Temporal Variations in Incidence andOutcomes of Critical Illness Among Pregnant and Postpartum Women inCanada: A Population-Based Observational Study

Critical care admissions and outcomes in pregnant and postpartum women: a systematic review

PURPOSE

To synthesise evidence for the incidence of intensive care unit (ICU) admission, characteristics and mortality of pregnant and postpartum women with a focus on differences between high-income countries (HICs) and low-middle-income countries (LMICs) and report changes in reported findings since the last review by Pollock et al. (2010).

METHODS

We searched Ovid Medline, EMBASE, and CINAHL (2010-2023), following best practice guidelines for abstract screening for large-evidence systematic reviews. Patient and study characteristics of extracted studies were analysed descriptively. Multivariable meta-regression analysis, employing mixed-effects models, was conducted for assessing ICU admission and mortality. Studies reviewed by Pollock et al. were included to perform an overall analysis, including each study period and geographic region in a model.

RESULTS

Seventy-one eligible studies reported data on 111,601 women admitted to ICU, with 41,291,168 deliveries reported in 65 studies. Fifty-six studies were retrospective. Case definitions, admission criteria, and causes of mortality reported were heterogeneous. The pooled ICU admission rate was 1.6% (95% confidence interval [CI] 1.28-1.99; I2 = 99.8%), 0.4% (95% CI 0.32-0.48, I2 = 99.9%) in HICs versus 2.8% (95% CI 0.65-6.4, I2 = 99.9%) in LMICs (p < 0.0001). The pooled ICU mortality rate among 140,780 admissions reported in 63 studies was 6.5% (95% CI 5.2-7.9; I2 = 98.7%), with mortality in HICs 1.4% (95% CI 0.8-2.1, I2 = 98.04%) lower than LMICs 12.4% (95% CI 8.1-17.5, I2 = 98.9%) (p < 0.0001). Multivariable meta-regression analysis found a significant association between the ICU admission rates (p = 0.0001) and mortality (p = 0.0003) with geographic region (HIC vs LMIC). Compared to the earlier study of Pollock et al. in 2010, there was an increase in reported studies (71 vs 40 in Pollock et al. study) and reported admissions (111,601 vs 7887 Pollock et al. study), particularly from LMICs'.

CONCLUSIONS

Mortality for critically ill peripartum women is substantial and the gap in reported ICU admissions and mortality for critically ill peripartum women between HIC and LMICs remains unacceptably high. The reports are often small and heterogeneous using many case definitions. Reporting standards focusing on critical care processes and outcomes and large multinational prospective studies are necessary to better understand and mitigate maternal and child health challenges as sustainable development goals in LMICs and HICs.

Using multi-level regression to determine associations and estimate causes and effects in clinical anesthesia due to patient, practitioner and hospital or health system practice variability

In this research methods tutorial of clinical anesthesia, we will explore techniques to estimate the influence of a myriad of factors on patient outcomes. Big data that contain information on patients, treated by individual anesthesiologists and surgical teams, at different hospitals, have an inherent multi-level data structure (Fig. 1). While researchers often attempt to determine the association between patient factors and outcomes, that does not provide clinicians with the whole story. Patient care is clustered together according to clinicians and hospitals where they receive treatment. Therefore, multi-level regression models are needed to validly estimate the influence of each factor at each level. In addition, we will explore how to estimate the influence that variability-for example, one anesthesiologist deciding to do one thing, while another takes a different approach-has on outcomes for patients, using the intra-class correlation coefficient for continuous outcomes and the median odds ratio for binary outcomes. From this tutorial, you should acquire a clearer understanding of how to perform and interpret multi-level regression modeling and estimate the influence of variable clinical practices on patient outcomes in order to answer common but complex clinical questions. Fig. 1 Infographics.

Critical Care Services for Pregnant Patients in Ontario: A Province-Wide Survey

Critically ill pregnant patients require advanced critical care support, but access to these services is variable. We surveyed active Ontario obstetric facilities regarding critical care access. Responses were received from 44 of 80 obstetric units (55%), 13 (30%) being rural. Transport to another facility was required by 59% (majority >1 hour transport time), and differences were noted in the availability of specialty support services such as anesthesia and internal/obstetric medicine, as well as radiology and laboratory facilities, and use of massive transfusion protocols. Training in early supportive care of obstetric complications and optimized facility transport are areas for potential improvement.

