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Bullard KA, Ramanadhan S, Caughey AB, Rodriguez MI. Immediate Postpartum Long-Acting Reversible Contraception for Preventing Severe Maternal Morbidity: A Cost-Effectiveness Analysis. Obstet Gynecol 2024:00006250-990000000-01121. [PMID: 39053007 DOI: 10.1097/aog.0000000000005679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/06/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE To estimate the cost effectiveness of Medicaid covering immediate postpartum long-acting reversible contraception (LARC) as a strategy to reduce future short interpregnancy interval (IPI), severe maternal morbidity (SMM), and preterm birth. METHODS We built a decision analytic model using TreeAge software to compare maternal health and cost outcomes in two settings, one in which immediate postpartum LARC is a covered option and the other where it is not, among a theoretical cohort of 100,000 people with Medicaid insurance who were immediately postpartum and did not have permanent contraception. The primary outcome was the incremental cost-effectiveness ratio (ICER), which represents the incremental cost increase per an incremental quality-adjusted life-years (QALY) gained from one health intervention compared with another. Secondary outcomes included subsequent short IPI, defined as time between last delivery and conception of less than 18 months, as well as SMM, preterm birth, overall costs, and QALYs. We performed sensitivity analyses on all costs, probabilities, and utilities. RESULTS Use of immediate postpartum LARC was the cost-effective strategy, with an ICER of -11,880,220,102. Use of immediate postpartum LARC resulted in 299 fewer repeat births overall, 178 fewer births with short IPI, two fewer cases of SMM, and 34 fewer preterm births. Coverage of immediate postpartum LARC resulted in 25 additional QALYs and saved $2,968,796. CONCLUSION Coverage of immediate postpartum LARC at the time of index delivery can improve quality of life and reduce health care costs for Medicaid programs. Expanding coverage to include immediate postpartum LARC can help to achieve optimal IPI and decrease SMM and preterm birth.
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Affiliation(s)
- Kimberley A Bullard
- Department of Obstetrics and Gynecology, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee; and the Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
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Diop H, Declercq ER, Liu CL, Cui X, Amutah-Onukagha N, Meadows AR, Cabral HJ. Leveraging a Longitudinally Linked Dataset to Assess Recurrence of Severe Maternal Morbidity. Womens Health Issues 2024:S1049-3867(24)00049-5. [PMID: 39019744 DOI: 10.1016/j.whi.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 05/20/2024] [Accepted: 06/07/2024] [Indexed: 07/19/2024]
Abstract
OBJECTIVES Among those with a severe maternal morbidity (SMM) event and a subsequent birth, we examined how the risk of a second SMM event varied by patient characteristics and intrapartum hospital utilization. METHODS We used a Massachusetts population-based dataset that longitudinally linked in-state births, hospital discharge records, prior and subsequent births, and non-birth-related hospital utilizations for birthing individuals and their children from January 1, 1999, to December 31, 2018, representing 1,460,514 births by 907,530 birthing people. We restricted our study sample to 2,814 people who had their first SMM event associated with a singleton birth and gave birth a second time within the study period. Our outcome measure was recurrence of SMM in the second birth. We calculated the prevalence of SMM at second birth, compared SMM conditions between births, and estimated the adjusted risk ratios and 95% confidence intervals for having an SMM event at second birth among those who had an SMM at the first birth. We also examined overall hospital utilization including inpatient admissions, emergency room visits, and observational stays, and hospital utilization by interpregnancy intervals (IPIs) between the first and second birth. RESULTS There were 2,814 birthing people with at least one birth after the first SMM singleton birth. Among those, 198 (7.0%) had a subsequent SMM. The percentage of people with a second SMM event varied by age, race/ethnicity, insurance, IPI, and history of hypertension at first case of SMM (all p < .05). Between births, people with a second SMM event had significantly higher proportions of inpatient admissions (60.1% vs. 33.2.0%; p < .001), emergency room visits (71.7% vs. 57.7%; p < .001), and observational stays (35.4% vs. 19.5%; p < .001) compared with those who did not experience a second SMM event. CONCLUSION Hospital utilization after a birth with SMM might indicate an elevated risk of a second SMM event. Providers should counsel their patients about prevention and warning signs.
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Affiliation(s)
- Hafsatou Diop
- Massachusetts Department of Public Health, Boston, Massachusetts.
