Fragmentation of postpartum readmissions in the United States

Racial and ethnic disparities in severe maternal morbidity from pregnancy through 1-year postpartum

BACKGROUND

Previous studies examining racial and ethnic disparities in severe maternal morbidity (SMM) have mainly focused on intrapartum hospitalization. There is limited information regarding the racial and ethnic distribution of SMM occurring in the antepartum and postpartum periods, including SMM occurring beyond the traditional 6 weeks postpartum period.

OBJECTIVE

To examine the racial and ethnic distribution of SMM during antepartum, intrapartum, and postpartum hospitalizations through 1-year postpartum, overall and stratified by maternal sociodemographic factors, and to estimate the percent increase in SMM by race and ethnicity and maternal sociodemographic factors within each racial and ethnic group after accounting for both antepartum and postpartum SMM through 1-year postpartum rather than just SMM occurring during the intrapartum hospitalization.

STUDY DESIGN

We conducted a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from Michigan, Oregon, and South Carolina from 2008-2020. We examined the distribution of non-transfusion SMM and total SMM per 10,000 cases during antepartum, intrapartum, and postpartum hospitalizations through 365 days postpartum by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. We subsequently examined "SMM cases added" by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. The "SMM cases added" represent cases among unique individuals that are identified by considering the antepartum and postpartum periods but that would be missed if only the intrapartum hospitalization cases were included.

RESULTS

Among 2,584,206 birthing individuals, a total of 37,112 (1.4%) individuals experienced non-transfusion SMM and 64,661 (2.5%) experienced any SMM during antepartum, intrapartum, and/or postpartum hospitalization. Black individuals had the highest rate of antepartum, intrapartum, and postpartum non-transfusion and total SMM followed by American Indian individuals. Asian individuals had the lowest rate of non-transfusion and total SMM during antepartum and postpartum hospitalizations while White individuals had the lowest rate of non-transfusion and total SMM during the intrapartum hospitalization. Black individuals were 1.9 times more likely to experience non-transfusion SMM during the intrapartum hospitalization than White individuals, which increased to 2.8 times during the antepartum period and to 2.5 times during the postpartum period. Asian and Hispanic individuals were less likely to experience SMM in the postpartum period than White individuals. Including antepartum and postpartum hospitalizations resulted in disproportionately more cases among Black and American Indian individuals than among White, Hispanic, and Asian individuals. The additional cases were also more likely to occur among individuals with lower educational levels and individuals on government insurance.

CONCLUSION

Racial disparities in SMM are underreported in estimates that focus on the intrapartum hospitalization. Additionally, individuals with low socio-economic status bear the greatest burden of SMM occurring during the antepartum and postpartum periods. Approaches that focus on mitigating SMM during the intrapartum period only do not address the full spectrum of health disparities. El resumen está disponible en Español al final del artículo.

Identification of Distinct Risk Factors for Antepartum and Postpartum Preeclampsia in a High-Risk Safety-Net Hospital

OBJECTIVE

Postpartum preeclampsia (PE), defined as de novo PE that develops at least 48 hours following delivery, can be particularly dangerous as many patients are already discharged at that point. The goal of our study was to identify risk factors uniquely associated with the development of late postpartum preeclampsia (PPPE).

STUDY DESIGN

In a retrospective cohort study of deliveries between July 1, 2016 and June 30, 2018 at a safety-net hospital in Atlanta, Georgia, we used multinomial logistic regression models to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between demographic, medical, and obstetric factors and development of PE, categorized as a three-level outcome: no PE, antepartum/intrapartum preeclampsia (APE) (diagnosed prior to or < 48 hours of delivery), and late PPPE (diagnosed ≥ 48-hour postpartum).

RESULTS

Among 3,681 deliveries, women were primarily of ages 20 to 35 years (76.4%), identified as non-Hispanic Black (68.5%), and covered by public health insurance (88.6%). PE was diagnosed prior to delivery or within 48-hour postpartum in 12% (n = 477) of the study population, and 1.5% (57) developed PE greater than 48-hour postpartum. In the adjusted models, maternal age ≥ 35, race/ethnicity, nulliparity, a diagnosis of pregestational or gestational diabetes, and chronic hypertension were associated with increased odds of APE only, while maternal obesity (OR: 1.9; 95% CI: 1.0-3.5) and gestational hypertension (OR: 2.7; 95% CI: 1.5-4.8) were uniquely associated with PPPE. Multifetal gestations and cesarean delivery predicted both PPPE and APE; however, the association was stronger for PPPE.