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

OBJECTIVE

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

DESIGN

Cohort study.

POPULATION

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

METHODS

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

MAIN OUTCOME MEASURES

Types and subtypes of SMM.

RESULTS

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

CONCLUSIONS

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

Maternal Emergency Department Use Before Pregnancy and Infant Emergency Department Use After Birth

IMPORTANCE

Maternal emergency department (ED) use before or during pregnancy is associated with worse obstetrical outcomes, for reasons including preexisting medical conditions and challenges in accessing health care. It is not known whether maternal prepregnancy ED use is associated with higher use of the ED by their infant.

OBJECTIVE

To study the association between maternal prepregnancy ED use and risk of infant ED use in the first year of life.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included all singleton livebirths in all of Ontario, Canada, from June 2003 to January 2020.

EXPOSURES

Any maternal ED encounter within 90 days preceding the start of the index pregnancy.

MAIN OUTCOMES AND MEASURES

Any infant ED visit up to 365 days after the index birth hospitalization discharge date. Relative risks (RR) and absolute risk differences (ARD) were adjusted for maternal age, income, rural residence, immigrant status, parity, having a primary care clinician, and number of prepregnancy comorbidities.

RESULTS

There were 2 088 111 singleton livebirths; the mean (SD) maternal age was 29.5 (5.4) years, 208 356 (10.0%) were rural dwelling, and 487 773 (23.4%) had 3 or more comorbidities. Among singleton livebirths, 206 539 mothers (9.9%) had an ED visit within 90 days before the index pregnancy. ED use in the first year of life was higher among infants whose mother had visited the ED before pregnancy (570 per 1000) vs those whose mother had not (388 per 1000) (RR, 1.19 [95% CI, 1.18-1.20]; ARD, 91.1 per 1000 [95% CI, 88.6-93.6 per 1000]). Compared with mothers without a prepregnancy ED visit, the RR of infant ED use in the first year was 1.19 (95% CI, 1.18-1.20) if its mother had 1 prepregnancy ED visit, 1.18 (95% CI, 1.17-1.20) following 2 visits, and 1.22 (95% CI, 1.20-1.23) after at least 3 maternal visits. A low-acuity maternal prepregnancy ED visit was associated with an adjusted odds ratio (aOR) of 5.52 (95% CI, 5.16-5.90) for a low-acuity infant ED visit, which was numerically higher than the pairing of a high-acuity ED use between mother and infant (aOR, 1.43, 95% CI, 1.38-1.49).

CONCLUSIONS AND RELEVANCE

In this cohort study of singleton livebirths, prepregnancy maternal ED use was associated with a higher rate of ED use by the infant in the first year of life, especially for low-acuity ED use. This study's results may suggest a useful trigger for health system interventions aimed at reducing some ED use in infancy.

Severe Maternal Morbidity and Mortality Among Immigrant and Canadian-Born Women Residing Within Low-Income Neighborhoods in Ontario, Canada

IMPORTANCE

Evidence indicates that immigrant women and women residing within low-income neighborhoods experience higher adversity during pregnancy. Little is known about the comparative risk of severe maternal morbidity or mortality (SMM-M) among immigrant vs nonimmigrant women living in low-income areas.

OBJECTIVE

To compare the risk of SMM-M between immigrant and nonimmigrant women residing exclusively within low-income neighborhoods in Ontario, Canada.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used administrative data for Ontario, Canada, from April 1, 2002, to December 31, 2019. Included were all 414 337 hospital-based singleton live births and stillbirths occurring between 20 and 42 weeks' gestation, solely among women residing in an urban neighborhood of the lowest income quintile; all women were receiving universal health care insurance. Statistical analysis was performed from December 2021 to March 2022.

EXPOSURES

Nonrefugee immigrant status vs nonimmigrant status.

