusetts
| | - Davida M Schiff
- Division of General Academic Pediatrics and Newborn Medicine, Mass General Hospital for Children, Boston, Massachusetts
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Docheva N, Heimberger S, Mueller A, Bisson C, Arenas G, Perdigao JL, Kordik A, Stewart K, Goodall P, Lengyel E, Rana S. A Comparison of Obstetric Interventions and Outcomes Between Black and White Patients at an Urban Tertiary Medical Center. Reprod Sci 2023; 30:2313-2323. [PMID: 36717463 DOI: 10.1007/s43032-023-01174-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/13/2023] [Indexed: 02/01/2023]
Abstract
The objective of the study is to evaluate whether rates of selected labor and delivery interventions and severe maternal morbidity (SMM) differ between Black and White pregnant patients. This retrospective observational cohort study included all Black or White pregnant patients who delivered at the University of Chicago Medical Center between January 2015 and December 2019. Data queried included demographic information, antepartum complications, preterm interventions, labor and delivery events, and neonatal outcomes. SMM was a composite outcome, including intensive care unit admission, blood transfusion, hysterectomy, eclampsia, cardiac arrest, or death. In total, 10,885 parturients (9001 Black and 1884 White) and 11,211 neonates (9254 born to Black and 1957 to White patients) were included in the study. Black patients were more likely to have preterm labor (3.51% vs. 1.86%, p = 0.0002) and no prenatal care (17.83% vs. 4.05%, p < 0.0001). There was no significant difference in the administration of magnesium sulfate for fetal neuroprotection (Black 44.78% vs. White 49.32%, p = 0.48) or antenatal corticosteroids (Black 67.83% vs. White 71.98%, p = 0.28) among those with preterm delivery. There was no significant difference in SMM (Black 2.24% vs. White 2.44%, p = 0.60), and SMM rates decreased over time (OR 0.79 per year, 95% CI: 0.72-0.87, p < 0.0001) for all patients. Black patients had more pregnancy complications, but their complications were addressed with similar rates of obstetrical interventions. In a high-resource setting, there was no difference in rates of SMM when compared to White patients.
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Affiliation(s)
- Nikolina Docheva
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Sarah Heimberger
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Ariel Mueller
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Courtney Bisson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Gabriel Arenas
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Joana Lopes Perdigao
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Abbe Kordik
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Karie Stewart
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Perpetua Goodall
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Ernst Lengyel
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Sarosh Rana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA.
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Liu P, Zhang X, Wang X, Liang Y, Wei N, Xiao Z, Li T, Zhe R, Zhao W, Fan S. Maternal sepsis in pregnancy and the puerperal periods: a cross-sectional study. Front Med (Lausanne) 2023; 10:1126807. [PMID: 37261123 PMCID: PMC10228646 DOI: 10.3389/fmed.2023.1126807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 04/17/2023] [Indexed: 06/02/2023] Open
Abstract
Maternal sepsis is a life-threatening condition and ranks among the top five causes of maternal death in pregnancy and the postpartum period. Herein, we conducted a retrospective study on sepsis cases to explain the related risk factors by comparing them with bloodstream infection (BSI) and control maternities. In total, 76 sepsis cases were enrolled, and 31 BSI and 57 maternal cases of the same age but with neither sepsis nor BSI were set as controls. Genital tract infection (GTI) and pneumonia were the two most common infection sources in both sepsis (22 cases, 29% and 29 cases, 38%) and BSI cases (18 cases, 58% and 8 cases, 26%). Urinary tract infection (UTI)/pyelonephritis (9 cases, 12%) and digestive infection cases (11 cases, 14%) only existed in the sepsis group. Significantly different infection sources were discovered between the sepsis-death and sepsis-cure groups. A higher proportion of pneumonia and a lower proportion of GTI cases were present in the sepsis-death group (17 cases, 45% pneumonia and 9 cases, 24% GTI) than in the sepsis-cure group (12 cases, 32% pneumonia and 13 cases, 34% GTI). In addition, although gram-negative bacteria were the dominant infectious microorganisms as previously reported, lower proportion of gram-negative bacteria infectious cases in sepsis (30 cases, 50%) and even lower in sepsis-death group (14 cases, 41%) was shown in this study than previous studies. As expected, significantly greater adverse maternal and fetal outcomes, such as higher maternal mortality (26.3% vs. 0% vs. 0%), higher fetal mortality (42.2% vs. 20.8% vs. 0%), earlier gestational age at delivery (26.4 ± 9.5 vs. 32.3 ± 8.1 vs. 37.7 ± 4.0) and lower newborn weight (1,590 ± 1287.8 vs. 2859.2 ± 966.0 vs. 3214.2 ± 506.4), were observed in the sepsis group. This study offered some potential pathogenesis and mortality risk factors for sepsis, which may inspire the treatment of sepsis in the future.
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Affiliation(s)
- Ping Liu
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
- Shenzhen Key Laboratory of Gynecological Diagnostic Technology Research, Peking University Shenzhen Hospital, Shenzhen, China
| | - Xiaowei Zhang
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
- Shenzhen Key Laboratory of Gynecological Diagnostic Technology Research, Peking University Shenzhen Hospital, Shenzhen, China
| | - Xinxin Wang
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
- Shenzhen Key Laboratory of Gynecological Diagnostic Technology Research, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yiheng Liang
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Nan Wei
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Zhansong Xiao
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Ting Li
- Department of Obstetrics and Gynecology, Suzhou Municipal Hospital, Suzhou, China
| | - Ruilian Zhe
- Department of Obstetrics, Shenzhen People’s Hospital, Shenzhen, China
| | - Weihua Zhao
- Department of Obstetrics, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Shangrong Fan
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
- Shenzhen Key Laboratory of Gynecological Diagnostic Technology Research, Peking University Shenzhen Hospital, Shenzhen, China
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Simpson KR, Spetz J, Gay CL, Fletcher J, Landstrom GL, Lyndon A. Hospital characteristics associated with nurse staffing during labor and birth: Inequities for the most vulnerable maternity patients. Nurs Outlook 2023; 71:101960. [PMID: 37004352 PMCID: PMC10913105 DOI: 10.1016/j.outlook.2023.101960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 01/06/2023] [Accepted: 02/22/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Evidence is limited on nurse staffing in maternity units. PURPOSE To estimate the relationship between hospital characteristics and adherence with Association of Women's Health, Obstetric and Neonatal Nurses nurse staffing guidelines. METHODS We enrolled 3,471 registered nurses in a cross-sectional survey and obtained hospital characteristics from the 2018 American Hospital Association Annual Survey. We used mixed-effects linear regression models to estimate associations between hospital characteristics and staffing guideline adherence. FINDINGS Overall, nurses reported strong adherence to AWHONN staffing guidelines (rated frequently or always met by ≥80% of respondents) in their hospitals. Higher birth volume, having a neonatal intensive care unit, teaching status, and higher percentage of births paid by Medicaid were all associated with lower mean guideline adherence scores. DISCUSSION AND CONCLUSIONS Important gaps in staffing were reported more frequently at hospitals serving patients more likely to have medical or obstetric complications, leaving the most vulnerable patients at risk.
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Affiliation(s)
| | - Joanne Spetz
- Phillip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA
| | - Caryl L Gay
- Department of Family Health Care Nursing, University of California San Francisco School of Nursing, San Francisco, CA
| | - Jason Fletcher
- Rory Meyers College of Nursing, New York University, New York, NY
| | | | - Audrey Lyndon
- Department of Family Health Care Nursing, University of California San Francisco School of Nursing, San Francisco, CA; Rory Meyers College of Nursing, New York University, New York, NY.
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11
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DeSisto CL, Goodman DA, Brantley MD, Menard MK, Declercq E. Examining the Ratio of Obstetric Beds to Births, 2000-2019. J Community Health 2022; 47:828-834. [PMID: 35771384 PMCID: PMC11036083 DOI: 10.1007/s10900-022-01116-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 11/24/2022]
Abstract
The number of U.S. births has been declining. There is also concern about rural obstetric units closing. To better understand the relationship between births and obstetric beds during 2000-2019, we examined changes over time in births, birth hospital distributions (i.e., hospital birth volume, ownership, and urban-rural designation), and the ratio of births to obstetric beds. We analyzed American Hospital Association Annual Survey data from 2000 to 2019. We included U.S. hospitals with at least 25 reported births during the year and at least 1 reported obstetric bed. We categorized birth volume to identify and describe hospitals with maternity services using seven categories. We calculated ratios of number of births to number of obstetric beds overall, by annual birth volume category, by three categories of hospital ownership, and by six urban-rural categories. The ratio of births to obstetric beds, which may represent need for maternity services, has stayed relatively consistent at 65 over the past two decades, despite the decline in births and changes in birth hospital distributions. The ratios were smallest in hospitals with < 250 annual births and largest in hospitals with ≥ 7000 annual births. The largest ratios of births to obstetric beds were in large metro areas and the smallest ratios were in noncore areas. At a societal level, the reduction in obstetric beds corresponds with the drop in the U.S. birth rate. However, consistency in the overall ratio can mask important differences that we could not discern, such as the impact of closures on distances to closest maternity care.