CONCLUSION

Patients with obesity, gestational hypertension, multifetal gestations, or cesarean delivery may benefit from additional follow-up in the early postpartum period to detect PPPE.

KEY POINTS

· Late postpartum preeclampsia may go undetected, particularly in low-income patients.. · In a delivery cohort in Georgia, 1.5% of patients developed late postpartum preeclampsia.. · Maternal obesity and gestational hypertension were strongly associated only with late postpartum preeclampsia..

Postpartum Psychiatric Outcomes following Severe Maternal Morbidity in an Urban Safety-Net Hospital

OBJECTIVE

Severe maternal morbidity (SMM) may be associated with postpartum psychiatric morbidity. However, the direction and strength of this relationship remain unclear. Our goal was to estimate the association between SMM and postpartum inpatient mental health care utilization.

STUDY DESIGN

We examined all liveborn deliveries at a large, safety-net hospital in Atlanta, Georgia, from 2013 to 2021. SMM at or within 42 days of delivery was identified using International Classification of Disease codes. The primary outcome of interest was hospitalization with a psychiatric diagnosis in the year following the delivery. We used inverse probability of treatment weighting based on propensity scores to adjust for demographics, index delivery characteristics, and medical, psychiatric, and obstetric history. We fit log-binomial models with generalized estimating equations to calculate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs).

RESULTS

Among 22,233 deliveries, the rates of SMM and postpartum hospitalization with a psychiatric diagnosis, respectively, were 6.8% (n = 1,149) and 0.8% (n = 169). The most common psychiatric diagnosis was nonpsychotic mood disorders (without SMM 0.4%, n = 79; with SMM 1.7% n = 24). After weighting, 2.2% of deliveries with SMM had a postpartum readmission with a psychiatric diagnosis, compared with 0.7% of deliveries without SMM (aRR: 3.2, 95% CI: [2.0, 5.2]). Associations were stronger among individuals without previous psychiatric hospitalization.

CONCLUSION

Experiencing SMM was associated with an elevated risk of postpartum psychiatric morbidity. These findings support screening and treatment for mild and moderate postpartum psychiatric disorders in the antenatal period.

KEY POINTS

· Experiencing SMM was associated with three-fold excess risk of postpartum psychiatric admission.. · Experiencing SMM was not associated with an elevated risk of outpatient psychiatric care use.. · Experience SMM was not associated with outpatient psychiatric morbidity diagnoses..

Postpartum readmission in Maryland by race and ethnicity, 2016-2019

BACKGROUND

The majority of maternal deaths occur in the postpartum period. We sought to compare postpartum readmission by race and ethnicity to better understand whether there are disparities in maternal health in the postpartum period as indicated by readmission to the hospital.

OBJECTIVE

This study aimed to use state-wide Maryland data to identify postpartum readmission rates by race and ethnicity, as well as the major risk factors, indications, and timing of readmission.

STUDY DESIGN

In this retrospective study (2016-2019), childbirth hospitalizations for patients of childbearing age were identified from the Maryland State Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Indication for readmission was described. Multivariable logistic regression models were employed to determine racial and ethnic differences in postpartum readmissions, adjusting for maternal and obstetrical characteristics.

RESULTS

Among total deliveries (n=260,778), 3914 patients (1.5%) were readmitted within 60 days of delivery. The most common primary diagnoses at readmission were hypertension and infection. The prevalence of readmission was 1.2% (1306/111,325) for White patients, 2.3% (1786/79,412) for Black patients, 1.2% (485/40,862) for Hispanic patients and 1.2% (337/29,179) for patients of Other race or ethnicity (P<.0001). Black patients had the highest rates of readmission for hypertensive disorders as compared with all other races (37%, P<.0001). In adjusted models, Black patients were more likely to be readmitted than White patients (odds ratio, 1.64; confidence interval, 1.52-1.77). The majority of all readmissions occurred in the first week after delivery with Black patients having higher rates of readmission in the second week relative to all other groups (P<.0001).