MAIN OUTCOMES AND MEASURES

The primary outcome, SMM-M, was a composite outcome of potentially life-threatening complications or mortality occurring within 42 days of the index birth hospitalization. A secondary outcome was SMM severity, approximated by the number of SMM indicators (0, 1, 2 or ≥3 indicators). Relative risks (RRs), absolute risk differences (ARDs), and odds ratios (ORs) were adjusted for maternal age and parity.

RESULTS

The cohort included 148 085 births to immigrant women (mean [SD] age at index birth, 30.6 [5.2] years) and 266 252 births to nonimmigrant women (mean [SD] age at index birth, 27.9 [5.9] years). Most immigrant women originated from South Asia (52 447 [35.4%]) and the East Asia and Pacific (35 280 [23.8%]) regions. The most frequent SMM indicators were postpartum hemorrhage with red blood cell transfusion, intensive care unit admission, and puerperal sepsis. The rate of SMM-M was lower among immigrant women (2459 of 148 085 [16.6 per 1000 births]) than nonimmigrant women (4563 of 266 252 [17.1 per 1000 births]), equivalent to an adjusted RR of 0.92 (95% CI, 0.88-0.97) and an adjusted ARD of -1.5 per 1000 births (95% CI, -2.3 to -0.7). Comparing immigrant vs nonimmigrant women, the adjusted OR of having 1 SMM indicator was 0.92 (95% CI, 0.87-0.98), the adjusted OR of having 2 indicators was 0.86 (95% CI, 0.76-0.98), and the adjusted OR of having 3 or more indicators was 1.02 (95% CI, 0.87-1.19).

CONCLUSIONS AND RELEVANCE

This study suggests that, among universally insured women residing in low-income urban areas, immigrant women have a slightly lower associated risk of SMM-M than their nonimmigrant counterparts. Efforts aimed at improving pregnancy care should focus on all women residing in low-income neighborhoods.

Prepregnancy Emergency Department Use and Risks of Severe Maternal and Neonatal Morbidity in Canada

IMPORTANCE

Emergency department (ED) use during pregnancy may be associated with worse obstetrical outcomes, possibly because of differences in access to health care. It is not known whether ED use before pregnancy is associated with serious adverse maternal and perinatal outcomes.

OBJECTIVE

To study the association between prepregnancy ED use and adverse maternal and perinatal outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study was conducted in Ontario, Canada, and included all livebirths and stillbirths from April 2003 to January 2020.

EXPOSURES

Main exposure was any ED encounter within 90 days preceding the start of the index pregnancy.

MAIN OUTCOMES AND MEASURES

Primary outcome was a composite of severe maternal morbidity (SMM) from 20 weeks' gestation to 42 days' post partum. Secondary outcomes included severe neonatal morbidity (SNM) from 0 to 27 days, neonatal death, and stillbirth. Relative risks (RRs) were adjusted for maternal age, income, and rurality.

RESULTS

Of 2 130 245 births, there were 2 119 335 livebirths (99.5%) and 10 910 stillbirths (0.5%). The mean (SD) maternal age was 29.6 (5.4) years, 212 478 (9.9%) were rural dwelling, and 498 219 (23%) had 3 or more comorbidities. Among all births, 218 011 (9.7%) had a prepregnancy ED visit. The rate of SMM was higher among women with a prepregnancy ED visit than those without (22.3 vs 16.5 per 1000 births), with an RR of 1.34 (95% CI, 1.30-1.38) and an adjusted RR (aRR) of 1.37 (95% CI, 1.33-1.42). Compared with no prepregnancy ED visit, the aRR was higher in those with 1 (1.29; 95% CI, 1.24-1.34), 2 (1.51; 95% CI, 1.42-1.61), and 3 or more (1.74; 95% CI, 1.61-1.90) ED visits. Prepregnancy ED visits for a hematological (aRR, 13.60; 95% CI, 10.48-17.64), endocrine (aRR, 4.96; 95% CI, 3.72-6.62), and circulatory (aRR, 2.27; 95% CI, 1.68-3.07) conditions were associated with the highest aRRs for SMM. The rate of SNM was higher among newborns whose mother visited the ED within 90 days before pregnancy (68.2 vs 55.4 per 1000 births; aRR, 1.24; 95% CI, 1.22-1.26) as was the risk of neonatal death (aRR, 1.26; 95% CI, 1.16-1.37) and stillbirth (aRR, 1.18; 95% CI, 1.11-1.25).