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Affiliation(s)
- Carla L DeSisto
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop S107-2, Chamblee, GA, 30341, USA.
| | - David A Goodman
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop S107-2, Chamblee, GA, 30341, USA
| | - Mary D Brantley
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop S107-2, Chamblee, GA, 30341, USA
| | - M Kathryn Menard
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, 321 S Columbia St, Chapel Hill, NC, 27599, USA
| | - Eugene Declercq
- Community Health Sciences, Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA
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12
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White RS, Lui B, Bryant-Huppert J, Chaturvedi R, Hoyler M, Aaronson J. Economic burden of maternal mortality in the USA, 2018-2020. J Comp Eff Res 2022; 11:927-933. [PMID: 35833509 DOI: 10.2217/cer-2022-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To evaluate the economic burden of age- and race/ethnicity-based US maternal mortality disparities. Economic burden is estimated by years of potential life lost (YPLL) and value of statistical life (VSL). Methods: Maternal mortality counts (2018-2020) were obtained from the CDC Wide-ranging Online Data for Epidemiologic Research database. Life-expectancy data were obtained from the Social Security actuarial tables. YPLL and VSL were calculated and stratified by age (classified as under 25, 25-39, and 40 and over) and race/ethnicity (classified as Hispanic, non-Hispanic White, non-Hispanic Black). Results: Economic measures associated with maternal mortality increased by an estimated 30%, from a YPLL of 32,824 and VSL of US$7.9 billion in 2018 to a YPLL of 43,131 and VSL of US$10.4 billion in 2020. Conclusion: Our findings suggest that age, race and ethnicity are major drivers of the US maternal mortality economic burden.
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Affiliation(s)
- Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Briana Lui
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Joe Bryant-Huppert
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Rahul Chaturvedi
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Marguerite Hoyler
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Jaime Aaronson
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
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13
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The prevalence of blood product transfusion after the implementation of a postpartum hemorrhage bundle: a retrospective cohort at a single safety net academic institution. Am J Obstet Gynecol MFM 2022; 4:100662. [PMID: 35577315 DOI: 10.1016/j.ajogmf.2022.100662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/05/2022] [Accepted: 05/10/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Postpartum hemorrhage, defined as blood loss of ≥1000 mL within 24 hours after birth, is a leading cause of maternal morbidity and is associated with substantial financial and emotional burden. Based on societal and regulatory guidelines, in 2019, our institution adopted a postpartum hemorrhage prevention and management bundle based on the California Maternal Quality Care Collaborative initiatives. OBJECTIVE The study aimed to compare the prevalence of maternal blood product transfusion before and after the implementation of the bundle. STUDY DESIGN This was a retrospective cohort study comparing the prevalence of blood product transfusion before and after the implementation of a California Maternal Quality Care Collaborative-based postpartum hemorrhage management bundle at a single safety net teaching hospital between October 2017 and December 2019 excluding a 4-month rollout period between September 2018 and December 2018. The study included all patients ≥18 years of age and at >20 weeks' gestation. Exclusion criteria were out-born deliveries, delivery at time of significant nonobstetrical trauma, and refusal of blood transfusion. The primary outcome was the frequency of any blood product transfusion in the pre- and postbundle implementation cohorts. Secondary outcomes included blood product transfusion type and amount, maternal death, intrauterine balloon placement, uterine artery embolization, unplanned peripartum hysterectomy, intensive care admission, and length of stay among all deliveries complicated by postpartum hemorrhage. We further evaluated compliance with bundle measures for all postpartum hemorrhage cases. Cohort characteristics were compared using chi-square tests or Fisher exact tests for categorical data and Satterthwaite or Wilcoxon 2-sample tests for continuous variables based on data distributions. The proportion of blood product transfusion were evaluated using a chi-square test. RESULTS A total of 6744 deliveries were included with 3310 in the pre- and 3425 in the postbundle cohort. The prevalence of any blood product transfusion was similar between the pre- and postbundle cohorts (3.41%; 113/3310 vs 3.47%; 119/3425; P=.892). The prevalence of postpartum hemorrhage was 7.05% (233/3310) in the prebundle cohort and 10.34% (354/3434) in the postbundle cohort (P<.001). Among women with postpartum hemorrhage, those in the prebundle cohort had a higher rate of blood product transfusion than those in the postbundle cohort (36.05%; 84/233 vs 26.84%; 95/354; P=.018). Compared with the prebundle counterparts, patients with postpartum hemorrhage in the postbundle cohort had higher rates of utilization of intrauterine balloon placement (10.30%; 24/233 vs 16.95%; 60/354; P=.024). There were no significant differences among other secondary outcomes. The overall compliance with the bundle among those with blood loss ≥1000 mL was 92.1%. CONCLUSION The implementation of the postpartum hemorrhage bundle did not decrease the overall prevalence of blood product transfusion and may have led to higher rates of utilization of resources.
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Chen N, Pan J. The causal effect of delivery volume on severe maternal morbidity: an instrumental variable analysis in Sichuan, China. BMJ Glob Health 2022; 7:bmjgh-2022-008428. [PMID: 35537760 PMCID: PMC9092146 DOI: 10.1136/bmjgh-2022-008428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 04/19/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Findings regarding the association between delivery volume and maternal health outcomes are mixed, most of which explored their correlation. This study aims to demonstrate the causal effect of delivery volume on severe maternal morbidity (SMM) in China. Methods We analysed all women giving birth in the densely populated Sichuan province with 83 million residents in China, during the fourth quarters of each of 4 years (from 2016 to 2019). The routinely collected discharge data, the health institutional annual report data and road network data were used for analysis. The maternal health outcome was measured by SMM. Instrumental variable (IV) methods were applied for estimation, while the surrounding average number of delivery cases per institution was used as the instrument. Results The study included 4545 institution-years of data from 1456 distinct institutions with delivery services, reflecting 810 049 associated delivery cases. The average SMM rate was approximately 33.08 per 1000 deliveries during 2016 and 2019. More than 86% of delivery services were provided by a third of the institutions with the highest delivery volume (≥143 delivery cases quarterly). In contrast, less than 2% of delivery services were offered by a third of the institutions with the lowest delivery volume (<19 delivery cases quarterly). After adjusting the confounders in the IV-logistic models, the average marginal effect of per 1000 cases in delivery volume was −0.162 (95% CI −0.169 to –0.155), while the adjusted OR of delivery volume was 0.005 (95% CI 0.004 to 0.006). Conclusion Increased delivery volume has great potential to improve maternal health outcomes, while the centralisation of delivery services might facilitate maternal health promotion in China. Our study also provides implications for other developing countries confronted with similar challenges to China.
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Affiliation(s)
- Nan Chen
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, People's Republic of China.,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, People's Republic of China
| | - Jay Pan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, People's Republic of China .,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, People's Republic of China
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15
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Bernstein SL, Catchpole K, Kelechi TJ, Nemeth LS. Systems Level Factors Affecting Registered Nurses During Care of Women in Labor Experiencing Clinical Deterioration. Jt Comm J Qual Patient Saf 2022; 48:309-318. [DOI: 10.1016/j.jcjq.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
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16
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Torres‐Torres J, Martinez‐Portilla RJ, Espino‐y‐Sosa S, Estrada‐Gutierrez G, Solis‐Paredes JM, Villafan‐Bernal JR, Medina‐Jimenez V, Rodriguez‐Morales AJ, Rojas‐Zepeda L, Poon LC. Comorbidity, poverty and social vulnerability as risk factors for mortality in pregnant women with confirmed SARS-CoV-2 infection: analysis of 13 062 positive pregnancies including 176 maternal deaths in Mexico. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:76-82. [PMID: 34672382 PMCID: PMC8662032 DOI: 10.1002/uog.24797] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/05/2021] [Accepted: 10/11/2021] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Mortality in pregnancy due to coronavirus disease 2019 (COVID-19) is a current health priority in developing countries. Identification of clinical and sociodemographic risk factors related to mortality in pregnant women with COVID-19 could guide public policy and encourage such women to accept vaccination. We aimed to evaluate the association of comorbidities and socioeconomic determinants with COVID-19-related mortality and severe disease in pregnant women in Mexico. METHODS This is an ongoing nationwide prospective cohort study that includes all pregnant women with a positive reverse-transcription quantitative polymerase chain reaction result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from the Mexican National Registry of Coronavirus. The primary outcome was maternal death due to COVID-19. The association of comorbidities and socioeconomic characteristics with maternal death was explored using a log-binomial regression model adjusted for possible confounders. RESULTS There were 176 (1.35%) maternal deaths due to COVID-19 among 13 062 consecutive SARS-CoV-2-positive pregnant women. Maternal age, as a continuous (adjusted relative risk (aRR), 1.08 (95% CI, 1.05-1.10)) or categorical variable, was associated with maternal death due to COVID-19; women aged 35-39 years (aRR, 3.16 (95% CI, 2.34-4.26)) or 40 years or older (aRR, 4.07 (95% CI, 2.65-6.25)) had a higher risk for mortality, as compared with those aged < 35 years. Other clinical risk factors associated with maternal mortality were pre-existing diabetes (aRR, 2.66 (95% CI, 1.65-4.27)), chronic hypertension (aRR, 1.75 (95% CI, 1.02-3.00)) and obesity (aRR, 2.15 (95% CI, 1.46-3.17)). Very high social vulnerability (aRR, 1.88 (95% CI, 1.26-2.80)) and high social vulnerability (aRR, 1.49 (95% CI, 1.04-2.13)) were associated with an increased risk of maternal mortality, while very low social vulnerability was associated with a reduced risk (aRR, 0.47 (95% CI, 0.30-0.73)). Being poor or extremely poor were also risk factors for maternal mortality (aRR, 1.53 (95% CI, 1.09-2.15) and aRR, 1.83 (95% CI, 1.32-2.53), respectively). CONCLUSION This study, which comprises the largest prospective consecutive cohort of pregnant women with COVID-19 to date, has confirmed that advanced maternal age, pre-existing diabetes, chronic hypertension, obesity, high social vulnerability and low socioeconomic status are risk factors for COVID-19-related maternal mortality. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J. Torres‐Torres