CONCLUSION

Hypertension is a leading cause of postpartum readmission in Maryland. Black patients were more likely to be readmitted for hypertensive disorders of pregnancy and to have delayed readmission relative to other race or ethnic groups. Maryland public health officials should address disparities with interventions targeting racial and ethnic minorities, patients at risk for hypertensive disorders, and barriers to timely care.

Postpartum readmission for hypertension and pre-eclampsia: development and validation of a predictive model

OBJECTIVE

To develop a model for predicting postpartum readmission for hypertension and pre-eclampsia at delivery discharge and assess external validation or model transportability across clinical sites.

DESIGN

Prediction model using data available in the electronic health record from two clinical sites.

SETTING

Two tertiary care health systems from the Southern (2014-2015) and Northeastern USA (2017-2019).

POPULATION

A total of 28 201 postpartum individuals: 10 100 in the South and 18 101 in the Northeast.

METHODS

An internal-external cross validation (IECV) approach was used to assess external validation or model transportability across the two sites. In IECV, data from each health system were first used to develop and internally validate a prediction model; each model was then externally validated using the other health system. Models were fit using penalised logistic regression, and accuracy was estimated using discrimination (concordance index), calibration curves and decision curves. Internal validation was performed using bootstrapping with bias-corrected performance measures. Decision curve analysis was used to display potential cut points where the model provided net benefit for clinical decision-making.

MAIN OUTCOME MEASURES

The outcome was postpartum readmission for either hypertension or pre-eclampsia <6 weeks after delivery.

RESULTS

The postpartum readmission rate for hypertension and pre-eclampsia overall was 0.9% (0.3% and 1.2% by site, respectively). The final model included six variables: age, parity, maximum postpartum diastolic blood pressure, birthweight, pre-eclampsia before discharge and delivery mode (and interaction between pre-eclampsia × delivery mode). Discrimination was adequate at both health systems on internal validation (c-statistic South: 0.88; 95% confidence interval [CI] 0.87-0.89; Northeast: 0.74; 95% CI 0.74-0.74). In IECV, discrimination was inconsistent across sites, with improved discrimination for the Northeastern model on the Southern cohort (c-statistic 0.61 and 0.86, respectively), but calibration was not adequate. Next, model updating was performed using the combined dataset to develop a new model. This final model had adequate discrimination (c-statistic: 0.80, 95% CI 0.80-0.80), moderate calibration (intercept -0.153, slope 0.960, Emax 0.042) and provided superior net benefit at clinical decision-making thresholds between 1% and 7% for interventions preventing readmission. An online calculator is provided here.

CONCLUSIONS

Postpartum readmission for hypertension and pre-eclampsia may be accurately predicted but further model validation is needed. Model updating using data from multiple sites will be needed before use across clinical settings.

Decision and economic analysis of hostile abortion laws compared with supportive abortion laws

BACKGROUND

On June 24, 2022, the US Supreme Court overturned Roe v Wade in Dobbs v Jackson Women's Health Organization. Therefore, several states banned abortion, and other states are considering more hostile abortion laws.

OBJECTIVE

This study aimed to assess the incidence of adverse maternal and neonatal outcomes in the hypothetical cohort where all states have hostile abortion laws compared with the pre-Dobbs v Jackson cohort (supportive abortion laws cohort) and examine the cost-effectiveness of these policies.

STUDY DESIGN

This study developed a decision and economic analysis model comparing the hostile abortion laws cohort with the supportive abortion laws cohort in a sample of 5.3 million pregnancies. Cost (inflated to 2022 US dollars) estimates were from a healthcare provider's perspective, including immediate and long-term costs. The time horizon was set to a lifetime. Probabilities, costs, and utilities were derived from the literature. The cost-effectiveness threshold was set to be at $100,000 per quality-adjusted life year. Probabilistic sensitivity analyses using the Monte Carlo simulation with 10,000 simulations were performed to assess the robustness of our results. The primary outcomes included maternal mortality and an incremental cost-effectiveness ratio. The secondary outcomes included hysterectomy, cesarean delivery, hospital readmission, neonatal intensive care unit admission, neonatal mortality, profound neurodevelopmental disability, and incremental cost and effectiveness.