CONCLUSIONS AND RELEVANCE

In this study, ED use was common before pregnancy. These findings suggest that ED use may not only reflect a woman's access to prepregnancy care but also higher future risk of severe maternal and perinatal morbidity, potentially offering a useful trigger for health system interventions to decrease adverse pregnancy outcomes.

Association between pre-pregnancy multimorbidity and adverse maternal outcomes: A systematic review

Objective

We reviewed the literature on the association between pre-pregnancy multimorbidity (co-occurrence of two or more chronic conditions) and adverse maternal outcomes in pregnancy and postpartum.

Data sources

Medline, EMBASE, and CINAHL were searched from inception to September, 2021.

Study selection

Observational studies were eligible if they reported on the association between ≥ 2 co-occurring chronic conditions diagnosed before conception and any adverse maternal outcome in pregnancy or within 365 days of childbirth, had a comparison group, were peer-reviewed, and were written in English.

Data extraction and synthesis

Two reviewers used standardized instruments to extract data and rate study quality and the certainty of evidence. A narrative synthesis was performed.

Results

Of 6,381 studies retrieved, seven met our criteria. There were two prospective cohort studies, two retrospective cohort studies, and 3 cross-sectional studies, conducted in the United States (n=6) and Canada (n=1), and ranging in size from n=3,110 to n=57,326,681. Studies showed a dose-response relation between the number of co-occurring chronic conditions and risk of adverse maternal outcomes, including severe maternal morbidity or mortality, hypertensive disorders of pregnancy, and acute health care use in the perinatal period. Study quality was rated as strong (n=1), moderate (n=4), or weak (n=2), and the certainty of evidence was very low to moderate.

Conclusion

Given the increasing prevalence of chronic disease risk factors such as advanced maternal age and obesity, more research is needed to understand the impact of pre-pregnancy multimorbidity on maternal health so that appropriate preconception and perinatal supports can be developed.

Neighbourhood material deprivation and severe maternal morbidity: a population-based cohort study in Ontario, Canada

OBJECTIVES

Rates of age-associated severe maternal morbidity (SMM) have increased in Canada, and an association with neighbourhood income is well established. Our aim was to examine SMM trends according to neighbourhood material deprivation quintile, and to assess whether neighbourhood deprivation effects are moderated by maternal age.

DESIGN, SETTING AND PARTICIPANTS

A population-based retrospective cohort study using linked administrative databases in Ontario, Canada. We included primiparous women with a live birth or stillbirth at ≥20 weeks' gestational age.

PRIMARY OUTCOME

SMM from pregnancy onset to 42 days postpartum. We calculated SMM rate differences (RD) and rate ratios (RR) by neighbourhood material deprivation quintile for each of four 4-year cohorts from 1 April 2002 to 31 March 2018. Log-binomial multivariable regression adjusted for maternal age, demographic and pregnancy-related variables.

RESULTS

There were 1 048 845 primiparous births during the study period. The overall rate of SMM was 18.0 per 1000 births. SMM rates were elevated for women living in areas with high material deprivation. In the final 4-year cohort, the RD between women living in high vs low deprivation neighbourhoods was 3.91 SMM cases per 1000 births (95% CI: 2.12 to 5.70). This was higher than the difference observed during the first 4-year cohort (RD 2.09, 95% CI: 0.62 to 3.56). SMM remained associated with neighbourhood material deprivation following multivariable adjustment in the pooled sample (RR 1.16, 95% CI: 1.11 to 1.21). There was no evidence of interaction with maternal age.

CONCLUSION

SMM rate increases were more pronounced for primiparous women living in neighbourhoods with high material deprivation compared with those living in low deprivation areas. This raises concerns of a widening social gap in maternal health disparities and highlights an opportunity to focus risk reduction efforts toward disadvantaged women during pregnancy and postpartum.

