1
|
Jones SE, Bradwell KR, Chan LE, McMurry JA, Olson-Chen C, Tarleton J, Wilkins KJ, Ly V, Ljazouli S, Qin Q, Faherty EG, Lau YK, Xie C, Kao YH, Liebman MN, Mariona F, Challa AP, Li L, Ratcliffe SJ, Haendel MA, Patel RC, Hill EL. Who is pregnant? Defining real-world data-based pregnancy episodes in the National COVID Cohort Collaborative (N3C). JAMIA Open 2023; 6:ooad067. [PMID: 37600074 PMCID: PMC10432357 DOI: 10.1093/jamiaopen/ooad067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/12/2023] [Accepted: 08/08/2023] [Indexed: 08/22/2023] Open
Abstract
Objectives To define pregnancy episodes and estimate gestational age within electronic health record (EHR) data from the National COVID Cohort Collaborative (N3C). Materials and Methods We developed a comprehensive approach, named Hierarchy and rule-based pregnancy episode Inference integrated with Pregnancy Progression Signatures (HIPPS), and applied it to EHR data in the N3C (January 1, 2018-April 7, 2022). HIPPS combines: (1) an extension of a previously published pregnancy episode algorithm, (2) a novel algorithm to detect gestational age-specific signatures of a progressing pregnancy for further episode support, and (3) pregnancy start date inference. Clinicians performed validation of HIPPS on a subset of episodes. We then generated pregnancy cohorts based on gestational age precision and pregnancy outcomes for assessment of accuracy and comparison of COVID-19 and other characteristics. Results We identified 628 165 pregnant persons with 816 471 pregnancy episodes, of which 52.3% were live births, 24.4% were other outcomes (stillbirth, ectopic pregnancy, abortions), and 23.3% had unknown outcomes. Clinician validation agreed 98.8% with HIPPS-identified episodes. We were able to estimate start dates within 1 week of precision for 475 433 (58.2%) episodes. 62 540 (7.7%) episodes had incident COVID-19 during pregnancy. Discussion HIPPS provides measures of support for pregnancy-related variables such as gestational age and pregnancy outcomes based on N3C data. Gestational age precision allows researchers to find time to events with reasonable confidence. Conclusion We have developed a novel and robust approach for inferring pregnancy episodes and gestational age that addresses data inconsistency and missingness in EHR data.
Collapse
Affiliation(s)
- Sara E Jones
- Office of Data Science and Emerging Technologies, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD 20852, United States
| | | | - Lauren E Chan
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR 97331, United States
| | - Julie A McMurry
- Department of Biomedical Informatics, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Courtney Olson-Chen
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY 14620, United States
| | - Jessica Tarleton
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Kenneth J Wilkins
- Biostatistics Program, Office of the Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, United States
| | - Victoria Ly
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY 14620, United States
| | - Saad Ljazouli
- Palantir Technologies, Denver, CO 80202, United States
| | - Qiuyuan Qin
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY 14618, United States
| | - Emily Groene Faherty
- School of Public Health, University of Minnesota, Minneapolis, MN 55455, United States
| | | | - Catherine Xie
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY 14618, United States
| | - Yu-Han Kao
- Sema4, Stamford, CT 06902, United States
| | | | - Federico Mariona
- Beaumont Hospital, Dearborn, MI 48124, United States
- Wayne State University, Detroit, MI 48202, United States
| | - Anup P Challa
- Department of Chemical and Biomolecular Engineering, Vanderbilt University, Nashville, TN 37212, United States
| | - Li Li
- Sema4, Stamford, CT 06902, United States
| | - Sarah J Ratcliffe
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA 22903, United States
| | - Melissa A Haendel
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR 97331, United States
| | - Rena C Patel
- Department of Medicine and Global Health, University of Washington, Seattle, WA 98105, United States
| | - Elaine L Hill
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY 14620, United States
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY 14618, United States
| |
Collapse
|
2
|