- Maternal–Fetal Medicine DepartmentGeneral Hospital of Mexico, ‘Dr Eduardo Liceaga’Mexico CityMexico
- Clinical Research BranchNational Institute of PerinatologyMexico CityMexico
- ABC Medical CenterMedical AssociationMexico CityMexico
| | - R. J. Martinez‐Portilla
- Clinical Research BranchNational Institute of PerinatologyMexico CityMexico
- ABC Medical CenterMedical AssociationMexico CityMexico
| | - S. Espino‐y‐Sosa
- Clinical Research BranchNational Institute of PerinatologyMexico CityMexico
- ABC Medical CenterMedical AssociationMexico CityMexico
| | | | | | | | | | - A. J. Rodriguez‐Morales
- Clinical Epidemiology and BiostatisticsUniversidad Científica del Sur, Lima, Peru
- Grupo de Investigación BiomedicinaFaculty of Medicine, Fundación Universitaria Autónoma de las Américas, PereiraRisaraldaColombia
| | - L. Rojas‐Zepeda
- Instituto Materno Infantil del Estado de MéxicoToluca, Mexico
| | - L. C. Poon
- Department of Obstetrics and GynaecologyPrince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR
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17
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Hunter A, Banaag A, Lutgendorf MA, Staat CB, Koehlmoos TP. Volume as an Indicator for Outcomes for Severe Maternal Morbidity in the Military Health System. Mil Med 2021; 187:e963-e968. [PMID: 34741453 DOI: 10.1093/milmed/usab442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/09/2021] [Accepted: 10/15/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Maternal obstetric morbidity is a growing concern in the USA, where rates of maternal morbidity exceed Europe and most developed countries. Prior studies have found that obstetric case volume affects maternal morbidity, with low-volume facilities having higher rates of morbidity. However, these studies were done in civilian healthcare systems that are different from the Military Health System (MHS). This study evaluates whether obstetric case volume impacts severe maternal morbidity (SMM) in military hospitals located in the continental United States. METHODS This cross-sectional study included all military treatment facilities (MTFs) (n = 35) that performed obstetric deliveries (n = 102,959) from October 2015 to September 2018. Data were collected from the MHS Data Repository and identified all deliveries for the study time period. Severe maternal morbidity was defined by the Centers for Disease Control. The 30-day readmission rates were also included in analysis. Military treatment facilities were separated into volume quartiles for analysis. Univariate logistic regressions were performed to determine the impact of MTF delivery volume on the probability of SMM and 30-day maternal readmissions. RESULTS The results for all regression models indicate that the MTF delivery volume had no significant impact on the probability of SMM. With regard to 30-day maternal readmissions, using the upper middle quartile as the comparison group due to the largest number of deliveries, MTFs in the lower middle quartile and in the highest quartile had a statistically significant higher likelihood of 30-day maternal readmissions. CONCLUSION This study shows no difference in SMM rates in the MHS based on obstetric case volume. This is consistent with previous studies showing differences in MHS patient outcomes compared to civilian healthcare systems. The MHS is unique in that it provides families with universal healthcare coverage and access and provides care for approximately 40,000 deliveries annually. There may be unique lessons on volume and outcomes in the MHS that can be shared with healthcare planners and decision makers to improve care in the civilian setting.
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Affiliation(s)
- Aimee Hunter
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Amanda Banaag
- Henry M. Jackson Foundation for the Advancement in Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Monica A Lutgendorf
- Department of Gynecologic Surgery and Obstetrics, Naval Medical Center San Diego, San Diego, CA 92314, USA.,Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Col Barton Staat
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Tracey P Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Handley SC, Passarella M, Herrick HM, Interrante JD, Lorch SA, Kozhimannil KB, Phibbs CS, Foglia EE. Birth Volume and Geographic Distribution of US Hospitals With Obstetric Services From 2010 to 2018. JAMA Netw Open 2021; 4:e2125373. [PMID: 34623408 PMCID: PMC8501399 DOI: 10.1001/jamanetworkopen.2021.25373] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Timely access to clinically appropriate obstetric services is critical to the provision of high-quality perinatal care. OBJECTIVE To examine the geographic distribution, proximity, and urban adjacency of US obstetric hospitals by annual birth volume. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study identified US hospitals with obstetric services using the American Hospital Association (AHA) Annual Survey of Hospitals and Centers for Medicare & Medicaid provider of services data from 2010 to 2018. Obstetric hospitals with 10 or more births per year were included in the study. Data analysis was performed from November 6, 2020, to April 5, 2021. EXPOSURE Hospital birth volume, defined by annual birth volume categories of 10 to 500, 501 to 1000, 1001 to 2000, and more than 2000 births. MAIN OUTCOMES AND MEASURES Outcomes assessed by birth volume category were percentage of births (from annual AHA data), number of hospitals, geographic distribution of hospitals among states, proximity between obstetric hospitals, and urban adjacency defined by urban influence codes, which classify counties by population size and adjacency to a metropolitan area. RESULTS The study included 26 900 hospital-years of data from 3207 distinct US hospitals with obstetric services, reflecting 34 054 951 associated births. Most infants (19 327 487 [56.8%]) were born in hospitals with more than 2000 births/y, and 2 528 259 (7.4%) were born in low-volume (10-500 births/y) hospitals. More than one-third of obstetric hospitals (37.4%; 10 064 hospital-years) were low volume. A total of 46 states had obstetric hospitals in all volume categories. Among low-volume hospitals, 18.9% (1904 hospital-years) were not within 30 miles of any other obstetric hospital and 23.9% (2400 hospital-years) were within 30 miles of a hospital with more than 2000 deliveries/y. Isolated hospitals (those without another obstetric hospital within 30 miles) were more frequently low volume, with 58.4% (1112 hospital-years) located in noncore rural areas. CONCLUSIONS AND RELEVANCE In this cohort study, marked variations were found in birth volume, geographic distribution, proximity, and urban adjacency among US obstetric hospitals from 2010 to 2018. The findings related to geographic isolation and rural-urban distribution of low-volume obstetric hospitals suggest the need to balance proximity with volume to optimize effective referral and access to high-quality perinatal care.
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Affiliation(s)
- Sara C. Handley
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
| | - Molly Passarella
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Heidi M. Herrick
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julia D. Interrante
- Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis
| | - Scott A. Lorch
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
| | - Katy B. Kozhimannil
- Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis
| | - Ciaran S. Phibbs
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University School of Medicine, Stanford, California
| | - Elizabeth E. Foglia
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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19
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Patterson J, Randall D, Isbister J, Peek M, Nippita T, Torvaldsen S. Place of birth and outcomes associated with large volume transfusion: an observational study. BMC Pregnancy Childbirth 2021; 21:620. [PMID: 34517834 PMCID: PMC8439088 DOI: 10.1186/s12884-021-04091-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Guidelines recommend that women at high risk of postpartum haemorrhage deliver at facilities able to handle heavy bleeding. However postpartum haemorrhage is often unexpected. This study aims to compare outcomes and health service use related to transfusion of ≥4 units of red blood cells between women delivering in tertiary and lower level hospitals. METHODS The study population was women giving birth in public hospitals in New South Wales, Australia, between July 2006 and December 2010. Data were obtained from linked hospital, birth and blood bank databases. The exposure of interest was transfusion of four or more units of red cells during admission for delivery. Outcomes included maternal morbidity, length of stay, neonatal morbidity and need for other blood products or transfer to higher care. Multivariable regression models were developed to predict need of transfusion of ≥4 units of red cells using variables known early in pregnancy and those known by the birth admission. RESULTS Data were available for 231,603 births, of which 4309 involved a blood transfusion, with 1011 (0.4%) receiving 4 or more units. Women giving birth in lower level and/or smaller hospitals were more likely to receive ≥4 units of red cells. Women receiving ≥4 units in tertiary settings were more likely to receive other blood products and have longer hospital stays, but morbidity, readmission and hysterectomy rates were similar. Although 46% of women had no identifiable risk factors early in pregnancy, 20% of transfusions of ≥4 units occurred within this group. By the birth admission 70% of women had at least one risk factor for requiring ≥4 units of red cells. CONCLUSIONS Overall outcomes for women receiving ≥4 units of red cells were comparable between tertiary and non-tertiary facilities. This is important given the inability of known risk factors to predict many instances of postpartum haemorrhage.
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Affiliation(s)
- Jillian Patterson
- The University of Sydney Northern Clinical School, Women and Babies Research, St Leonards, New South Wales, Australia.
- Northern Sydney Local Health District, Kolling Institute, St Leonards, New South Wales, Australia.