Risk of Severe Maternal Morbidity After Bariatric Surgery: Retrospective Cohort Study

OBJECTIVE

We assessed whether bariatric surgery before pregnancy lowers the risk of severe maternal morbidity to a level comparable to no obesity.

SUMMARY OF BACKGROUND DATA

Obesity is a risk factor for severe maternal morbidity, but the potential for bariatric surgery to reduce the risk has not been studied.

METHODS

We analyzed a retrospective cohort of 2,412,075 deliveries between 1989 and 2019 in Quebec, Canada. The main exposure measures were bariatric surgery before pregnancy and obesity without bariatric surgery, compared with no obesity. The outcome was severe maternal morbidity, a composite of life-threatening pregnancy complications. We estimated risk ratios (RR) and 95% confidence intervals (CI) for the association between bariatric surgery and severe maternal morbidity, adjusted for maternal characteristics.

RESULTS

A total of 2654 deliveries (0.1%) were in women who had bariatric surgery, and 70,041 (29.0 per 1000) were in women who had severe maternal morbidity. Risk of severe maternal morbidity was not significantly elevated for bariatric surgery (RR 1.20; 95% CI 0.98-1.46), but was greater for obesity compared with no obesity (RR 1.60; 95% CI 1.55-1.64). Bariatric surgery was not associated with morbidities such as severe preeclampsia, sepsis, and cardiac complications compared with no obesity, but obesity was associated with elevated risks of these and other severe morbidities. Bariatric surgery was associated, however, with intensive care unit admission, compared with no obesity.

CONCLUSIONS

Pregnant women with prior bariatric surgery have similar risks as nonobese women for most types of severe maternal morbidity, except for intensive care unit admission.

Association of Preexisting Disability With Severe Maternal Morbidity or Mortality in Ontario, Canada

Importance

Severe maternal morbidity and mortality are important indicators of maternal health. Pregnancy rates are increasing in women with disabilities, but their risk of severe maternal morbidity and mortality is unknown, despite their significant social and health disparities.

Objective

To determine the risk of severe maternal morbidity or mortality among women with a physical, sensory, or intellectual/developmental disability compared with women without disabilities.

Design, Setting, and Participants

This population-based cohort study used linked health administrative data in Ontario, Canada, from 2003 to 2018. The cohort included all singleton births to women with preexisting physical, sensory, and intellectual/developmental disabilities as well as with 2 disabilities or more compared with women without a disability. Data analysis was conducted from September 2019 to September 2020.

Exposures

Disabilities were identified with published algorithms applied to diagnoses in 2 physician visits or more or at least 1 emergency department visit or hospitalization.

Main Outcomes and Measures

Severe maternal morbidity (a validated composite of 40 diagnostic and procedural indicators) or all-cause maternal mortality, arising between conception and 42 days post partum. Relative risks were adjusted for maternal age, parity, income quintile, rurality, chronic medical conditions, mental illness, and substance use disorders.

Results

The cohort comprised women with physical disabilities (144 972 women; mean [SD] age, 29.8 [5.6] years), sensory disabilities (45 259 women; mean [SD] age, 29.1 [6.0] years), intellectual/developmental disabilities (2227 women; mean [SD] age, 26.1 [6.4] years), and 2 or more disabilities (8883 women; mean [SD] age, 29.1 [6.1] years), and those without disabilities (1 601 363 women; mean [SD] age, 29.6 [5.4] years). The rate of severe maternal morbidity or death was 1.7% (27 242 women) in women without a disability. Compared with these women, the risk of severe maternal morbidity or death was higher in women with a physical disability (adjusted relative risk [aRR], 1.29; 95% CI, 1.25-1.34), a sensory disability (aRR, 1.14; 95% CI, 1.06-1.21), an intellectual/developmental disability (aRR, 1.57; 95% CI, 1.23-2.01), and 2 or more disabilities (aRR, 1.74; 95% CI, 1.55-1.95). Similar aRRs were observed for severe maternal morbidity or death arising in pregnancy, from birth to 42 days post partum, and from 43 to 365 days post partum. Women with disabilities were more likely than those without disabilities to experience multiple severe maternal morbidity indicators. The most prevalent indicators in all groups were intensive care unit admission, severe postpartum hemorrhage, puerperal sepsis, and severe preeclampsia.