RESULTS

In the base case analysis, the hostile abortion laws cohort had 12,911 more maternal mortalities, 7518 more hysterectomies, 234,376 more cesarean deliveries, 102,712 more hospital readmissions, 83,911 more neonatal intensive care unit admissions, 3311 more neonatal mortalities, and 904 more cases of profound neurodevelopmental disability than the supportive abortion laws cohort. The hostile abortion laws cohort was associated with more cost ($109.8 billion [hostile abortion laws cohort] vs $75.6 billion [supportive abortion laws cohort]) and 120,749,900 fewer quality-adjusted life years with an incremental cost-effectiveness ratio of negative $140,687.60 than the supportive abortion laws cohort. Probabilistic sensitivity analyses suggested that the chance of the supportive abortion laws cohort being the preferred strategy was more than 95%.

CONCLUSION

When states consider enacting hostile abortion laws, legislators should consider an increase in the incidence of adverse maternal and neonatal outcomes.

Weaknesses in the Continuity of Care of Puerperal Women: An Integrative Literature Review

The aim of the present study was to identify how the transition of care from the hospital to the community occurs from the perspective of puerperal women at risk. An integrative literature review was performed, with the question: "How does the transition of care for at-risk puerperal women from the hospital to the community occur?" The search period ranged from 2013 to 2020, in the following databases: PubMed, LILACS, SciELO, and Scopus. MESH, DeCS and Boolean operators "OR" and "AND" are used in the following crossover analysis: patient transfer OR transition care OR continuity of patient care OR patient discharge AND postpartum period, resulting in 6 articles. The findings denote discontinuity of care, given the frequency of non-adherence to the puerperal consultation. Transition studies of care in the puerperium were not found, which requires proposing new studies.

An Initiative to Improve Postpartum Discharge Education

OBJECTIVE

To evaluate an online POST-BIRTH Warning Signs (PBWS) project focused on improving nurses' knowledge and how they teach individuals in the postpartum period about potential complications.

DESIGN

Quality improvement project with exploratory pretest/posttest.

SETTING

Seventy hospitals with maternity services throughout the United States.

PARTICIPANTS

A sample of 2,363 registered nurses.

INTERVENTION/MEASUREMENTS

An online educational program with four surveys and a chart audit tool were used as evaluation measures.

RESULTS

There was an 11% increase in nurses' knowledge after the online course intervention. A majority of nurses reported that they would improve how they educate patients and families about PBWS, that they would change their clinical practice based on what they learned, and that their facility implemented a protocol to educate patients about PBWS after the implementation of the course. The nurses' reported confidence in their teaching increased 59% after implementation of the course.

CONCLUSION

The majority of maternal deaths in the United States occur during the postpartum period. Therefore, it is vital that nurses provide standardized and structured educational messaging when teaching individuals in the postpartum period about signs and symptoms of potential complications. This quality improvement project demonstrated that the PBWS online education course was associated with an increase in nurses' knowledge and confidence when teaching about potential complications that can arise during the postpartum period.

Association of Neighborhood Socioeconomic Disadvantage and Postpartum Readmission

We assessed whether neighborhood socioeconomic disadvantage, as measured by the Area Deprivation Index (ADI), was associated with an increased risk of postpartum readmission. This is a secondary analysis from nuMoM2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be), a prospective cohort of nulliparous pregnant individuals from 2010 to 2013. The exposure was the ADI in quartiles, and the outcome was postpartum readmission; Poisson regression was used. Among 9,061 assessed individuals, 154 (1.7%) were readmitted postpartum within 2 weeks of delivery. Individuals living with the most neighborhood deprivation (ADI quartile 4) were at increased risk of postpartum readmission compared with those living with the lowest neighborhood deprivation (ADI quartile 1) (adjusted risk ratio 1.80, 95% CI 1.11-2.93). Measures of community-level adverse social determinants of health, such as the ADI, may inform postpartum care after delivery discharge.

Association of Social Determinants of Health and Clinical Factors with Postpartum Hospital Readmissions among Nulliparous Individuals

OBJECTIVE

Prior data suggest that there are racial and ethnic disparities in postpartum readmission among individuals, especially among those with hypertensive disorders of pregnancy. Existing reports commonly lack granular information on social determinants of health. The objective of this study was to investigate factors associated with postpartum readmission for individuals and address whether such risk factors differed by whether an individual had an antecedent diagnosis of a hypertensive disorder of pregnancy (HDP).