- Women and Babies Research, c/o University Department of O&G, Level 5, Douglas Building, Royal North Shore Hospital, St Leonards, New South Wales, 2065, Australia.
| | - Deborah Randall
- The University of Sydney Northern Clinical School, Women and Babies Research, St Leonards, New South Wales, Australia
- Northern Sydney Local Health District, Kolling Institute, St Leonards, New South Wales, Australia
- Women and Babies Research, c/o University Department of O&G, Level 5, Douglas Building, Royal North Shore Hospital, St Leonards, New South Wales, 2065, Australia
| | - James Isbister
- The University of Sydney Northern Clinical School, St Leonards, New South Wales, Australia
| | - Michael Peek
- Australian National University Medical School, ANU, Garran, Australian Capital Territory, Australia
| | - Tanya Nippita
- The University of Sydney Northern Clinical School, Women and Babies Research, St Leonards, New South Wales, Australia
- Northern Sydney Local Health District, Kolling Institute, St Leonards, New South Wales, Australia
- Women and Babies Research, c/o University Department of O&G, Level 5, Douglas Building, Royal North Shore Hospital, St Leonards, New South Wales, 2065, Australia
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Siranda Torvaldsen
- The University of Sydney Northern Clinical School, Women and Babies Research, St Leonards, New South Wales, Australia
- Northern Sydney Local Health District, Kolling Institute, St Leonards, New South Wales, Australia
- Women and Babies Research, c/o University Department of O&G, Level 5, Douglas Building, Royal North Shore Hospital, St Leonards, New South Wales, 2065, Australia
- School of Population Health, UNSW, Sydney, Australia
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Bernstein SL, Kelechi TJ, Catchpole K, Nemeth LS. Prevention of Failure to Rescue in Obstetric Patients: A Realist Review. Worldviews Evid Based Nurs 2021; 18:352-360. [PMID: 34482602 DOI: 10.1111/wvn.12531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND At least 40% of maternal deaths are attributable to failure to rescue (FTR) events. Nurses are positioned to prevent FTR events, but there is minimal understanding of systems-level factors affecting obstetric nurses when patients require rescue. AIMS To identify the nurse-specific contexts, mechanisms, and outcomes underlying obstetric FTR and the interventions designed to prevent these events. METHODS A realist review was conducted to meet the aims. This review included literature from 1999 to 2020 to understand the systems-level factors affecting obstetric nurses during FTR events using a human factors framework designed by the Systems Engineering Initiative for Patient Safety. RESULTS Existing interventions addressed the prevention of maternal death through education of clinicians, improved protocols for care and maternal transfer, and an emphasis on communication and teamwork. LINKING EVIDENCE TO ACTION Few researchers addressed task overload or connected employee and organizational outcomes with patient outcomes, and the physical environment was minimally considered. Future research is needed to understand how systems-level factors affect nurses during FTR events.
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Affiliation(s)
| | - Teresa J Kelechi
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Kenneth Catchpole
- S.C. SmartState endowed Chair in Clinical Practice and Human Factors, Anesthesia and Perioperative Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Lynne S Nemeth
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
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Zephyrin LC. Changing the Narrative and Accelerating Action to Reduce Racial Inequities in Maternal Mortality. Am J Public Health 2021; 111:1575-1577. [PMID: 34436918 PMCID: PMC8589067 DOI: 10.2105/ajph.2021.306462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Laurie C Zephyrin
- Laurie C. Zephyrin is vice-president of Health System Equity, the Commonwealth Fund, New York, NY
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Snowden JM, Lyndon A, Kan P, El Ayadi A, Main E, Carmichael SL. Severe Maternal Morbidity: A Comparison of Definitions and Data Sources. Am J Epidemiol 2021; 190:1890-1897. [PMID: 33755046 DOI: 10.1093/aje/kwab077] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 03/11/2021] [Accepted: 03/16/2021] [Indexed: 11/14/2022] Open
Abstract
Severe maternal morbidity (SMM) is a composite outcome measure that indicates serious, potentially life-threatening maternal health problems. There is great interest in defining SMM using administrative data for surveillance and research. In the United States, one common way of defining SMM at the population level is an index developed by the Centers for Disease Control and Prevention. Modifications to this index (e.g., exclusion of maternal blood transfusion) have been proposed; some research defines SMM using an index introduced by Bateman et al. (Obstet Gynecol. 2013;122(5):957-965). Birth certificate data are also increasingly being used to define SMM. We compared commonly used US definitions of SMM among all California births (2007-2012) using the kappa (κ) statistic and other measures. We also evaluated agreement between maternal morbidity fields on the birth certificate as compared with health insurance claims data. Concordance between the 7 definitions of SMM analyzed was generally low (i.e., κ < 0.41 for 13 of 21 two-way comparisons). Low concordance was particularly driven by the presence/absence of transfusion and claims data versus birth certificate definitions. Low agreement between administrative data-based definitions of SMM highlights that results can be expected to differ between them. Further research on validity of SMM definitions, using more fine-grained data sources, is needed.
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Bernstein SL. Accurate Respiratory Rate Assessment for Women in Labor. MCN Am J Matern Child Nurs 2021; 46:307. [PMID: 34398835 DOI: 10.1097/nmc.0000000000000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Samantha L Bernstein
- Samantha L. Bernstein is a PhD candidate, Medical University of South Carolina, Charleston, SC and a 2021 MCN Editorial Fellow. She can be reached via email at
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Abstract
BACKGROUND The purpose of this study was to measure trends in the use of tranexamic acid (TXA) during delivery in the United States and to evaluate demographic data and morbidity outcomes among these patients. METHODS This retrospective cohort study includes data from 19 hospitals in the Universal Health Services network. We compared rates of TXA use between January 2015 and June 2019 across geographic sectors. We also evaluated associations of demographic variables and perinatal outcomes of women who received TXA. RESULTS 209 cases of TXA use were found from analysis of 101,564 deliveries. TXA use increased over time and rates were higher in the West than in Central and East; the slope of increase over years did not differ between regions. Women who received TXA were more likely to have a history of postpartum hemorrhage (59 (28.2%) vs. 2290 (2.2%), P < 0.0001) but were not more likely to have a chronic disease, including diabetes mellitus, hypertension and heart disease. Women who received TXA were more likely to have estimated blood loss greater than or equal to 1000 mL (adjusted odds ratio (aOR) 15.3; 95% CI 11.1-21.1; P < 0.0001). Likelihood of venous thromboembolism was not significantly increased in TXA recipients (aOR 2.0; 95% CI 0.3-14.6; P = 0.49). CONCLUSION Increasing national trends of TXA use in the peripartum period was observed, with variable increases by geographic region. Likelihood of venous thromboembolism was not significantly increased among women who received TXA. Increasing TXA use throughout the country suggests that updated hemorrhage guidelines from national obstetrical organizations can shape clinical practice.
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Racial and Ethnic Disparities in Death Associated With Severe Maternal Morbidity in the United States: Failure to Rescue. Obstet Gynecol 2021; 137:791-800. [PMID: 33831938 DOI: 10.1097/aog.0000000000004362] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/18/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To analyze racial and ethnic disparities in failure to rescue (ie, death) associated with severe maternal morbidity and describe temporal trends. METHODS This was a retrospective cohort study using administrative data. Data for delivery hospitalizations with severe maternal morbidity, as defined by the Centers for Disease Control and Prevention, were abstracted from the 1999-2017 National Inpatient Sample. Race and ethnicity were categorized into non-Hispanic White (reference), non-Hispanic Black, Hispanic, other, and missing. The outcome was failure to rescue from severe maternal morbidity. Disparities were assessed using the failure-to-rescue rate ratio (ratio of the failure-to-rescue rate in the racial and minority group to the failure-to-rescue rate in White women), adjusted for patient and hospital characteristics. Temporal trends in severe maternal morbidity and failure to rescue were assessed. RESULTS During the study period, 73,934,559 delivery hospitalizations were identified, including 993,864 with severe maternal morbidity (13.4/1,000; 95% CI 13.3-13.5). Among women with severe maternal morbidity, 4,328 died (4.3/1,000; 95% CI 4.2-4.5). The adjusted failure-to-rescue rate ratio was 1.79 (95% CI 1.77-1.81) for Black women, 1.39 (95% CI 1.37-1.41) for women of other race and ethnicity, 1.43 (95% CI 1.42-1.45) for women with missing race and ethnicity data, and 1.08 (95% CI 1.06-1.09) for Hispanic women. During the study period, the severe maternal morbidity rate increased significantly in each of the five racial and ethnic groups but started declining in 2012. Meanwhile, the failure-to-rescue rate decreased significantly during the entire study period. CONCLUSION Despite improvement over time, failure to rescue from severe maternal morbidity remains a major contributing factor to excess maternal mortality in racial and ethnic minority women.
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Walther F, Kuester D, Bieber A, Malzahn J, Rüdiger M, Schmitt J. Are birth outcomes in low risk birth cohorts related to hospital birth volumes? A systematic review. BMC Pregnancy Childbirth 2021; 21:531. [PMID: 34315416 PMCID: PMC8314545 DOI: 10.1186/s12884-021-03988-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/02/2021] [Indexed: 01/08/2023] Open
Abstract
Background There is convincing evidence that birth in hospitals with high birth volumes increases the chance of healthy survival in high-risk infants. However, it is unclear whether this is true also for low risk infants. The aim of this systematic review was to analyze effects of hospital’s birth volume on mortality, mode of delivery, readmissions, complications and subsequent developmental delays in all births or predefined low risk birth cohorts. The search strategy included EMBASE and Medline supplemented by citing and cited literature of included studies and expert panel highlighting additional literature, published between January/2000 and February/2020. We included studies which were published in English or German language reporting effects of birth volumes on mortality in term or all births in countries with neonatal mortality < 5/1000. We undertook a double-independent title-abstract- and full-text screening and extraction of study characteristics, critical appraisal and outcomes in a qualitative evidence synthesis. Results 13 retrospective studies with mostly acceptable quality were included. Heterogeneous volume-thresholds, risk adjustments, outcomes and populations hindered a meta-analysis. Qualitatively, four of six studies reported significantly higher perinatal mortality in lower birth volume hospitals. Volume-outcome effects on neonatal mortality (n = 7), stillbirths (n = 3), maternal mortality (n = 1), caesarean sections (n = 2), maternal (n = 1) and neonatal complications (n = 1) were inconclusive. Conclusion Analyzed studies indicate higher rates of perinatal mortality for low risk birth in hospitals with low birth volumes. Due to heterogeneity of studies, data synthesis was complicated and a meta-analysis was not possible. Therefore international core outcome sets should be defined and implemented in perinatal registries. Systematic review registration PROSPERO: CRD42018095289 Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03988-y.