Conclusions and Relevance

In this study, women with a preexisting disability were more likely to experience severe maternal morbidity or mortality. Preconception and perinatal care provisions should be considered among women with a disability to mitigate the risk of these rare but serious outcomes.

Severe Maternal Morbidity and Infant Mortality in Canada

BACKGROUND

Severe maternal morbidity (SMM) comprises an array of conditions and procedures denoting an acutely life-threatening pregnancy-related condition. SMM may further compromise fetal well-being. Empirical data are lacking about the relation between SMM and infant mortality.

METHODS

This population-based cohort study included 1 892 857 singleton births between 2002 and 2017 in Ontario, Canada, within a universal health care system. The exposure was SMM as an overall construct arising from 23 weeks' gestation up to 42 days after the index delivery. The primary outcome was infant mortality from birth to 365 days. Multivariable modified Poisson regression generated relative risks and 95% confidence intervals (CIs), adjusted for maternal age, income, rurality, world region of origin, diabetes mellitus, and chronic hypertension.

RESULTS

Infant mortality occurred among 174 of 19 587 live births with SMM (8.9 per 1000) vs 5289 of 1 865 791 live births without SMM (2.8 per 1000) (an adjusted relative risk of 2.93 [95% CI 2.51-3.41]). Of 19 587 pregnancies with SMM, 4523 (23.1%) had sepsis. Relative to births without SMM, the adjusted odds ratio for infant death from sepsis was 1.95 (95% CI 1.10-3.45) if SMM occurred without maternal sepsis and 6.36 (95% CI 3.50-11.55) if SMM included sepsis.

CONCLUSIONS

SMM confers a higher risk of infant death. There is also coupling tendency (concurrent event of interest) between SMM with sepsis and infant death from sepsis. Identification of preventable SMM indicators, as well as the development of strategies to limit their onset or progression, may reduce infant mortality.

Emergency department use by pregnant women in Ontario: a retrospective population-based cohort study

BACKGROUND

Peripregnancy emergency department use may be common, but data specific to health care systems like that in Canada are lacking. As prior research was limited to livebirths, omitting pregnancies ending in miscarriage or induced abortion, the current study quantified and characterized emergency department use among women in Ontario with a recognized pregnancy.

METHODS

This retrospective population-based cohort study included all recognized pregnancies among Ontario residents aged 10-55 years with an estimated date of conception between Apr. 1, 2002, and Mar. 31, 2017. We defined peripregnancy emergency department use as any emergency department visit during pregnancy or within 42 days after pregnancy. We used modified Poisson regression with a robust error variance to generate relative risks (RRs) and 95% confidence intervals (CIs) for the outcome of any peripregnancy emergency department use in association with maternal age, parity, residential income quintile, location of residence, immigrant status, antenatal care provider and number of comorbidities within 120 days before the clinical start of the pregnancy (expressed as total number of Aggregated Diagnosis Groups [ADGs] obtained with the Johns Hopkins Adjusted Clinical Group System). All RRs, except for number of comorbidities, were further adjusted for number of ADGs.

