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Liu LY, Friedman AM, Goffman D, Nathan L, Sheen JJ, Reddy UM, D'Alton ME, Wen T. Infection and Sepsis Trends during United States' Delivery Hospitalizations from 2000 to 2020. Am J Perinatol 2024; 41:1767-1778. [PMID: 38408480 DOI: 10.1055/s-0044-1780538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
OBJECTIVE This study aimed to evaluate trends, risk factors, and outcomes associated with infections and sepsis during delivery hospitalizations in the United States. STUDY DESIGN The 2000-2020 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of patients aged 15 to 54 with and without infection and sepsis were identified. Common infection diagnoses during delivery hospitalizations analyzed included (i) pyelonephritis, (ii) pneumonia/influenza, (iii) endometritis, (iv) cholecystitis, (v) chorioamnionitis, and (vi) wound infection. Temporal trends in sepsis and infection during delivery hospitalizations were analyzed. The associations between sepsis and infection and common chronic health conditions including asthma, chronic hypertension, pregestational diabetes, and obesity were analyzed. The associations between clinical, demographic, and hospital characteristics, and infection and sepsis were determined with unadjusted and adjusted logistic regression models with unadjusted odds ratio (OR) and adjusted odds ratios with 95% confidence intervals as measures of association. RESULTS An estimated 80,158,622 delivery hospitalizations were identified and included in the analysis, of which 2,766,947 (3.5%) had an infection diagnosis and 32,614 had a sepsis diagnosis (4.1 per 10,000). The most common infection diagnosis was chorioamnionitis (2.7% of deliveries) followed by endometritis (0.4%), and wound infections (0.3%). Infection and sepsis were more common in the setting of chronic health conditions. Evaluating trends in individual infection diagnoses, endometritis and wound infection decreased over the study period both for patients with and without chronic conditions, while risk for pyelonephritis and pneumonia/influenza increased. Sepsis increased over the study period for deliveries with and without chronic condition diagnoses. Risks for adverse outcomes including mortality, severe maternal morbidity, the critical care composite, and acute renal failure were all significantly increased in the presence of sepsis and infection. CONCLUSION Endometritis and wound infections decreased over the study period while risk for sepsis increased. Infection and sepsis were associated with chronic health conditions and accounted for a significant proportion of adverse obstetric outcomes including severe maternal morbidity. KEY POINTS · Sepsis increased over the study period for deliveries with and without chronic condition diagnoses.. · Endometritis and wound infection decreased over the study period.. · Infection and sepsis accounted for a significant proportion of adverse obstetric outcomes..
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Affiliation(s)
- Lilly Y Liu
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Dena Goffman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Lisa Nathan
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Jean-Ju Sheen
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Timothy Wen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
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Kishkovich TP, James KE, McCoy TH, Perlis RH, Kaimal AJ, Clapp MA. Performance of a Maternal Risk Stratification System for Predicting Low Apgar Scores. Am J Perinatol 2024; 41:1808-1814. [PMID: 38301722 DOI: 10.1055/a-2259-0472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Maternal risk stratification systems are increasingly employed in predicting and preventing obstetric complications. These systems focus primarily on maternal morbidity, and few tools exist to stratify neonatal risk. We sought to determine if a maternal risk stratification score was associated with neonatal morbidity. STUDY DESIGN Retrospective cohort study of patients with liveborn infants born at ≥24 weeks at four hospitals in one health system between January 1, 2020, and December 31, 2020. The Expanded Obstetric Comorbidity Score (EOCS) is used as the maternal risk score. The primary neonatal outcome was 5-minute Apgar <7. Logistic regression models determined associations between EOCS and neonatal morbidity. Secondary analyses were performed, including stratifying outcomes by gestational age and limiting analysis to "low-risk" term singletons. Model discrimination assessed using the area under the receiver operating characteristic curves (AUC) and calibration via calibration plots. RESULTS A total of 14,497 maternal-neonatal pairs were included; 236 (1.6%) had 5-minute Apgar <7; EOCS was higher in 5-minute Apgar <7 group (median 41 vs. 11, p < 0.001). AUC for EOCS in predicting Apgar <7 was 0.72 (95% Confidence Interval (CI) 0.68, 0.75), demonstrating relatively good discrimination. Calibration plot revealed that those in the highest EOCS decile had higher risk of neonatal morbidity (7.6 vs. 1.7%, p < 0.001). When stratified by gestational age, discrimination weakened with advancing gestational age: AUC 0.70 for <28 weeks, 0.63 for 28 to 31 weeks, 0.64 for 32 to 36 weeks, and 0.61 for ≥37 weeks. When limited to term low-risk singletons, EOCS had lower discrimination for predicting neonatal morbidity and was not well calibrated. CONCLUSION A maternal morbidity risk stratification system does not perform well in most patients giving birth, at low risk for neonatal complications. The findings suggest that the association between EOCS and 5-minute Apgar <7 likely reflects a relationship with prematurity. This study cautions against intentional or unintentional extrapolation of maternal morbidity risk for neonatal risk, especially for term deliveries. KEY POINTS · EOCS had moderate discrimination for Apgar <7.. · Predictive performance declined when limited to low-risk term singletons.. · Relationship between EOCS and Apgar <7 was likely driven by prematurity..