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Affiliation(s)
- Felix Walther
- Center for Evidence-Based Healthcare, Medical Faculty Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany. .,Quality and Medical Risk Management, University Hospital Carl, Gustav Carus, Fetscherstraße 74, 01307, Dresden, Germany.
| | - Denise Kuester
- Center for Evidence-Based Healthcare, Medical Faculty Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Anja Bieber
- Institute of Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Postfach 302, 06097, Halle, Saale, Germany
| | - Jürgen Malzahn
- Federation of Local Health Insurance Funds, Clinical Care, Rosenthaler Str. 31, 10178, Berlin, Germany
| | - Mario Rüdiger
- Department for Neonatology and Pediatric Intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany.,Medical Faculty Carl Gustav Carus, Saxony Center for Feto-Neonatal Health, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, Medical Faculty Carl Gustav Carus, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany.,Medical Faculty Carl Gustav Carus, Saxony Center for Feto-Neonatal Health, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany
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Burris HH, Passarella M, Handley SC, Srinivas SK, Lorch SA. Black-White disparities in maternal in-hospital mortality according to teaching and Black-serving hospital status. Am J Obstet Gynecol 2021; 225:83.e1-83.e9. [PMID: 33453183 PMCID: PMC8254791 DOI: 10.1016/j.ajog.2021.01.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Maternal mortality is higher among Black than White people in the United States. Whether Black-White disparities in maternal in-hospital mortality during the delivery hospitalization vary across hospital types (Black-serving vs nonBlack-serving and teaching vs nonteaching) and whether overall maternal mortality differs across hospital types is not known. OBJECTIVE The aims of this study were to determine whether risk-adjusted Black-White disparities in maternal mortality during the delivery hospitalization vary by hospital types (this is analysis of disparities in mortality within hospital types) and compare risk-adjusted in-hospital maternal mortality among Black-serving and nonBlack-serving teaching and nonteaching hospitals regardless of race (this is an analysis of overall mortality across hospital types). STUDY DESIGN We performed a population-based, retrospective cohort study of 5,679,044 deliveries among Black (14.2%) and White patients (85.8%) in 3 states (California, Missouri, and Pennsylvania) from 1995 to 2009. A hospital discharge disposition of "death" defined maternal in-hospital mortality. Black-serving hospitals had at least 7% Black obstetrical patients (top quartile). We performed risk adjustment by calculating expected death rates using predictions from logistic regression models incorporating sociodemographics, rurality, comorbidities, multiple gestations, gestational age at delivery, year, state, and mode of delivery. We calculated risk-adjusted risk ratios of mortality by comparing observed-to-expected ratios among Black and White patients within hospital types and then examined mortality across hospital types, regardless of patient race. We quantified the proportion of Black-White disparities in mortality attributable to delivering in Black-serving hospitals using causal mediation analysis. RESULTS There were 330 maternal deaths among 5,679,044 patients (5.8 per 100,000). Black patients died more often (11.5 per 100,000) than White patients (4.8 per 100,000) (relative risk, 2.38; 95% confidence interval, 1.89-2.98). Examination of Black-White disparities revealed that after risk adjustment, Black patients had significantly greater risk of death (adjusted relative risk, 1.44; 95% confidence interval, 1.17-1.79) and that the disparity was similar within each of the hospital types. Comparison of mortality, regardless of race, across hospital types revealed that among teaching hospitals, mortality was similar in Black-serving and nonBlack-serving hospitals. However, among nonteaching hospitals, mortality was significantly higher in Black-serving vs nonBlack-serving hospitals (adjusted relative risk, 1.47; 95% confidence interval, 1.15-1.87). Notably, 53% of Black patients delivered in nonteaching, Black-serving hospitals compared with just 19% of White patients. Among nonteaching hospitals, 47% of Black-White disparities in maternal in-hospital mortality were attributable to delivering at Black-serving hospitals. CONCLUSION Maternal in-hospital mortality during the delivery hospitalization among Black patients is more than double that of White patients. Our data suggest this disparity is caused by excess mortality among Black patients within each hospital type, in addition to excess mortality in nonteaching, Black-serving hospitals where most Black patients deliver. Addressing downstream effects of racism to achieve equity in maternal in-hospital mortality will require transparent reporting of quality metrics by race to reduce differential care and outcomes within hospital types, improvements in care delivery at Black-serving hospitals, overcoming barriers to accessing high-quality care among Black patients, and eventually desegregation of healthcare.
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Affiliation(s)
- Heather H Burris
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Molly Passarella
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sara C Handley
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Sindhu K Srinivas
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Scott A Lorch
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Easter SR, Gilmore KC, Schulkin J, Robinson JN. Provider Attitudes on Regionalization of Maternity Care: A National Survey. Matern Child Health J 2021; 25:1402-1409. [PMID: 34097190 DOI: 10.1007/s10995-021-03179-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Sarah Rae Easter
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02215, USA.
| | - Kelly C Gilmore
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Jay Schulkin
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02215, USA
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Development and validation of a prediction model for postpartum hemorrhage at a single safety net tertiary care center. Am J Obstet Gynecol MFM 2021; 3:100404. [PMID: 34048966 DOI: 10.1016/j.ajogmf.2021.100404] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Postpartum hemorrhage is a leading cause of pregnancy-related morbidity and mortality; however, there is limited ability to identify women at risk of this obstetrical complication. OBJECTIVE This study aimed to develop and validate a prediction model for postpartum hemorrhage based on antenatal and intrapartum risk factors. STUDY DESIGN This was a retrospective cohort study of women who delivered between April 2016 and March 2019 at a single safety net hospital. The prevalence of postpartum hemorrhage, defined as blood loss of ≥1000 mL at the time of delivery, was determined, and characteristics were compared between women with and without postpartum hemorrhage. Women were randomly assigned to a prediction or a validation cohort. The selection of predictors to be included in the model was based on known antenatal and intrapartum risk factors for postpartum hemorrhage. A multivariable logistic regression with a backward stepwise approach was used to create a prediction model. Area under the receiver operating characteristic curve and 95% bootstrap confidence intervals were calculated. Using the final model, a single threshold for classifying postpartum hemorrhage was chosen, and the resulting sensitivity, specificity, and false-negative and false-positive rates were explored. RESULTS The prevalence rates of postpartum hemorrhage in the prediction and validation cohorts were 6.3% (377 of 6000 cases) and 6.4% (241 of 3774 cases), respectively (P=.83). The following predictors were selected for the final model: maternal body mass index (kg/m2), number of fetuses, history of postpartum hemorrhage, admission platelets of <100,000/µL, chorioamnionitis, arrest of descent, placental abruption, and active labor duration. The predictive model had an area under the receiver operating characteristic curve of 0.82 (95% confidence interval, 0.81-0.84). When applied to the validation cohort, the model had an area under the receiver operating characteristic curve of 0.81 (95% confidence interval, 0.78-0.83), a sensitivity of 86.9%, a specificity of 74.2%, a positive predictive value of 18.6%, a negative predictive value of 98.8%, a false-negative rate of 13.1%, and a false-positive rate of 25.9%. CONCLUSION The model performed reasonably well in identifying women at risk of postpartum hemorrhage. Further studies are necessary to evaluate the model in clinical practice and its effect on decreasing the prevalence of postpartum hemorrhage and associated maternal morbidity.
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Bernstein S. Scoping Review on the Use of Early Warning Trigger Tools for Women in Labor. J Obstet Gynecol Neonatal Nurs 2021; 50:256-265. [PMID: 33549533 DOI: 10.1016/j.jogn.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To identify existing obstetric trigger tools, evaluate their sensitivity and specificity to correctly identify women in need of care escalation, and describe clinicians' experiences of using these tools while caring for women in labor. DATA SOURCES Iterative searches of three databases, CINAHL, PubMed, and SCOPUS, in October 2019 and June 2020 using the keywords maternal surveillance system, obstetric∗, early warning scores, early warning systems, and trigger tools. STUDY SELECTION Primary quantitative and qualitative studies on the utility or implementation of trigger tools for women in labor that were written in English. Through the initial search, I identified 208 articles and included 11 full-text articles in this review. DATA EXTRACTION I extracted data related to aims, population, methodology, outcomes, and key findings for each study and entered them into a matrix based on the Joanna Briggs Institute Review Guidelines. DATA SYNTHESIS Quantitative researchers found that the sensitivity and specificity to correctly identify women in need of care escalation of tools varied and recommended that institutions should consider the burdens of false positives versus the risks of false negatives when choosing a tool for their contexts. Qualitative researchers described clinicians' experiences with the use of trigger tools and systems-level barriers to implementation, including lack of training, poor management of implementation, increased workload due to redundant charting, and belief that tools were not appropriate for women with low-risk pregnancies. Greater rates of false positives led clinicians to use trigger tools only for women with high-risk pregnancies rather than as a screening tool for all women. CONCLUSION Trigger tools may help with early identification of worsening clinical condition, but further research is needed to refine and improve tools, as well as understand best practices for tool implementation. Systems-level factors should be considered in tool selection.