RESULTS

Peripregnancy emergency department use occurred in 1 075 991 (39.4%) of 2 728 236 recognized pregnancies, including 35.8% of livebirths, 47.3% of stillbirths, 73.7% of miscarriages and 84.8% of threatened abortions. A peripregnancy emergency department visit was more likely among women who were less than 25 years of age (adjusted RR 1.16, 95% CI 1.16-1.17), were nulliparous (adjusted RR 1.13, 95% CI 1.13-1.13), resided in the lowest income quintile area (adjusted RR 1.16, 95% CI 1.15-1.16) or in a rural area (adjusted RR 1.50, 95% CI 1.50-1.51), were Canadian-born (adjusted RR 1.22, 95% CI 1.22-1.23), were not seen by an obstetrician (adjusted RR 1.66, 95% CI 1.54-1.80) or had a greater number of ADGs. Emergency department use peaked in the first trimester and in the first week postpartum. Compared to women residing in urban areas, those residing in rural areas had an odds ratio (OR) of 3.44 (95% CI 3.39-3.49) for 3 or more emergency department visits. Women with 3-4 (OR 1.99, 95% CI 1.97-2.01), 5-6 (OR 3.55, 95% CI 3.49-3.61), or 7 or more (OR 7.59, 95% CI 7.39-7.78) prepregnancy comorbidities were more likely to have 3 or more peripregnancy emergency department visits than were those with 2 or fewer comorbidities.

INTERPRETATION

Peripregnancy emergency department use occurred in nearly 40% of pregnancies, notably in the first trimester and early in the postpartum period. Efforts are needed to streamline rapid access to ambulatory obstetric care during these peak periods, when women are susceptible to miscarriage or a complication after a livebirth.

Variability in intensive care unit admission among pregnant and postpartum women in Canada: a nationwide population-based observational study

Background

Pregnancy-related critical illness results in approximately 300,000 deaths globally each year. The objective was to describe the variation in ICU admission and the contribution of patient- and hospital-based factors in ICU admission among acute care hospitals for pregnant and postpartum women in Canada.

Methods

A nationwide cohort study between 2004 and 2015, comprising all pregnant or postpartum women admitted to Canadian hospitals. The primary outcome was ICU admission. Secondary outcomes were severe maternal morbidity (a potentially life-threatening condition) and maternal death (during and within 6 weeks after pregnancy). The proportion of total variability in ICU admission rates due to the differences among hospitals was described using the median odds ratio from multi-level logistic regression models, adjusting for individual hospital clusters.

Results

There were 3,157,248 identifiable pregnancies among women admitted to 342 Canadian hospitals. The overall ICU admission rate was 3.2 per 1000 pregnancies. The rate of severe maternal morbidity was 15.8 per 1000 pregnancies, of which 10% of women were admitted to an ICU. The most common severe maternal morbidity events included postpartum hemorrhage (n = 16,364, 0.52%) and sepsis (n = 11,557, 0.37%). Of the 195 maternal deaths (6.2 per 100,000 pregnancies), only 130 (67%) were admitted to ICUs. Patients dying in hospital, without admission to ICU, included those with cardiovascular compromise, hemorrhage, and sepsis. For 2 pregnant women with similar characteristics at different hospitals, the average (median) odds of being admitted to ICU was 1.92 in 1 hospital compared to another. Hospitals admitting the fewest number of pregnant patients had the highest incidence of severe maternal morbidity and mortality. Patient-level factors associated with ICU admission were maternal comorbidity index (OR 1.88 per 1 unit increase, 95%CI 1.86–1.99), urban residence (OR 1.09, 95%CI 1.02–1.16), and residing at the lowest income quintile (OR 1.44, 95%CI 1.34–1.55).

Conclusions

Most women who experience severe maternal morbidity are not admitted to an ICU. There exists a wide hospital-level variability in ICU admission, with patients living in urban locations and patients of lowest income levels most likely to be admitted to ICU. Cardiovascular compromise, hemorrhage, and sepsis represent an opportunity for improved patient care and outcomes.

Association of Maternal Age With Severe Maternal Morbidity and Mortality in Canada

IMPORTANCE

Over the past 2 decades, there has been a trend toward increasing maternal age in many high-income countries. Maternal age may lead to greater attendant morbidity and mortality for Canadian mothers.

OBJECTIVE

To investigate the association of maternal age, adjusting for patient-level and hospital-level factors, with severe maternal morbidity (SMM) and maternal death in Canada.

DESIGN, SETTING, AND PARTICIPANTS

A nationwide population-based cohort study of all antepartum, peripartum, and postpartum women and adolescents seen at Canadian acute care hospitals from April 1, 2004, to March 31, 2015. All analyses were completed on September 13, 2018.

EXPOSURES

Maternal age at the index delivery.