STUDY DESIGN

This is a secondary analysis of a large, multicenter prospective cohort study of 10,038 nulliparous participants. The primary outcome of this analysis was postpartum readmission. A priori, participants were analyzed separately based on whether they had HDP. Participant characteristics previously associated with a greater risk of perinatal morbidity or readmission (including social determinants of health, preexisting and chronic comorbidities, and intrapartum characteristics) were compared with bivariable analyses and retained in multivariable models if p < 0.05. Social determinants of health evaluated in this analysis included insurance status, self-identified race and ethnicity (as a proxy for structural racism), income, marital status, primary language, and educational attainment.

RESULTS

Of 9,457 participants eligible for inclusion, 1.7% (n = 165) were readmitted following initial hospital discharge. A higher proportion of individuals with HDP were readmitted compared with individuals without HDP (3.4 vs 1.3%, p < 0.001). Among participants without HDP, the only factors associated with postpartum readmission were chorioamnionitis and cesarean delivery. Among participants with HDP, gestational diabetes and postpartum hemorrhage requiring transfusion were associated with postpartum readmission. While the number of postpartum readmissions included in our analysis was relatively small, social determinants of health that we examined were not associated with postpartum readmission for either group.

CONCLUSION

In this diverse cohort of nulliparous pregnant individuals, there was a higher frequency of postpartum readmission among participants with HDP. Preexisting comorbidity and intrapartum complications were associated with postpartum readmission among this population engaged in a longitudinal study.

KEY POINTS

· Non-HDP patients had higher odds of PPR with chorioamnionitis or cesarean.. · HDP patients had higher odds of PPR if they had GDM or PPH.. · Characterizing PPR may identify and highlight modifiable factors..

Examining changes in clinical management and postpartum readmissions for hypertensive disorders of pregnancy over time

OBJECTIVE

In response to 2013 guidelines for hypertensive disorders of pregnancy (HDP), our study examined changes in antenatal management and postpartum readmission (PPR) over time.

STUDY DESIGN

This is a retrospective cohort study of individuals diagnosed antenatally with HDP who delivered at a tertiary care center from 2012 to 2017.

MAIN OUTCOME MEASURES

The primary outcome was postpartum readmission for HDP in 2012-2013 vs 2014-2017. Secondary outcomes included intravenous magnesium administration and prescription for oral (PO) antihypertensive medication during delivery admission. Multivariable logistic regression models assessed differences in outcomes over time, adjusted for age, race, and payer status, for HDP with and without severe features, defined by ACOG criteria.

RESULTS

Of 5,300 eligible individuals, 73.5 % had HDP without severe features and 26.5 % had severe features. The PPR frequency in this cohort was 1.1 % (N = 59). There was no difference in PPR for individuals with HDP without severe features (aOR 0.73; 95 % CI 0.28-1.88) or with severe features (aOR 1.30; 95 % CI 0.50-3.39) by epoch. Magnesium administration for HDP with severe features remained below 80 % over time. Magnesium administration for HDP without severe features and discharge prescriptions for PO medications for HDP with severe features were lower after 2013. Neither magnesium administration nor discharge prescriptions were associated with decreased odds of PPR.

CONCLUSION

Although there was no difference in PPR for HDP after 2013, there were changes in antenatal management of HDP, including decreased magnesium administration for individuals with HDP without severe features and PO medication for individuals with severe features.

Societal cost of nine selected maternal morbidities in the United States

OBJECTIVE

To estimate the cost of maternal morbidity for all 2019 pregnancies and births in the United States.

METHODS

Using data from 2010 to 2020, we developed a cost analysis model that calculated the excess cases of outcomes attributed to nine maternal morbidity conditions with evidence of outcomes in the literature. We then modeled the associated medical and nonmedical costs of each outcome incurred by birthing people and their children in 2019, projected through five years postpartum.

RESULTS

We estimated that the total cost of nine maternal morbidity conditions for all pregnancies and births in 2019 was $32.3 billion from conception to five years postpartum, amounting to $8,624 in societal costs per birthing person.

CONCLUSION

We found only nine maternal morbidity conditions with sufficient supporting evidence of linkages to outcomes and costs. The lack of comprehensive data for other conditions suggests that maternal morbidity exacts a higher toll on society than we found.