Lyu T, Liang C, Liu J, Campbell B, Hung P, Shih YW, Ghumman N, Li X. Temporal Events Detector for Pregnancy Care (TED-PC): A rule-based algorithm to infer gestational age and delivery date from electronic health records of pregnant women with and without COVID-19. PLoS One 2022; 17:e0276923. [PMID: 36315520 PMCID: PMC9621451 DOI: 10.1371/journal.pone.0276923] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/16/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Identifying the time of SARS-CoV-2 viral infection relative to specific gestational weeks is critical for delineating the role of viral infection timing in adverse pregnancy outcomes. However, this task is difficult when it comes to Electronic Health Records (EHR). In combating the COVID-19 pandemic for maternal health, we sought to develop and validate a clinical information extraction algorithm to detect the time of clinical events relative to gestational weeks. MATERIALS AND METHODS We used EHR from the National COVID Cohort Collaborative (N3C), in which the EHR are normalized by the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). We performed EHR phenotyping, resulting in 270,897 pregnant women (June 1st, 2018 to May 31st, 2021). We developed a rule-based algorithm and performed a multi-level evaluation to test content validity and clinical validity, and extreme length of gestation (<150 or >300). RESULTS The algorithm identified 296,194 pregnancies (16,659 COVID-19, 174,744 without COVID-19) in 270,897 pregnant women. For inferring gestational age, 95% cases (n = 40) have moderate-high accuracy (Cohen's Kappa = 0.62); 100% cases (n = 40) have moderate-high granularity of temporal information (Cohen's Kappa = 1). For inferring delivery dates, the accuracy is 100% (Cohen's Kappa = 1). The accuracy of gestational age detection for the extreme length of gestation is 93.3% (Cohen's Kappa = 1). Mothers with COVID-19 showed higher prevalence in obesity or overweight (35.1% vs. 29.5%), diabetes (17.8% vs. 17.0%), chronic obstructive pulmonary disease (0.2% vs. 0.1%), respiratory distress syndrome or acute respiratory failure (1.8% vs. 0.2%). DISCUSSION We explored the characteristics of pregnant women by different gestational weeks of SARS-CoV-2 infection with our algorithm. TED-PC is the first to infer the exact gestational week linked with every clinical event from EHR and detect the timing of SARS-CoV-2 infection in pregnant women. CONCLUSION The algorithm shows excellent clinical validity in inferring gestational age and delivery dates, which supports multiple EHR cohorts on N3C studying the impact of COVID-19 on pregnancy.
Collapse
Affiliation(s)
- Tianchu Lyu
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Chen Liang
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Jihong Liu
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Berry Campbell
- Department of Obstetrics and Gynecology, School of Medicine, University of South Carolina, Columbia, South Carolina, United States of America
| | - Peiyin Hung
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Yi-Wen Shih
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Nadia Ghumman
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Xiaoming Li
- Department of Health Promotion Education and Behaviors, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | | |
Collapse
|
3
|
Jones S, Bradwell KR, Chan LE, Olson-Chen C, Tarleton J, Wilkins KJ, Qin Q, Faherty EG, Lau YK, Xie C, Kao YH, Liebman MN, Mariona F, Challa A, Li L, Ratcliffe SJ, McMurry JA, Haendel MA, Patel RC, Hill EL. Who is pregnant? defining real-world data-based pregnancy episodes in the National COVID Cohort Collaborative (N3C). MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.08.04.22278439. [PMID: 35982668 PMCID: PMC9387155 DOI: 10.1101/2022.08.04.22278439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective To define pregnancy episodes and estimate gestational aging within electronic health record (EHR) data from the National COVID Cohort Collaborative (N3C). Materials and Methods We developed a comprehensive approach, named H ierarchy and rule-based pregnancy episode I nference integrated with P regnancy P rogression S ignatures (HIPPS) and applied it to EHR data in the N3C from 1 January 2018 to 7 April 2022. HIPPS combines: 1) an extension of a previously published pregnancy episode algorithm, 2) a novel algorithm to detect gestational aging-specific signatures of a progressing pregnancy for further episode support, and 3) pregnancy start date inference. Clinicians performed validation of HIPPS on a subset of episodes. We then generated three types of pregnancy cohorts based on the level of precision for gestational aging and pregnancy outcomes for comparison of COVID-19 and other characteristics. Results We identified 628,165 pregnant persons with 816,471 pregnancy episodes, of which 52.3% were live births, 24.4% were other outcomes (stillbirth, ectopic pregnancy, spontaneous abortions), and 23.3% had unknown outcomes. We were able to estimate start dates within one week of precision for 431,173 (52.8%) episodes. 66,019 (8.1%) episodes had incident COVID-19 during pregnancy. Across varying COVID-19 cohorts, patient characteristics were generally similar though pregnancy outcomes differed. Discussion HIPPS provides support for pregnancy-related variables based on EHR data for researchers to define pregnancy cohorts. Our approach performed well based on clinician validation. Conclusion We have developed a novel and robust approach for inferring pregnancy episodes and gestational aging that addresses data inconsistency and missingness in EHR data.