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Affiliation(s)
- Thomas P Kishkovich
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kaitlyn E James
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas H McCoy
- Massachusetts General Hospital, Center for Quantitative Health, Boston, Massachusetts
| | - Roy H Perlis
- Massachusetts General Hospital, Center for Quantitative Health, Boston, Massachusetts
| | - Anjali J Kaimal
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida
| | - Mark A Clapp
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
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Diab YH, Huang J, Nehme L, Saade G, Kawakita T. Temporal Trend in Maternal Morbidity and Comorbidity. Am J Perinatol 2024; 41:1867-1873. [PMID: 38471526 DOI: 10.1055/s-0044-1782598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
OBJECTIVE This study aimed to examine the temporal trends of severe maternal morbidity (SMM) in the U.S. population in relation to trends in maternal comorbidity. STUDY DESIGN We performed a repeated cross-sectional analysis of data from individuals at 20 weeks' gestation or greater using U.S. birth certificate data from 2011 to 2021. Our primary outcome was SMM defined as the occurrence of intensive care unit admission, eclampsia, hysterectomy, uterine rupture, and blood product transfusion. We also examined the proportions of maternal comorbidity. Outcomes of the adjusted incidence rate ratio (IRR) with 99% confidence intervals (99% CIs) for 2021 m12 compared with 2011 m1 were calculated using negative binomial regression, controlling for predefined confounders. RESULTS There were 42,504,125 births included in the analysis. From 2011 m1 to 2021 m12, there was a significant increase in the prevalence of advanced maternal age (35-39 [45%], 40-44 [29%], and ≥45 [43%] years), morbid obesity (body mass index 40-49.9 [66%], 50-59.9 [91%], and 60-69.9 [98%]), previous cesarean delivery (14%), chronic hypertension (104%), pregestational diabetes (64%), pregnancy-associated hypertension (240%), gestational diabetes (74%), and preterm delivery at 34 to 36 weeks (12%). There was a significant decrease in the incidence of multiple gestation (9%), preterm delivery at 22 to 27 weeks (9%), and preterm delivery at 20 to 21 weeks (22%). From 2011 m1 to 2021 m12, the incidence of SMM increased from 0.7 to 1.0% (crude IRR 1.60 [99% CI 1.54-1.66]). However, the trend was no longer statistically significant after controlling for confounders (adjusted IRR 1.01 [95% CI 0.81-1.27]). The main comorbidity that was associated with the increase in SMM was pregnancy-associated hypertension. CONCLUSION The rise in the prevalence of comorbidity in pregnancy seems to fuel the rise in SMM. Interventions to prevent SMM should include the management and prevention of pregnancy-associated hypertension. KEY POINTS · The rise in maternal mortality is related to morbidity.. · Pregnancy-associated hypertension increases morbidity.. · There were increasing trends in age, body mass index, and medical conditions..