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Mujahid MS, Kan P, Leonard SA, Hailu EM, Wall-Wieler E, Abrams B, Main E, Profit J, Carmichael SL. Birth hospital and racial and ethnic differences in severe maternal morbidity in the state of California. Am J Obstet Gynecol 2021; 224:219.e1-219.e15. [PMID: 32798461 DOI: 10.1016/j.ajog.2020.08.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 07/10/2020] [Accepted: 08/10/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Birth hospital has recently emerged as a potential key contributor to disparities in severe maternal morbidity, but investigations on its contribution to racial and ethnic differences remain limited. OBJECTIVE We leveraged statewide data from California to examine whether birth hospital explained racial and ethnic differences in severe maternal morbidity. STUDY DESIGN This cohort study used data on all births at ≥20 weeks gestation in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least 1 of the 21 diagnoses and procedures (eg, eclampsia, blood transfusion, hysterectomy). Mixed-effects logistic regression models (ie, women nested within hospitals) were used to compare racial and ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, comorbidities, and hospital characteristics. We also estimated the risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percentage reduction in severe maternal morbidity if each group of racially and ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic white women. RESULTS Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian and Pacific Islander; 1.1% white; 1.6% American Indian and Alaska Native, and Mixed-race referred to as Other). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, the odds of severe maternal morbidity were greater among nonwhite women than white women in a given hospital (Black: odds ratio, 1.25; 95% confidence interval, 1.19-1.31); US-born Hispanic: odds ratio, 1.25; 95% confidence interval, 1.20-1.29; foreign-born Hispanic: odds ratio, 1.17; 95% confidence interval, 1.11-1.24; Asian and Pacific Islander: odds ratio, 1.26; 95% confidence interval, 1.21-1.32; Other: odds ratio, 1.31; 95% confidence interval, 1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of white women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared with 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and white women and accounted for 16.1% to 24.2% of the differences for all other racial and ethnic groups. CONCLUSION In California, excess odds of severe maternal morbidity among racially and ethnically minoritized women were not fully explained by birth hospital. Structural causes of racial and ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.
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Affiliation(s)
- Mahasin S Mujahid
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA.
| | - Peiyi Kan
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Stephanie A Leonard
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Elleni M Hailu
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA
| | - Elizabeth Wall-Wieler
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Barbara Abrams
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA
| | - Elliott Main
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Jochen Profit
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Suzan L Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
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Vilkko R, Räisänen S, Gissler M, Stefanovic V, Heinonen S. Busy day effect on intrapartum adverse maternal outcomes - a population-based study of 601 247 singleton deliveries. BMC Pregnancy Childbirth 2021; 21:66. [PMID: 33468091 PMCID: PMC7816350 DOI: 10.1186/s12884-021-03552-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 01/11/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND This was a retrospective population-based study, utilizing the data of 601 247 singleton hospital deliveries collected from the Finnish Medical Birth Register (MBR) in 2006-2016. The aim of this study was to analyse the busy day effect on intrapartum adverse maternal outcomes. METHODS To implement the study design, daily delivery frequencies and ranges (min-max) for each delivery unit (n = 26) were stratified to the daily delivery volume distributions by the delivery unit's annual delivery volume and profile: Category (C)1 < 1000, C2 1000-1999, C3 2000-2999, C4 ≥ 3000 and C5 the profile of university hospitals. To study the busy day effect, the quiet, optimal and busy days were defined by calculating the number of days (%) with the lowest and highest daily delivery frequencies and summed to the nearest 10 % in each hospital category. Optimal days were determined by calculating approximately 80 % of deliveries occurring between the lowest 10 %, and highest 10 % in each hospital category. Crude and adjusted odd ratios (ORs) with 99 % confidence intervals (CIs) were used to analyze the busy day effect on adverse maternal outcomes, blood transfusions, manual removal of the placenta and obstetric anal sphincter injuries, separately in each hospital category. RESULTS The busy day effect was associated with the 28 % (99 % CI 8-52 %) and 25 % (99 % CI 11-40 %) increased need for blood transfusions in C2 and university hospitals (C5), respectively, whereas 22 % (99 % CI 10-31 %) less blood transfusions were needed at university hospitals during quiet days. In C3 hospitals, 83 % (99 % CI 65-92 %) less blood transfusions were needed during busy days. Obstetric and anal sphincter injury rates declined during quiet days by 22 % (99 % CI 3-38 %) only in university hospitals. CONCLUSIONS The findings of this study identify no specific pattern to the busy day effect for adverse maternal outcomes defined as manual removal of the placenta or obstetric and anal sphincter injuries. However, both quiet and busy days seem to be associated with increased or decreased need for blood transfusions in different sized delivery units. Findings also suggest that quiet days are associated with a decreased number of obstetric and anal sphincter injuries.
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Affiliation(s)
- Riitta Vilkko
- Doctoral Programme in Clinical Research, Faculty of Medicine, University of Helsinki, Haartmanninkatu 8, 00290, Helsinki, Finland.
| | - Sari Räisänen
- School of Health, Tampere University of Applied Sciences, Kuntokatu 3, 33520, Tampere, Finland
| | - Mika Gissler
- Information Services Department, THL Finnish Institute for Health and Welfare, Mannerheimintie 166, 00270, Helsinki, Finland
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland
| | - Seppo Heinonen
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland
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Korst LM, Gregory KD, Nicholas LA, Saeb S, Reynen DJ, Troyan JL, Greene N, Fridman M. A scoping review of severe maternal morbidity: describing risk factors and methodological approaches to inform population-based surveillance. Matern Health Neonatol Perinatol 2021; 7:3. [PMID: 33407937 PMCID: PMC7789633 DOI: 10.1186/s40748-020-00123-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/09/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Lisa M Korst
- Childbirth Research Associates, LLC, North Hollywood, CA, USA.
| | - Kimberly D Gregory
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen Research Institute, Los Angeles, CA, USA.,Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Community Health Sciences, Fielding School of Public Health at UCLA, Los Angeles, CA, USA
| | - Lisa A Nicholas
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Samia Saeb
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen Research Institute, Los Angeles, CA, USA
| | - David J Reynen
- Maternal, Child and Adolescent Health Division, California Department of Public Health, Sacramento, CA, USA
| | - Jennifer L Troyan
- Maternal, Child and Adolescent Health Division, California Department of Public Health, Sacramento, CA, USA
| | - Naomi Greene
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen Research Institute, Los Angeles, CA, USA
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Abstract
Failure to rescue refers to the inability to prevent death from health care complications. The fact that more than half of severe maternal morbidity and maternal deaths are classified as preventable, and black women have 2 to 3 times the risk for adjusted severe morbidity and maternal mortality suggest there is a problem with failure to rescue in US maternity care. This article reviews national efforts to improve rescue capacity in maternity care and data on communication breakdowns and disrespect in maternity care, and outlines individual and organizational actions that can be taken to improve communication and rescue processes.
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Janevic T, Zeitlin J, Egorova N, Hebert PL, Balbierz A, Howell EA. Neighborhood Racial And Economic Polarization, Hospital Of Delivery, And Severe Maternal Morbidity. Health Aff (Millwood) 2020; 39:768-776. [PMID: 32364858 PMCID: PMC9808814 DOI: 10.1377/hlthaff.2019.00735] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Recent national and state legislation has called attention to stark racial/ethnic disparities in maternal mortality and severe maternal morbidity (SMM), the latter of which is defined as having a life-threatening condition or life-saving procedure during childbirth. Using linked New York City birth and hospitalization data for 2012-14, we examined whether racial and economic spatial polarization is associated with SMM rates, and whether the delivery hospital partially explains the association. Women in ZIP codes with the highest concentration of poor blacks relative to wealthy whites experienced 4.0 cases of SMM per 100 deliveries, compared with 1.7 cases per 100 deliveries among women in the neighborhoods with the lowest concentration (risk difference = 2.4 cases per 100). Thirty-five percent of this difference was attributable to the delivery hospital. Women in highly polarized neighborhoods were most likely to deliver in hospitals located in similarly polarized neighborhoods. Housing policy that targets racial and economic spatial polarization may address a root cause of SMM, while hospital quality improvement may mitigate the impact of such polarization.
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Affiliation(s)
- Teresa Janevic
- Blavatnik Family Women’s Health Research Institute, Departments of Population Health Science and Policy and Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, in New York City
| | - Jennifer Zeitlin
- Center for Epidemiology and Biostatistics, Inserm UMR 1153, Obstetrical, Perinatal, and Pediatric Epidemiology Research Team (Epopé), Paris Descartes University, in France
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai
| | - Paul L. Hebert
- Veterans Affairs (VA) Health Services Research and Development Center for Veteran-Centered, Value-Driven Health, VA Puget Sound Health Care System, and a research associate professor in the Department of Health Services, School of Public Health, University of Washington, both in Seattle
| | - Amy Balbierz
- Blavatnik Family Women’s Health Research Institute, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai
| | - Elizabeth A. Howell
- Blavatnik Family Women’s Health Research Institute, Departments of Population Health Science and Policy and Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai
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Wang E, Glazer KB, Howell EA, Janevic TM. Social Determinants of Pregnancy-Related Mortality and Morbidity in the United States: A Systematic Review. Obstet Gynecol 2020; 135:896-915. [PMID: 32168209 PMCID: PMC7104722 DOI: 10.1097/aog.0000000000003762] [Citation(s) in RCA: 179] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To synthesize the literature on associations between social determinants of health and pregnancy-related mortality and morbidity in the United States and to highlight opportunities for intervention and future research. DATA SOURCES We performed a systematic search using Ovid MEDLINE, CINAHL, Popline, Scopus, and ClinicalTrials.gov (1990-2018) using MeSH terms related to maternal mortality, morbidity, and social determinants of health, and limited to the United States. METHODS OF STUDY SELECTION Selection criteria included studies examining associations between social determinants and adverse maternal outcomes including pregnancy-related death, severe maternal morbidity, and emergency hospitalizations or readmissions. Using Covidence, three authors screened abstracts and two screened full articles for inclusion. TABULATION, INTEGRATION, AND RESULTS Two authors extracted data from each article and the data were analyzed using a descriptive approach. A total of 83 studies met inclusion criteria and were analyzed. Seventy-eight of 83 studies examined socioeconomic position or individual factors as predictors, demonstrating evidence of associations between minority race and ethnicity (58/67 studies with positive findings), public or no insurance coverage (21/30), and lower education levels (8/12), and increased incidence of maternal death and severe maternal morbidity. Only 2 of 83 studies investigated associations between these outcomes and socioeconomic, political, and cultural context (eg, public policy), and 20 of 83 studies investigated material and physical circumstances (eg, neighborhood environment, segregation), limiting the diversity of social determinants of health studied as well as evaluation of such evidence. CONCLUSION Empirical studies provide evidence for the role of race and ethnicity, insurance, and education in pregnancy-related mortality and severe maternal morbidity risk, although many other important social determinants, including mechanisms of effect, remain to be studied in greater depth. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42018102415.