Collapse
Affiliation(s)
- Sara Jones
- Office of Data Science and Emerging Technologies, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD
| | | | - Lauren E Chan
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR
| | - Courtney Olson-Chen
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY
| | - Jessica Tarleton
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
| | - Kenneth J Wilkins
- Biostatistics Program, Office of the Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Qiuyuan Qin
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | | | | | - Catherine Xie
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | | | | | - Federico Mariona
- Beaumont Hospital, Dearborn, MI
- Wayne State University, Detroit, MI
| | - Anup Challa
- Department of Chemical and Biomolecular Engineering, Vanderbilt University, Nashville, TN
| | | | - Sarah J Ratcliffe
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA
| | - Julie A McMurry
- Department of Biomedical Informatics, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Melissa A Haendel
- Department of Biomedical Informatics, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Rena C Patel
- Department of Medicine and Global Health, University of Washington, Seattle, WA
| | - Elaine L Hill
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| |
Collapse
|
4
|
Davidson L, Canelón SP, Boland MR. Medication-Wide Association Study Using Electronic Health Record Data of Prescription Medication Exposure and Multifetal Pregnancies: Retrospective Study. JMIR Med Inform 2022; 10:e32229. [PMID: 35671076 PMCID: PMC9214620 DOI: 10.2196/32229] [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: 07/19/2021] [Revised: 02/19/2022] [Accepted: 04/21/2022] [Indexed: 11/25/2022] Open
Abstract
Background Medication-wide association studies (MWAS) have been applied to assess the risk of individual prescription use and a wide range of health outcomes, including cancer, acute myocardial infarction, acute liver failure, acute renal failure, and upper gastrointestinal ulcers. Current literature on the use of preconception and periconception medication and its association with the risk of multiple gestation pregnancies (eg, monozygotic and dizygotic) is largely based on assisted reproductive technology (ART) cohorts. However, among non-ART pregnancies, it is unknown whether other medications increase the risk of multifetal pregnancies. Objective This study aimed to investigate the risk of multiple gestational births (eg, twins and triplets) following preconception and periconception exposure to prescription medications in patients who delivered at Penn Medicine. Methods We used electronic health record data between 2010 and 2017 on patients who delivered babies at Penn Medicine, a health care system in the Greater Philadelphia area. We explored 3 logistic regression models: model 1 (no adjustment); model 2 (adjustment for maternal age); and model 3—our final logistic regression model (adjustment for maternal age, ART use, and infertility diagnosis). In all models, multiple births (MBs) were our outcome of interest (binary outcome), and each medication was assessed separately as a binary variable. To assess our MWAS model performance, we defined ART medications as our gold standard, given that these medications are known to increase the risk of MB. Results Of the 63,334 distinct deliveries in our cohort, only 1877 pregnancies (2.96%) were prescribed any medication during the preconception and first trimester period. Of the 123 medications prescribed, we found 26 (21.1%) medications associated with MB (using nominal P values) and 10 (8.1%) medications associated with MB (using Bonferroni adjustment) in fully adjusted model 3. We found that our model 3 algorithm had an accuracy of 85% (using nominal P values) and 89% (using Bonferroni-adjusted P values). Conclusions Our work demonstrates the opportunities in applying the MWAS approach with electronic health record data to explore associations between preconception and periconception medication exposure and the risk of MB while identifying novel candidate medications for further study. Overall, we found 3 novel medications linked with MB that could be explored in further work; this demonstrates the potential of our method to be used for hypothesis generation.