POLICY IMPLICATIONS

Although this study likely provides lower bound cost estimates, it establishes the substantial adverse societal impact of maternal morbidity and suggests further opportunities to invest in maternal health.

Risk of Postpartum Flare Hospitalizations in Patients with Inflammatory Bowel Disease Persists After Six Months

BACKGROUND

Although patients with IBD are at higher risk for flares during the postpartum period, little is known about the risk factors, timeline, and healthcare-associated costs of a readmission flare.

AIMS

To ascertain the timeline in which patients are hospitalized for postpartum inflammatory bowel disease (IBD) flares, and the associated risk factors.

METHODS

This is a nationwide retrospective cohort study of 7054 patients with IBD who delivered between 2010-2014 obtained from the National Readmissions Database. The presence of IBD was defined using previously validated International Classification of Diseases codes, and univariable and multivariable regression models were performed to assess risk factors associated with a postpartum flare hospitalization over the nine-month observation period.

RESULTS

A total of 353 (5.0%) patients were hospitalized for a postpartum IBD flare, with approximately one-third (30.0%) readmitted after 6 months. On multivariable analysis, having Crohn's disease (aRR 1.47, 95%CI 1.16-1.88), Medicare insurance (aRR 3.30, 95%CI 2.16-5.02), and ≥ 2 comorbidities (aRR 1.34, 95%CI 1.03-1.74) were independently associated with a higher risk of an IBD flare hospitalization. Compared to patients aged 25-29, those 20-24 were at higher risk for an IBD flare readmission (aRR 1.58, 95%CI 1.17-2.13), whereas patients aged 35-39 years were at lower risk (aRR 0.63, 95%CI 0.43-0.92).

CONCLUSIONS

Among patients with IBD, Crohn's disease, Medicare insurance, multiple comorbidities, and younger age were independent risk factors for a postpartum IBD flare hospitalization. As approximately one-third of these readmissions occurred after 6 months, it is imperative to ensure adequate follow-up and treatment for postpartum IBD patients, particularly in the extended postpartum period.

Double, Triple, and Quadruple Jeopardy: Entering Pregnancy With Two or More Multimorbid Diagnoses and Increased Risk of Severe Maternal Morbidity and Postpartum Readmission

INTRODUCTION

Multimorbidity, the presence of two or more chronic disease diagnoses, is associated with an increased risk of mortality and high health care costs in the general population and older adults. However, little evidence is available about the prevalence and impact of multimorbidity in obstetric populations. The goal of this analysis was to estimate the association between multimorbidity and severe maternal morbidity (SMM) and 90-day postpartum readmission in an obstetric cohort in Atlanta, Georgia.

STUDY DESIGN

We conducted a retrospective cohort study of livebirths and stillbirths at Grady Memorial Hospital, from October 2015 to April 2021. To determine preexisting chronic conditions, we linked information on births to inpatient diagnoses within the prior year. Multimorbidity was defined as the presence of two or more chronic disease diagnoses at birth or within the prior year. We conducted multivariable log binomial regression to estimate risk ratios and 95% confidence intervals for the crude and adjusted (for age, race/ethnicity, parity, and insurance) association between multimorbidity (two or more chronic conditions vs. zero or one) and SMM (at or within 42 days after birth) or 90-day postpartum readmission for any reason.

RESULTS

Of 14,225 included births, 10.1% were to patients with multimorbidity. Overall, SMM complicated 7.5% of births, and the 90-day readmission rate was 2.4%. Both SMM and readmission were more common among women with multimorbidity (SMM, 18.6% among women with multimorbidity compared with 6.3% without; 90-day readmission, 5.4% compared with 2.1%). Adjusting for potential confounders, multimorbidity was associated with increased risk of SMM (adjusted risk ratio, 2.9; 95% confidence interval, 2.5-3.0) and readmission (adjusted risk ratio, 2.2; 95% confidence interval, 1.7-2.9).

CONCLUSIONS

Individuals entering pregnancy with two or more chronic diseases were at an increased risk of SMM and postpartum readmission compared with individuals with one or zero chronic disease diagnoses.