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Affiliation(s)
- Eileen Wang
- Department of Medical Education, Icahn School of Medicine at Mount Sinai
| | - Kimberly B. Glazer
- Blavatnik Family Women’s Health Institute, Icahn School of Medicine at Mount Sinai; Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elizabeth A. Howell
- Blavatnik Family Women’s Health Institute, Icahn School of Medicine at Mount Sinai; Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Teresa M. Janevic
- Blavatnik Family Women’s Health Institute, Icahn School of Medicine at Mount Sinai; Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Abstract
OBJECTIVE To examine the current patterns of care for women at high risk for delivery-related morbidity to inform discussions about the feasibility of this regionalized approach. METHODS We performed a cross-sectional study and linked 2014 American Hospital Association survey and State Inpatient Database data from seven representative states. We used American Hospital Association-reported hospital characteristics and State Inpatient Database procedure codes to assign a level of maternal care to each hospital. We then assigned each patient to a minimum required level of maternal care (I-IV) based on maternal comorbidities captured in the State Inpatient Database. Our outcome was delivery at a hospital with an inappropriately low level of maternal care. Comorbidities associated with delivery at an inappropriate hospital were assessed using descriptive statistics. RESULTS The analysis included 845,545 deliveries occurring at 556 hospitals. The majority of women had risk factors appropriate for delivery at level I or II hospitals (85.1% and 12.6%, respectively). A small fraction (2.4%) of women at high risk for maternal morbidity warranted delivery in level III or IV hospitals. The majority (97.6%) of women delivered at a hospital with an appropriate level of maternal care, with only 2.4% of women delivering at a hospital with an inappropriate level of maternal care. However, 43.4% of the 19,988 high-risk patients warranting delivery at level III or IV hospitals delivered at level I or II hospitals. Women with comorbidities likely to benefit from specialized care (eg, maternal cardiac disease, placenta previa with prior uterine surgery) had high rates of delivery at hospitals with an inappropriate level of maternal care (68.2% and 37.7%, respectively). CONCLUSION Though only 2.41% of deliveries occurred at hospitals with an inappropriate level of maternal care, a substantial fraction of women at risk for maternal morbidity delivered at hospitals potentially unequipped with resources to manage their needs. Promoting triage of high-risk patients to hospitals optimized to provide risk-appropriate care may improve maternal outcomes with minimal effect on most deliveries.
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Mallinson DC, Ehrenthal DB. Classification of Medicaid Coverage on Birth Records in Wisconsin, 2011-2012. Public Health Rep 2019; 134:542-551. [PMID: 31269411 DOI: 10.1177/0033354919860503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES In 2011, Wisconsin introduced the 2003 Revision of the US Standard Certificate of Live Birth, which includes a variable for principal payer. This variable could help in estimating Medicaid coverage for delivery services, but its accuracy in most states is not known. Our objective was to validate Medicaid payer classification on Wisconsin birth records. METHODS We linked 128 141 Wisconsin birth records (2011-2012 calendar years) to 54 600 Medicaid claims. Using claims as the gold standard, we measured the payer variable's validity (sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV]) overall and by maternal age, race/ethnicity, education, facility delivery volume, and the Medicaid proportion of facility delivery volume. Multivariable log-binomial regression tested the association between each characteristic and payer misclassification among Medicaid-paid births. RESULTS Of 128 141 birth records, 50 652 (39.5%) indicated Medicaid as the principal payer and 54 600 (42.6%) linked to a Medicaid claim. The birth record misclassified 10 007 of 54 600 (18.3%) Medicaid-paid births as non-Medicaid and 6059 of 73 541 (8.2%) non-Medicaid births as Medicaid-paid. The payer variable was less sensitive (81.7%) than specific (91.8%), and PPV and NPV were similar (∼88%). Sensitivity was highest among mothers who were Hispanic, had no high school diploma, or delivered in Medicaid-majority delivery facilities. Maternal age ≥40, maternal education >high school, and delivering in a non-Medicaid-majority delivery facility were positively associated with payer misclassification among Medicaid-paid births. CONCLUSION Differential misclassification of principal payer in the birth record may bias risk surveillance of Medicaid deliveries.
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Affiliation(s)
- David C Mallinson
- 1 Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Deborah B Ehrenthal
- 1 Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,2 Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Watson D, Tita A, Dimperio L, Howard T, Harper L. Antibiotic Prophylaxis for Cesarean Delivery Among Alabama Providers. South Med J 2019; 112:170-173. [PMID: 30830231 DOI: 10.14423/smj.0000000000000943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES A multicenter, randomized controlled trial has demonstrated the benefit of adding azithromycin to routine preoperative antibiotics in unscheduled cesarean deliveries (CDs) to prevent surgical site infections. We sought to describe and identify barriers to the implementation of azithromycin prophylaxis for CDs by Alabama healthcare providers. METHODS We conducted an online, self-administered survey of obstetrics and gynecology (OB/GYN) providers in Alabama. E-mail addresses were obtained from a publicly available list. We sent an invitation to complete an anonymous online survey to 478 providers after excluding incompatible addresses and providers who previously opted out of the survey platform. After the initial survey, three reminders to complete the survey were sent. Standard questions regarding population and provider demographics were asked. We assessed timing, duration, and type of antibiotic used for scheduled cesareans and unscheduled (labor) cesareans, and the reasons for not using azithromycin for prophylaxis. Results were compared using the Student t test and χ2 test as appropriate. RESULTS Of the 66 OB/GYN providers who responded to the survey, 44 (66.7%) performed CDs. Most providers (59.1%) identified as female, served a mix of urban and rural communities (54.5%), and performed deliveries at a level IV hospital (54.5%) with >2000 deliveries annually (52.3%). Most providers (77.3%) reported that an antibiotic stewardship committee supervised antibiotic use at their hospital. For unscheduled cesareans, 54.5% reported the use of azithromycin and 47.7% for scheduled cesareans. The most common reason for not currently using azithromycin was being unaware of evidence for its use (55.6%). The only factors associated with azithromycin use were the urban/rural mix of the provider's patient population (P = 0.03) and the hospital level (P < 0.01). More providers serving a primarily urban population reported azithromycin use (87.5%) compared with those serving in a rural (33.3%) or mixed (47.6%) population. In addition, 74.2% of the obstetricians who delivered in a level 3 or 4 hospital reported using azithromycin prophylaxis, whereas only 22.2% of level 1 or 2 hospital providers reported this usage. CONCLUSIONS Only 56.8% of Alabama obstetrics providers reported using azithromycin for CD, which is both effective and cost saving for prevention of surgical site infections. More needs to be done to increase awareness of these benefits.
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Affiliation(s)
- Dana Watson
- From the Department of Obstetrics and Gynecology, University of Alabama, Birmingham
| | - Alan Tita
- From the Department of Obstetrics and Gynecology, University of Alabama, Birmingham
| | - Lisa Dimperio
- From the Department of Obstetrics and Gynecology, University of Alabama, Birmingham
| | - Tera Howard
- From the Department of Obstetrics and Gynecology, University of Alabama, Birmingham
| | - Lorie Harper
- From the Department of Obstetrics and Gynecology, University of Alabama, Birmingham
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Kennedy HG, Simpson A, Haque Q. Perspective On Excellence in Forensic Mental Health Services: What We Can Learn From Oncology and Other Medical Services. Front Psychiatry 2019; 10:733. [PMID: 31681042 PMCID: PMC6813277 DOI: 10.3389/fpsyt.2019.00733] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/12/2019] [Indexed: 12/11/2022] Open
Abstract
We propose that excellence in forensic and other mental health services can be recognized by the abilities necessary to conduct randomized controlled trials (RCTs) and equivalent forms of rigorous quantitative research to continuously improve the outcomes of treatment as usual (TAU). Forensic mental health services (FMHSs) are growing, are high cost, and increasingly provide the main access route to more intensive, organized, and sustained pathways through care and treatment. A patient newly diagnosed with a cancer can expect to be enrolled in RCTs comparing innovations with the current best TAU. The same should be provided for patients newly diagnosed with severe mental illnesses and particularly those detained and at risk of prolonged periods in a secure hospital. We describe FMHSs in four levels 1 to 4, basic to excellent, according to seven domains: values or qualities, clinical organization, consistency, timescale, specialization, routine outcome measures, and research. Excellence is not elitism. Not all centers need to achieve excellence, though all should be of high quality. Services can provide each population with a network of centers with access to one center of excellence. Excellence is the standard needed to drive the virtuous circle of research and development that is necessary for teaching, training, and the pursuit of new knowledge and better outcomes. Substantial advances in treatment of severe mental disorders require a drive at a national and international level to create services that meet these standards of excellence and are focused, active, and productive to drive better functional outcomes for service users.