Collapse
Affiliation(s)
- Lena Davidson
- Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Silvia P Canelón
- Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Mary Regina Boland
- Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
5
|
Meeker JR, Burris HH, Bai R, Levine LD, Boland MR. Neighborhood deprivation increases the risk of Post-induction cesarean delivery. J Am Med Inform Assoc 2022; 29:329-334. [PMID: 34921313 PMCID: PMC8757307 DOI: 10.1093/jamia/ocab258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/24/2021] [Accepted: 11/03/2021] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The purpose of this study was to measure the association between neighborhood deprivation and cesarean delivery following labor induction among people delivering at term (≥37 weeks of gestation). MATERIALS AND METHODS We conducted a retrospective cohort study of people ≥37 weeks of gestation, with a live, singleton gestation, who underwent labor induction from 2010 to 2017 at Penn Medicine. We excluded people with a prior cesarean delivery and those with missing geocoding information. Our primary exposure was a nationally validated Area Deprivation Index with scores ranging from 1 to 100 (least to most deprived). We used a generalized linear mixed model to calculate the odds of postinduction cesarean delivery among people in 4 equally-spaced levels of neighborhood deprivation. We also conducted a sensitivity analysis with residential mobility. RESULTS Our cohort contained 8672 people receiving an induction at Penn Medicine. After adjustment for confounders, we found that people living in the most deprived neighborhoods were at a 29% increased risk of post-induction cesarean delivery (adjusted odds ratio = 1.29, 95% confidence interval, 1.05-1.57) compared to the least deprived. In a sensitivity analysis, including residential mobility seemed to magnify the effect sizes of the association between neighborhood deprivation and postinduction cesarean delivery, but this information was only available for a subset of people. CONCLUSIONS People living in neighborhoods with higher deprivation had higher odds of postinduction cesarean delivery compared to people living in less deprived neighborhoods. This work represents an important first step in understanding the impact of disadvantaged neighborhoods on adverse delivery outcomes.
Collapse
Affiliation(s)
- Jessica R Meeker
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Heather H Burris
- Center for Excellence in Environmental Toxicology, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Divsion of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ray Bai
- Department of Statistics, University of South Carolina, Columbia, South Carolina, USA
| | - Lisa D Levine
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary Regina Boland
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Center for Excellence in Environmental Toxicology, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Corresponding Author: Mary Regina Boland, PhD, FAMIA, 423 Guardian Drive, 421 Blockley Hall, Philadelphia, PA 19104, USA;
| |
Collapse
|
6
|
Canelón SP, Butts S, Boland MR. Evaluation of Stillbirth Among Pregnant People With Sickle Cell Trait. JAMA Netw Open 2021; 4:e2134274. [PMID: 34817585 PMCID: PMC8613600 DOI: 10.1001/jamanetworkopen.2021.34274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/18/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Relative to what is known about pregnancy complications and sickle cell disease (SCD), little is known about the risk of pregnancy complications among those with sickle cell trait (SCT). There is a lack of clinical research among sickle cell carriers largely due to low sample sizes and disparities in research funding. Objective To evaluate whether there is an association between SCT and a stillbirth outcome. Design, Setting, and Participants This retrospective cohort study included data on deliveries occurring between January 1, 2010, and August 15, 2017, at 4 quaternary academic medical centers within the Penn Medicine health system in Pennsylvania. The population included a total of 2482 deliveries from 1904 patients with SCT but not SCD, and 215 deliveries from 164 patients with SCD. Data were analyzed from May 3, 2019, to September 16, 2021. Exposures The primary exposure of interest was SCT, identified using clinical diagnosis codes recorded in the electronic health record. Main Outcomes and Measures A multivariate logistic regression