Adverse Cardiovascular Events Following Severe Maternal Morbidity

Severe maternal morbidity (SMM) affects 50,000 women annually in the United States, but its consequences are not well understood. We aimed to estimate the association between SMM and risk of adverse cardiovascular events during the 2 years postpartum. We analyzed 137,140 deliveries covered by the Pennsylvania Medicaid program (2016-2018), weighted with inverse probability of censoring weights to account for nonrandom loss to follow-up. SMM was defined as any diagnosis on the Centers for Disease Control and Prevention list of SMM diagnoses and procedures and/or intensive care unit admission occurring at any point from conception through 42 days postdelivery. Outcomes included heart failure, ischemic heart disease, and stroke/transient ischemic attack up to 2 years postpartum. We used marginal standardization to estimate average treatment effects. We found that SMM was associated with increased risk of each adverse cardiovascular event across the follow-up period. Per 1,000 deliveries, relative to no SMM, SMM was associated with 12.1 (95% confidence interval (CI): 6.2, 18.0) excess cases of heart failure, 6.4 (95% CI: 1.7, 11.2) excess cases of ischemic heart disease, and 8.2 (95% CI: 3.2, 13.1) excess cases of stroke/transient ischemic attack at 26 months of follow-up. These results suggest that SMM identifies a group of women who are at high risk of adverse cardiovascular events after delivery. Women who survive SMM may benefit from more comprehensive postpartum care linked to well-woman care.

Postpartum Readmission and Uninsurance at Readmission for Medicaid versus Privately Insured Births

BACKGROUND

Routine postpartum care is essential to managing pregnancy complications, like hypertension and diabetes, or screening for new conditions, such as depression. Insurance coverage can impact women's ability to access these postpartum services, with women who change or lose insurance postpartum having a lower likelihood of receiving recommended postpartum care. Pregnancy-related Medicaid eligibility is only federally guaranteed for a minimum 60 days after birth, creating the potential for publicly insured women to lose their insurance and their access to postpartum care.

OBJECTIVE

The objective of this study was to examine the rates of postpartum readmission and predictors of uninsurance at readmission before and after 60-days postpartum for Medicaid versus privately paid births.

STUDY DESIGN

This is a retrospective cohort study using the 2017 Nationwide Readmissions Database (NRD). Women who delivered with Medicaid or private insurance between January and June 2017 were included. Potential readmissions were observed between 0-180 days after their childbirth hospitalization were included. The primary outcomes of interest were postpartum readmission and delivery payer at postpartum readmission, observed at 30-day intervals through 180 days postpartum. Multivariable logistic regressions were used to determine the association between the risk of readmission and the risk of being uninsured at the time of readmission among those with private insurance and Medicaid at the time of delivery. The analysis was also conducted in a subset of "acute-cause" readmissions, or those not likely to be related to chronic or pre-existing medical conditions.

RESULTS

24,719 (2.7%) were readmitted within 180 days after delivery: 14,179 (54.1%) had Medicaid delivery insurance, 10,540 (40.2%) had private insurance at delivery. Readmission rates decreased over the time intervals after delivery for both delivery payer types, though were consistently higher for those with Medicaid. The rate of uninsurance at readmission increased more each month postpartum for those with Medicaid compared to private insurance at delivery: 0.9% (95% confidence interval (CI) 0.7, 1.1%) at 0-30 days to 9.7% (95% CI 8.1, 11.6%) at 150-180 days postpartum and from 0.2% (95% CI 0.1, 0.4%) at 0-30 days to 2.6% (95% CI 1.6, 4.1%) at 150-180 days postpartum, respectively. Medicaid coverage at the time of delivery was a significant predictor of being readmitted [adjusted odds ratio (aOR) 1.86 (95% confidence interval (CI) 1.75, 1.97) and uninsured at the time of readmission [aOR 3.99 (95% CI 2.88, 5.52)] compared to being privately insured. Findings were similar in the acute-cause readmissions.

CONCLUSIONS

Women with Medicaid at delivery have a higher risk of readmission and uninsurance at readmission compared to privately insured women beyond 60 days postpartum. This analysis provides further evidence of the insurance instability women face in the postpartum period, especially by those insured by Medicaid at the time of delivery, and should promote discussions among policymakers, payers, and providers on strategies to ensure coverage and access to care for women and their families after childbirth. For states considering expanding their eligibility criteria to 1 year postpartum, this study provides evidence on the vulnerabilities and unique risks that women with Medicaid face after 60 days postpartum.