| | | | | | - Xiaohui Cui
- Massachusetts Department of Public Health, Boston, Massachusetts
| | - Ndidiamaka Amutah-Onukagha
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Audra R Meadows
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, San Diego, California
| | - Howard J Cabral
- Boston University School of Public Health, Boston, Massachusetts
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Ramisetty-Mikler S, Willis A, Tiwari C. Pre-pregnancy Weight and Racial-Ethnic Disparities in Pregnancy-Associated Conditions in the State of Georgia: A Population-Based Study. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-01932-2. [PMID: 38378940 DOI: 10.1007/s40615-024-01932-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/13/2024] [Accepted: 01/31/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION We investigate racial-ethnic disparities in pre-pregnancy obesity and pregnancy weight gain, which are known to increase the risk of pregnancy-associated conditions. METHODS We used 4-year (2017-2020) combined Georgia Pregnancy Risk Assessment Monitoring System data (N = 3208) to investigate racial-ethnic disparities in the incidence of gestational hypertension (GHT), gestational diabetes mellitus (GDM), and postpartum depression (PPD) and their associated risk with pre-pregnancy overweight/obesity after controlling for demographic and other confounders using regression modeling. The geographic distributions of hypertension and PPD rates at the county level were compared to the patterns of racial-ethnic populations and hospitals. RESULTS The PPD rates were higher among Asian (17.6), Hispanic (14.4), and Black (14.3); GDM was highest among Asian (16.0) mothers; and GHT was the highest among Black (11.7) followed by White mothers (9.0). Pre-pregnancy overweight and obese conditions increased the odds of hypertension in Black (2 ½ times) and White (> 3 ½ times) mothers. Premature birth increased the odds of hypertension (2-3 times) in all mothers. Pre-pregnancy weight also increased the odds of GDM (3-7 times) in these racial groups. Premature birth increases the odds twice as likely for PPD in Hispanic and White mothers. The convergence of high PPD and hypertension rates with high proportions of racial and ethnic minorities, and lack of hospital presence, indicates areas where healthcare interventions are required. CONCLUSIONS These findings underscore the importance of promoting a healthy pre-pregnancy weight to reduce the burden of maternal morbidity and pregnancy outcomes in general. More comprehensive prenatal monitoring using technological interventions for self-care has a great promise of being effective in maintaining a healthy pregnancy.
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Affiliation(s)
- Suhasini Ramisetty-Mikler
- Department of Population Health Sciences, School of Public Health, Georgia State University, Atlanta, USA.
- Department of Health Policy & Behavioral Sciences, School of Public Health, Georgia State University, Atlanta, USA.
- Urban Life Building, Room 406, 140 Decatur St, Atlanta, GA, 30303, USA.
| | - Angelique Willis
- Department of Geosciences, Georgia State University, Atlanta, USA
| | - Chetan Tiwari
- Department of Geosciences, Georgia State University, Atlanta, USA
- Center for Disaster Informatics and Computational Epidemiology, Georgia State University, Atlanta, USA
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McIlwraith C, Sanusi A, McGwin G, Battarbee A, Subramaniam A. Recurrent Severe Maternal Morbidity in an Obstetric Population With a High Comorbidity Burden. Obstet Gynecol 2024; 143:265-271. [PMID: 37989147 DOI: 10.1097/aog.0000000000005453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/14/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVE To evaluate the risk of severe maternal morbidity (SMM) in subsequent pregnancies in patients who experienced SMM in a previous pregnancy compared with those who did not. METHODS We conducted a retrospective cohort study of patients with two or more deliveries at 23 or more weeks of gestation at a single Southeastern U.S. tertiary care center between 2015 and 2018. The primary exposure was SMM including transfusion (transfusion SMM) in a previous pregnancy, as defined by the Centers for Disease Control and Prevention, using International Classification of Diseases, Ninth or Tenth Revision codes. The primary outcome was transfusion SMM in any subsequent pregnancy in the study time frame. Generalized estimating equation models were used to estimate the relative risk (RR) and associated 95% CIs of transfusion SMM in patients with transfusion SMM in a prior pregnancy compared with patients without transfusion SMM in a previous pregnancy. Severe maternal morbidity without transfusion (nontransfusion SMM) and cross-analysis to determine risk of a different type of SMM after a history of SMM were analyzed similarly. RESULTS Of 852 included patients, transfusion SMM and nontransfusion SMM occurred in 90 (10.6%) and 18 (2.1%), respectively, in the first captured pregnancy and in 79 (9.3%) and 9 (1.1%), respectively, in subsequent pregnancies. Anemia (34.6-40.0%), obesity (33.4-40.4%), substance use disorder (14.2-14.6%), and preeclampsia (12.0-11.4%) were the most prevalent morbidities at first captured and subsequent pregnancies, respectively. There was a 16-fold higher risk of transfusion SMM in a subsequent pregnancy after experiencing transfusion SMM in the first captured pregnancy (57.8% vs 3.5%, RR 16.3 95% CI, 10.8-24.6). Nontransfusion SMM was similarly higher in patients with nontransfusion SMM in their first captured pregnancy compared with those without (16.7% vs 0.7%, RR 23.2 95% CI, 6.3-85.4). Additionally, patients who experienced transfusion SMM in their first captured pregnancies were at sixfold higher risk of developing nontransfusion SMM in a subsequent pregnancy (RR 6.2, 95% CI, 1.7-22.6). However, in cross-analysis of patients who experienced nontransfusion SMM, the risk of transfusion SMM in a subsequent pregnancy was not statistically significant. CONCLUSION The risks of SMM in subsequent pregnancies after previous SMM are extremely high and are higher than previous estimates. Future studies should estimate the contributions of comorbidities and other structural determinants including social vulnerability to help design interventions to reduce subsequent pregnancy risks.