MAIN OUTCOMES AND MEASURES

Severe maternal morbidity and maternal death during pregnancy and within 6 weeks after termination of pregnancy.

RESULTS

During the study period, there were 3 162 303 new pregnancies (mean [SD] maternal age, 29.5 [5.6] years) and 3 533 259 related hospital admissions. There were 54 219 episodes of SMM (17.7 cases per 1000 deliveries) in the entire study period, with a 9.8% relative increase from 2004-2005 to 2014-2015, in addition to an increasing proportion of pregnancies to older mothers. Independent patient-level factors associated with SMM included increasing Maternal Comorbidity Index; maternal age 19 years or younger and 30 years or older, with the greatest risk experienced by women 45 years or older (odds ratio [OR], 2.69; 95% CI, 2.34-3.06 compared with maternal age 20-24 years); and lowest income quintile (OR, 1.19; 95% CI, 1.14-1.22 compared with highest income quintile). Hospital-level factors associated with SMM included specific provinces. Independent patient-level factors associated with maternal mortality included increasing Maternal Comorbidity Index, age 40 to 44 years (OR, 3.39; 95% CI, 1.68-6.82 compared with age 20-24 years), age 45 years or older (OR, 4.39; 95% CI, 1.01-19.10 compared with age 20-24 years), and lowest income quintile (OR, 4.14; 95% CI, 2.03-8.50 compared with highest income quintile). Hospital-level factors associated with maternal mortality included lowest hospital pregnancy volume.

CONCLUSIONS AND RELEVANCE

In Canada, maternal age and SMM have increased over the past decade. Results of this study suggest that province of residence, maternal comorbidity, residence income quintile, and extremes of maternal age, especially those 45 years or older, were associated with SMM and mortality. These findings are relevant to prospective parents, their health care team, and public health planning.

Delivery-associated sepsis: trends in prevalence and mortality

BACKGROUND

Sepsis is a leading cause of pregnancy-related mortality. Previous studies have reported an increased prevalence of sepsis during pregnancy. Despite national campaigns to increase sepsis awareness, there is a lack of pregnancy-specific guidelines.

OBJECTIVE

We aimed to provide updated national estimates of the prevalence and trends of sepsis, sepsis-related in-hospital mortality, and factors associated with in-hospital mortality among women with sepsis at delivery.

STUDY DESIGN

We conducted a serial, cross-sectional analysis using data from the 2002-2015 National Inpatient Sample, the largest publicly available all-payer inpatient database in the United States. We used International Classification of Diseases, ninth edition, Clinical Modification diagnosis and procedure codes to identify the study sample of delivery-associated hospitalizations and to capture diagnoses of sepsis (defined as infection with associated end-organ dysfunction). The primary outcome was in-hospital mortality. Obstetric comorbidities and pregnancy-related outcomes were also analyzed. Logistic regression was used to explore factors associated with sepsis during pregnancy and, among those with sepsis, to identify predictors of in-hospital mortality. Joinpoint regression was used to estimate the temporal trends in both sepsis and in-hospital mortality.

RESULTS

Of the more than 55 million delivery-associated hospitalizations, 13,129 women met criteria for sepsis, corresponding to a rate of 2.4 per 10,000 deliveries. This rate increased from 1.2 to 3.7 per 10,000 over the study period, representing an annual increase of 6.6% (95% confidence interval, 4.2-9.1). The highest crude rates of sepsis (per 10,000) were among deliveries paid for by Medicare (14.8), deliveries to women aged 40 years or older (8.0), and deliveries to non-Hispanic black women (4.6). Compared with women without sepsis, women with sepsis had a greater than 10-fold increased prevalence of most selected obstetric comorbidities. One in 11 women with sepsis died prior to discharge, compared with 1 death in every 15,411 deliveries without sepsis. The sepsis-related mortality rate decreased 21.8% each year from 2010 through 2015. Maternal age greater than 40 years and nonprivate insurance demonstrated the highest odds of sepsis-related in-hospital mortality.

CONCLUSION

While rates of delivery-associated sepsis have increased, case fatality has decreased.