model was constructed to assess the risk of stillbirth using the following risk factors: SCD, numbers of pain crises and blood transfusions before delivery, delivery episode (as a proxy for parity), prior cesarean delivery, multiple gestation, patient age, marital status, race and ethnicity, ABO blood type, Rhesus (Rh) factor, and year of delivery. Results This cohort study included 50 560 patients (63 334 deliveries), most of whom were aged 25 to 34 years (29 387 of 50 560 [58.1%]; mean [SD] age, 29.5 [6.1] years), were single at the time of delivery (28 186 [55.8%]), were Black or African American (23 777 [47.0%]), had ABO blood type O (22 879 [45.2%]), and were Rhesus factor positive (44 000 [87.0%]). From this general population, 2068 patients (4.1%) with a sickle cell gene variation were identified: 1904 patients (92.1%) with SCT (2482 deliveries) and 164 patients (7.9%) with SCD (215 deliveries). In the fully adjusted model, SCT was associated with an increased risk of stillbirth (adjusted odds ratio [aOR], 8.94; 95% CI, 1.05-75.79; P = .045) while adjusting for the risk factors of SCD (aOR, 26.40; 95% CI, 2.48-280.90; P = .007) and multiple gestation (aOR, 4.68; 95% CI, 3.48-6.29; P < .001). Conclusions and Relevance The results of this large, retrospective cohort study indicate an increased risk of stillbirth among pregnant people with SCT. These findings underscore the need for additional risk assessment during pregnancy for sickle cell carriers.
Collapse
Affiliation(s)
- Silvia P. Canelón
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
| | - Samantha Butts
- Division of Reproductive Endocrinology and Infertility, Penn State College of Medicine and Penn State Health, Hershey, Pennsylvania
| | - Mary Regina Boland
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
- Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia
- Center for Excellence in Environmental Toxicology, University of Pennsylvania, Philadelphia
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
7
|
Individual-Level and Neighborhood-Level Risk Factors for Severe Maternal Morbidity. Obstet Gynecol 2021; 137:847-854. [PMID: 33831923 DOI: 10.1097/aog.0000000000004343] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/21/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the association between individual-level and neighborhood-level risk factors and severe maternal morbidity. METHODS This was a retrospective cohort study of all pregnancies delivered between 2010 and 2017 in the University of Pennsylvania Health System. International Classification of Diseases codes classified severe maternal morbidity according to the Centers for Disease Control and Prevention guidelines. Logistic regression modeling evaluated individual-level risk factors for severe maternal morbidity, such as maternal age and preeclampsia diagnosis. Additionally, we used spatial autoregressive modeling to assess Census-tract, neighborhood-level risk factors for severe maternal morbidity such as violent crime and poverty. RESULTS Overall, 63,334 pregnancies were included, with a severe maternal morbidity rate of 2.73%, or 272 deliveries with severe maternal morbidity per 10,000 delivery hospitalizations. In our multivariable model assessing individual-level risk factors for severe maternal morbidity, the magnitude of risk was highest for patients with a cesarean delivery (adjusted odds ratio [aOR] 3.50, 95% CI 3.15-3.89), stillbirth (aOR 4.60, 95% CI 3.31-6.24), and preeclampsia diagnosis (aOR 2.71, 95% CI 2.41-3.03). Identifying as White was associated with lower odds of severe maternal morbidity at delivery (aOR 0.73, 95% CI 0.61-0.87). In our final multivariable model assessing neighborhood-level risk factors for severe maternal morbidity, the rate of severe maternal morbidity increased by 2.4% (95% CI 0.37-4.4%) with every 10% increase in the percentage of individuals in a Census tract who identified as Black or African American when accounting for the number of violent crimes and percentage of people identifying as White. CONCLUSION Both individual-level and neighborhood-level risk factors were associated with severe maternal morbidity. These factors may contribute to rising severe maternal morbidity rates in the United States. Better characterization of risk factors for severe maternal morbidity is imperative for the design of clinical and public health interventions seeking to lower rates of severe maternal morbidity and maternal mortality.
Collapse
|