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Affiliation(s)
- Yara H Diab
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Jim Huang
- Department of Business Management, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Lea Nehme
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - George Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Tetsuya Kawakita
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
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Straub L, Bateman BT, Hernández-Díaz S, Zhu Y, Suarez EA, Vine SM, Jones HE, Connery HS, Davis JM, Gray KJ, Lester B, Terplan M, Zakoul H, Mogun H, Huybrechts KF. Comparative Safety of In Utero Exposure to Buprenorphine Combined With Naloxone vs Buprenorphine Alone. JAMA 2024; 332:805-816. [PMID: 39133511 PMCID: PMC11320336 DOI: 10.1001/jama.2024.11501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/28/2024] [Indexed: 08/13/2024]
Abstract
Importance Buprenorphine combined with naloxone is commonly used to treat opioid use disorders outside of pregnancy. In pregnancy, buprenorphine alone is generally recommended because of limited perinatal safety data on the combination product. Objective To compare perinatal outcomes following prenatal exposure to buprenorphine with naloxone vs buprenorphine alone. Design, Settings, and Participants Population-based cohort study using health care utilization data from Medicaid-insured beneficiaries in the US from 2000 to 2018. The cohort was restricted to pregnant individuals linked to their liveborn infants, with maternal Medicaid enrollment from 3 months before pregnancy to 1 month after delivery and infant enrollment for the first 3 months after birth, unless they died sooner. Exposure Use of buprenorphine with naloxone vs buprenorphine alone during the first trimester based on outpatient dispensings. Main Outcomes and Measures Outcomes included major congenital malformations, low birth weight, neonatal abstinence syndrome, neonatal intensive care unit admission, preterm birth, respiratory symptoms, small for gestational age, cesarean delivery, and maternal morbidity. Confounder-adjusted risk ratios were calculated using propensity score overlap weights. Results This study identified 3369 pregnant individuals exposed to buprenorphine with naloxone during the first trimester (mean [SD] age, 28.8 [4.6] years) and 5326 exposed to buprenorphine alone or who switched from the combination to buprenorphine alone by the end of the first trimester (mean [SD] age, 28.3 [4.5] years). When comparing buprenorphine combined with naloxone with buprenorphine alone, a lower risk for neonatal abstinence syndrome (absolute risk, 37.4% vs 55.8%; weighted relative risk, 0.77 [95% CI, 0.70-0.84]) and a modestly lower risk for neonatal intensive care unit admission (absolute risk, 30.6% vs 34.9%; weighted relative risk, 0.91 [95% CI, 0.85-0.98]) and small for gestational age (absolute risk, 10.0% vs 12.4%; weighted relative risk, 0.86 [95% CI, 0.75-0.98]) was observed. For maternal morbidity, the comparative rates were 2.6% vs 2.9%, respectively, and the weighted relative risk was 0.90 (95% CI, 0.68-1.19). No differences were observed with respect to major congenital malformations overall, low birth weight, preterm birth, respiratory symptoms, or cesarean delivery. Results were consistent across sensitivity analyses. Conclusions and Relevance There were similar and, in some instances, more favorable neonatal and maternal outcomes for pregnancies exposed to buprenorphine combined with naloxone compared with buprenorphine alone. For the outcomes assessed, compared with buprenorphine alone, buprenorphine with naloxone during pregnancy appears to be a safe treatment option. This supports the view that both formulations are reasonable options for the treatment of opioid use disorder in pregnancy, affirming flexibility in collaborative treatment decision-making.