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Affiliation(s)
- Claire McIlwraith
- Department of Obstetrics and Gynecology, the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, the Center for Women's Reproductive Health, and the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
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Ukah UV, Platt RW, Auger N, Lisonkova S, Ray JG, Malhamé I, Ayoub A, El-Chaâr D, Dayan N. Risk of recurrent severe maternal morbidity: a population-based study. Am J Obstet Gynecol 2023; 229:545.e1-545.e11. [PMID: 37301530 DOI: 10.1016/j.ajog.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/24/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Severe maternal morbidity is a composite indicator of maternal health and obstetrical care. Little is known about the risk of recurrent severe maternal morbidity in a subsequent delivery. OBJECTIVE This study aimed to estimate the risk of recurrent severe maternal morbidity in the next delivery after a complicated first delivery. STUDY DESIGN We analyzed a population-based cohort study of women with at least 2 singleton hospital deliveries between 1989 and 2021 in Quebec, Canada. The exposure was severe maternal morbidity in the first hospital-recorded delivery. The study outcome was severe maternal morbidity at the second delivery. Log-binomial regression models adjusted for maternal and pregnancy characteristics were used to generate relative risks and 95% confidence intervals comparing women with and without severe maternal morbidity at first delivery. RESULTS Among 819,375 women, 43,501 (3.2%) experienced severe maternal morbidity in the first delivery. The rate of severe maternal morbidity recurrence at second delivery was 65.2 vs 20.3 per 1000 in women with and without previous severe maternal morbidity (adjusted relative risk, 3.11; 95% confidence interval, 2.96-3.27). The adjusted relative risk for recurrence of severe maternal morbidity was greatest among women who had ≥3 different types of severe maternal morbidity at their first delivery, relative to those with none (adjusted relative risk, 5.50; 95% confidence interval, 4.26-7.10). Women with cardiac complication at first delivery had the highest risk of severe maternal morbidity in the next delivery. CONCLUSION Women who experience severe maternal morbidity have a relatively high risk of recurrent morbidity in the subsequent pregnancy. In women with severe maternal morbidity, these study findings have implications for prepregnancy counseling and maternity care in the next pregnancy.
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Affiliation(s)
- Ugochinyere Vivian Ukah
- Institut national de santé publique du Québec, Montreal, Canada; HealthPartners Institute, Pregnancy and Child Health Research Center, Bloomington, MN; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Robert W Platt
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Nathalie Auger
- Institut national de santé publique du Québec, Montreal, Canada
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology and the BC Children's and Women's Hospital, The University of British Columbia, Vancouver, Canada
| | - Joel G Ray
- Department of Medicine and the Institute of Health Policy and Evaluation, University of Toronto, Toronto, Canada
| | - Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montreal, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Aimina Ayoub
- Institut national de santé publique du Québec, Montreal, Canada
| | - Darine El-Chaâr
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
| | - Natalie Dayan
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada; Department of Medicine, McGill University Health Centre, Montreal, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada.
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Boulet SL, Stanhope KK, Worrell N, Jamieson DJ. Risk of recurrent severe maternal morbidity in an urban safety net health system. Am J Obstet Gynecol MFM 2022; 4:100568. [PMID: 35033749 DOI: 10.1016/j.ajogmf.2022.100568] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/04/2022] [Accepted: 01/09/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Rates of severe maternal morbidity (SMM) are steadily increasing in the US and are highest among women who are Black, publicly insured, or deliver at a safety net hospital. There is limited information on the risk of SMM recurrence in subsequent births, particularly among socially vulnerable women. OBJECTIVE To estimate the risk of SMM recurrence among a singleton births in a large, public hospital system. STUDY DESIGN We conducted a population-based cohort study using electronic medical record data on deliveries occurring at an urban public hospital between 2011 and 2020. We included all women with two singleton deliveries at ≥20 weeks gestation (live or stillborn) during the study period and assessed SMM recorded at delivery or within 42 days postpartum. We used generalized linear models to estimate adjusted risk ratios (aRR), adjusted risk differences (aRD) and 95% confidence intervals (CI) for SMM at the subsequent birth, controlling for age, parity, self-reported race/ethnicity, insurance type, chronic hypertension and diabetes, and obesity at the index delivery. RESULTS Between 2011 and 2020, there were 26,994 singleton deliveries to 21,638 women. Among 4,368 women with two singleton births at ≥20 weeks gestation, 4.8% (n=211) had SMM at the index birth, and 5.7% (n=250) had SMM at the subsequent birth. SMM at the index birth was associated with an over 3-fold increased risk of SMM in a subsequent pregnancy (aRR 3.65, 95% CI: 2.65-5.03) and an excess risk of 12.9 per 100 deliveries (aRD 12.9, 95% CI: 7.7-18.1). CONCLUSIONS The results of our study suggest that women who experienced SMM in a prior birth are at increased risk for SMM recurrence and may warrant additional monitoring in subsequent pregnancies.
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Affiliation(s)
- Sheree L Boulet
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA (Drs Boulet, Stanhope, and Jamieson).
| | - Kaitlyn K Stanhope
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA (Drs Boulet, Stanhope, and Jamieson)
| | | | - Denise J Jamieson
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA (Drs Boulet, Stanhope, and Jamieson)
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