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Affiliation(s)
- Harry G Kennedy
- Department of Psychiatry, Trinity College Dublin, Dublin, Ireland.,National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, Ireland
| | - Alexander Simpson
- Division for Forensic Psychiatry-University of Toronto Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Quazi Haque
- Elysium Healthcare, London, United Kingdom.,Division for Forensic Psychiatry-University of Toronto Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health-University of Toronto, Toronto, ON, Canada
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Effect of China's maternal health policy on improving rural hospital delivery: Evidence from two cross-sectional surveys. Sci Rep 2018; 8:12326. [PMID: 30120264 PMCID: PMC6098125 DOI: 10.1038/s41598-018-29830-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 07/11/2018] [Indexed: 11/25/2022] Open
Abstract
This population-based cross-sectional study aims to explore the effect of China’s Rural Hospital Delivery Subsidy (RHDS) policy on the utilization of women’s hospital delivery between rural and urban areas. A total of 2398 women were drawn from the Fourth and Fifth National Health Service Surveys, from the Shaanxi province. A generalized linear mixed model was used to analyze the influence of the RHDS policy on the hospital delivery rate. Concentration index and decomposition methods were used to explore the equity of hospital delivery utilization. Prior to introduction of the RHDS policy, the difference in hospital delivery rates was −0.09 (95% CL: −0.16, −0.01) between rural and urban women when adjusting the influence of socioeconomic factors on hospital delivery; after implementation of the policy, the difference was reduced to 0.02 (95% CL: −0.01, 0.06). The horizontal inequity index was reduced from 0.084 to 0.009 for rural women and from 0.070 to 0.011 for urban women. China’s Rural Hospital Delivery Subsidy policy had some positive effect on reducing the gap between rural and urban women’s hospital delivery rate and inequity. However, there is still a pro-rich inequity of hospital delivery utilization for both rural and urban women.
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Clapp MA, James KE, Kaimal AJ. The effect of hospital acuity on severe maternal morbidity in high-risk patients. Am J Obstet Gynecol 2018; 219:111.e1-111.e7. [PMID: 29673571 DOI: 10.1016/j.ajog.2018.04.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 03/30/2018] [Accepted: 04/10/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND In 2015, the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists published guidelines that established levels of maternal care. These guidelines outlined the nursing, provider, and facility requirements for hospitals to be designated a birthing center or 1 of 4 levels of care. To date, these levels of maternal care have not been adopted widely; currently, no data exist on how these designations may affect maternal or neonatal outcomes. OBJECTIVE Because the levels of maternal care attempt to reflect a hospital's ability to treat patients with certain conditions that are associated with increased risk of complications, our objective was to compare outcomes among high- and low-risk patients between high- and low-acuity hospitals. We hypothesized that hospitals that cared for a high rate of high-risk patients, which we considered "high-acuity" centers, would have a lower risk of severe maternal morbidity among high-risk patients compared with low-acuity centers. STUDY DESIGN Deliveries were identified in the 2013 Nationwide Readmission Database. A patient's comorbidity index was assigned based on diagnosis and procedure codes with the use of previously validated methods; a comorbidity index of ≥3 has been associated with increased odds of severe maternal morbidity. Patients were classified as low, intermediate, or high risk by their comorbidity index for analysis. Patients at hospitals with <100 deliveries per year and transferred patients were excluded. A hospital was defined as low or high-acuity if it was in the bottom or top quartile, respectively, based on its percent of patients with a comorbidity index of ≥3. Log-binomial regression models were constructed to assess the effects of a patient's comorbidity index group on the risk of severe morbidity in high- and low-acuity hospitals. The models controlled for available patient and hospital factors. The regression used patient-level data with robust standard errors that were clustered at the level of the hospital. The Wald test was used to assess for the effect modification between comorbidity index group and hospital acuity. RESULTS From 1203 hospitals, 1,656,659 delivering patients met the inclusion criteria. There were 58.7% low-risk, 39.0% intermediate-risk, and 2.3% high-risk patients in the overall sample, and the overall rate of severe maternal morbidity was 1.2%. Less than 3.7% of delivering patients in low-acuity hospitals had a high-risk condition. In comparison, >7.1% patients in high-acuity centers had a high-risk condition. In the adjusted analysis, intermediate-risk patients had a slightly increased risk of morbidity in both low-acuity and high-acuity centers compared with low-risk patients (adjusted risk ratios, 1.53 [95% confidence interval, 1.33-1.77] vs 1.57 [95% confidence interval, 1.49-1.65]). However, there was a notable difference in the adjusted risk ratios for severe maternal morbidity in the high-risk population: the adjusted risk ratio was 9.55 (95% confidence interval, 6.83-13.35) in low-acuity hospitals compared with 6.50 (95% confidence interval, 5.94-7.09) in high-acuity hospitals. CONCLUSION High-risk patients have a higher risk of severe maternal morbidity at low-acuity hospitals compared with high-acuity centers. These findings support the concept of regionalization of maternity care to improve outcomes for high-risk patients.
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Affiliation(s)
- Mark A Clapp
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Kaitlyn E James
- Deborah Kelly Center for Outcomes Research, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
| | - Anjali J Kaimal
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Booker WA, Ananth CV, Wright JD, Siddiq Z, D'Alton ME, Cleary KL, Goffman D, Friedman AM. Trends in comorbidity, acuity, and maternal risk associated with preeclampsia across obstetric volume settings. J Matern Fetal Neonatal Med 2018; 32:2680-2687. [PMID: 29478359 DOI: 10.1080/14767058.2018.1446077] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The objective of this study was to characterize morbidity, acuity, and maternal risks associated with preeclampsia across hospitals with varying obstetric volumes. METHODS This retrospective cohort analysis used a large administrative data source, the Perspective database, to characterize the risk for preeclampsia from 2006 to 2015. Hospitals were classified as having either low (≤1000), moderate (1001-2000), or high (≥2000) delivery volume. The primary outcomes included preeclampsia, antihypertensive administration, comorbidity, and related severe maternal morbidity. Severe maternal morbidity was estimated using criteria from the Centers for Disease Control and Prevention. Comorbidity was estimated using an obstetric comorbidity index. Univariable comparisons were made with Chi-squared test. Adjusted log linear regression models were fit to assess factors associated with severe morbidity with risk ratios with 95% confidence intervals as the measures of effect. Population weights were applied to create national estimates. RESULTS Of 36,985,729 deliveries included, 1,414,484 (3.8%) had a diagnosis of preeclampsia. Of these, 779,511 (2.1%) had mild, 171,109 (0.5%) superimposed, and 463,864 (1.3%) severe preeclampsia. The prevalence of mild, superimposed, and severe preeclampsia each increased over the study period with severe and superimposed preeclampsia as opposed to mild preeclampsia increasing the most proportionately (53.2 and 102.5 versus 10.8%, respectively). The use of antihypertensives used to treat severe range hypertension increased with use of intravenous labetalol increasing 31.5%, 43.2%, and 36.1% at low-, medium-, and high-volume hospitals. Comorbid risk also increased across hospital volume settings as did risk for severe maternal morbidity. CONCLUSIONS Preeclampsia is increasing across obstetric care settings with preeclamptic patients demonstrating increasing comorbid risk, increased risk for severe morbidity, and more frequent need for treatment of acute hypertension.
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Affiliation(s)
- Whitney A Booker
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Cande V Ananth
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA.,b Department of Epidemiology , Joseph L. Mailman School of Public Health, Columbia University , New York , NY , USA
| | - Jason D Wright
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Zainab Siddiq
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Mary E D'Alton
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Kirstin L Cleary
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Dena Goffman
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
| | - Alexander M Friedman
- a Department of Obstetrics and Gynecology , College of Physicians and Surgeons, Columbia University , New York , NY , USA
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Różańska A, Pac A, Romanik M, Bulanda M, Wójkowska-Mach J. Outpatient post-partum antibiotic prescription: method of identification of infection control areas demanding improvements and verification of sensitivity of infection registration. J Antimicrob Chemother 2017; 73:240-245. [DOI: 10.1093/jac/dkx369] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/10/2017] [Indexed: 11/14/2022] Open
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Howell EA, Zeitlin J. Improving hospital quality to reduce disparities in severe maternal morbidity and mortality. Semin Perinatol 2017; 41:266-272. [PMID: 28735811 PMCID: PMC5592149 DOI: 10.1053/j.semperi.2017.04.002] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Significant racial/ethnic disparities in maternal morbidity and mortality exist in the United States. Black women are 3-4 times more likely to die a pregnancy-related death as compared with white women. Growing research suggests that hospital quality may be a critical lever for improving outcomes and narrowing disparities. This overview reviews the evidence demonstrating that hospital quality is related to maternal mortality and morbidity, discusses the pathways through which these associations between quality and severe maternal morbidity generate disparities, and concludes with a discussion of possible levers for action to reduce disparities by improving hospital quality.
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Affiliation(s)
- Elizabeth A Howell
- Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY.
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Patient safety issues in office-based surgery and anaesthesia in Switzerland: a qualitative study. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2017; 125:23-29. [PMID: 28711421 DOI: 10.1016/j.zefq.2017.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/08/2017] [Accepted: 06/19/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To identify the spectrum of patient safety issues in office-based surgery and anaesthesia in Switzerland. METHODS Purposive sample of 23 experts in surgery and anaesthesia and quality and regulation in Switzerland. Data were collected via individual qualitative interviews using a researcher-developed semi-structured interview guide between March 2016 and September 2016. Interviews were transcribed and analysed using conventional content analysis. Issues were categorised under the headings "structure", "process", and "outcome". RESULTS Experts identified two key overarching patient safety and regulatory issues in relation to office-based surgery and anaesthesia in Switzerland. First, experts repeatedly raised the current lack of data and transparency of the setting. It is unknown how many surgeons are operating in offices, how many and what types of operations are being done, and what the outcomes are. Secondly, experts also noted the limited oversight and regulation of the setting. While some standards exists, most experts felt that more minimal safety standards are needed regarding the requirements that must be met to do office-based surgery and what can and cannot be done in the office-based setting are needed, but they advocated a self-regulatory approach. CONCLUSION There is a lack of empirical data regarding the quantity and quality office-based surgery and anaesthesia in Switzerland. Further research is needed to address these research gaps and inform health policy in relation to patient safety in office-based surgery and anaesthesia in Switzerland.
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