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Affiliation(s)
- Loreen Straub
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yanmin Zhu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elizabeth A. Suarez
- Center for Pharmacoepidemiology and Treatment Science, Rutgers Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
| | - Seanna M. Vine
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hendrée E. Jones
- UNC Horizons and Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill
| | - Hilary S. Connery
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Jonathan M. Davis
- Department of Pediatrics, Tufts Medical Center and Tufts Clinical and Translational Science Institute, Boston, Massachusetts
| | - Kathryn J. Gray
- Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - Barry Lester
- Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Women & Infants Hospital, Providence, Rhode Island
| | | | - Heidi Zakoul
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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McCarthy KJ, Liu SH, Kennedy J, Chan HT, Howell F, Boychuk N, Mayer VL, Vieira L, Tabaei B, Seil K, Van Wye G, Janevic T. Preconception HbA1c Levels in Adolescents and Young Adults and Adverse Birth Outcomes. JAMA Netw Open 2024; 7:e2435136. [PMID: 39316396 PMCID: PMC11423169 DOI: 10.1001/jamanetworkopen.2024.35136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/25/2024] Open
Abstract
Importance Subclinical hyperglycemia before pregnancy may be associated with the likelihood of maternal morbidity but is understudied among young people. Objective To explore the association of preconception hemoglobin A1c (HbA1c) levels among adolescents and young adults with risk of gestational diabetes at first live birth. Design, Setting, and Participants This retrospective cohort study used linked 2009 to 2017 birth registry, hospital discharge, and New York City Department of Health A1C Registry data for birthing individuals aged 10 to 24 years with no history of diabetes and at least 1 preconception HbA1c test in New York, New York. Statistical analysis was performed from August to November 2022. Exposure Preconception HbA1c values categorized as no diabetes (HbA1c <5.7%) or prediabetes (HbA1c ≥5.7% to <6.5%). Main Outcomes and Measures The primary outcome was gestational diabetes at first birth. Secondary outcomes included hypertensive disorders of pregnancy, preterm birth, cesarean delivery, and macrosomia. Log binomial regression was used to estimate the relative risk (RR) of gestational diabetes at first birth by preconception HbA1c level, adjusting for prepregnancy characteristics. The optimal HbA1c threshold for gestational diabetes was examined using receiver operating curve regression. Results A total of 14 302 individuals (mean [SD] age, 22.10 [1.55] years) met study eligibility criteria. Of these, 5896 (41.0%) were Hispanic, 4149 (29.0%) were Black, 2583 (18.1%) were White, 1516 (10.6%) were Asian, and 185 (1.3%) had other or unknown race and ethnicity. Most (11 407 individuals [79.7%]) had normoglycemia before pregnancy, and 2895 individuals (20.2%) had prediabetes. Adjusting for prepregnancy characteristics, those with preconception prediabetes had more than twice the risk of gestational diabetes vs those with normoglycemia (adjusted RR [aRR], 2.21; 95% CI, 1.91-2.56). Preconception prediabetes was associated with small increases in the likelihood of a hypertensive disorder of pregnancy (aRR, 1.18; 95% CI, 1.03-1.35) and preterm delivery (aRR, 1.18; 95% CI, 1.02-1.37). The aRRs for cesarean delivery (aRR, 1.09; 95% CI, 0.99-1.20) and macrosomia (aRR, 1.13; 95% CI, 0.93-1.37) were increased but not statistically significant. The optimal HbA1c threshold to identify gestational diabetes among adolescents and young adults was 5.6%. The threshold did not vary by obesity status but was slightly lower among Hispanic individuals (HbA1c of 5.5%). Conclusions and Relevance In this study of adolescents and young adults with at least 1 preconception HbA1c test, prediabetes was associated with increased likelihood of maternal cardiometabolic morbidity at first birth. Efforts to optimize cardiometabolic health before pregnancy may avert excess maternal risk.
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Affiliation(s)
- Katharine J McCarthy
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shelley H Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph Kennedy
- Department of Health and Mental Hygiene, Bureau of Vital Statistics, New York, New York
| | - Hiu Tai Chan
- Department of Health and Mental Hygiene, Bureau of Vital Statistics, New York, New York
| | - Frances Howell
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Natalie Boychuk
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Victoria L Mayer
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Luciana Vieira
- Department of Maternal and Fetal Medicine, Stamford Hospital, Stamford, Connecticut
| | - Bahman Tabaei
- Department of Health and Mental Hygiene, Bureau of Health Equity, New York, New York
| | - Kacie Seil
- Department of Health and Mental Hygiene, Bureau of Vital Statistics, New York, New York
| | - Gretchen Van Wye
- Department of Health and Mental Hygiene, Bureau of Vital Statistics, New York, New York
| | - Teresa Janevic
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Yonekura H, Mazda Y, Noguchi S, Berg BW. Impact of the 2017 revised Japanese obstetric hemorrhage management guidelines on tranexamic acid use in patients undergoing cesarean delivery: an interrupted time series analysis. Int J Obstet Anesth 2024; 60:104258. [PMID: 39265271 DOI: 10.1016/j.ijoa.2024.104258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 07/31/2024] [Accepted: 08/21/2024] [Indexed: 09/14/2024]
Abstract
BACKGROUND Tranexamic acid is one component of a complex management algorithm for postpartum hemorrhage. In Japan, the 2010 obstetric hemorrhage management guidelines was revised in 2017, adding the recommendation for the administration of tranexamic acid for postpartum hemorrhage. This research aims to delineate the temporal trends in tranexamic acid administration in patients undergoing cesarean deliveries and to examine the impact of the obstetric hemorrhage management guidelines implementation. METHODS An interrupted time series analysis was conducted on data from patients who underwent cesarean deliveries from April 2012 to August 2021, sourced from Japan's nationwide health insurance claims database. We examined the trends of tranexamic acid usage and blood transfusion use before and after the implementation of the revised guidelines in 2017. RESULTS The study cohort comprised 91 166 cesarean deliveries. Prior to the guideline implementation, the rate of tranexamic acid usage decreased. Post-guidelines implementation, there was a statistically significant increase in the rate of tranexamic acid use, with a quarterly percentage change of 0.48% (95% confidence interval: 0.36 to 0.60; P < 0.001). The guidelines implementation in 2017 was not significantly associated with a change in the rate of transfusions. CONCLUSIONS This interrupted time series analysis demonstrated a significant increase in the rate of tranexamic acid administration following the implementation of the revised guidelines, reversing the previously observed downward trend. Our findings could reflect the impact of the revised guideline on the use of tranexamic acid for postpartum hemorrhage, but this did not translate to fewer blood transfusions.
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Affiliation(s)
- H Yonekura
- Sim Tiki Simulation Center, John A. Burns School of Medicine, University of Hawaii at Manoa, USA; Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Japan.
| | - Y Mazda
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Japan
| | - S Noguchi
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Japan
| | - B W Berg
- Sim Tiki Simulation Center, John A. Burns School of Medicine, University of Hawaii at Manoa, USA
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Savelli Binsted AC, Saade G, Kawakita T. External validation and comparison of four prediction scores for severe maternal morbidity. Am J Obstet Gynecol MFM 2024; 6:101471. [PMID: 39179157 DOI: 10.1016/j.ajogmf.2024.101471] [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: 06/12/2024] [Revised: 08/05/2024] [Accepted: 08/13/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Severe maternal morbidity (SMM) is increasing in the United States. Several tools and scores exist to stratify an individual's risk of SMM. OBJECTIVE We sought to examine and compare the validity of four scoring systems for predicting SMM. STUDY DESIGN This was a retrospective cohort study of all individuals in the Consortium on Safe Labor dataset, which was conducted from 2002 to 2008. Individuals were excluded if they had missing information on risk factors. SMM was defined based on the Centers for Disease Control and Prevention excluding blood transfusion. Blood transfusion was excluded due to concerns regarding the specificity of International Classification of Diseases codes for this indicator and its variable clinical significance. Risk scores were calculated for each participant using the Assessment of Perinatal Excellence (APEX), California Maternal Quality Care Collaborative (CMQCC), Obstetric Comorbidity Index (OB-CMI), and modified OB-CMI. We calculated the probability of SMM according to the risk scores. The discriminative performance of the prediction score was examined by the areas under receiver operating characteristic curves and their 95% confidence intervals (95% CI). The area under the curve for each score was compared using the bootstrap resampling. Calibration plots were developed for each score to examine the goodness-of-fit. The concordance probability method was used to define an optimal cutoff point for the best-performing score. RESULTS Of 153, 463 individuals, 1115 (0.7%) had SMM. The CMQCC scoring system had a significantly higher area under the curve (95% CI) (0.78 [0.77-0.80]) compared to the APEX scoring system, OB-CMI, and modified OB-CMI scoring systems (0.75 [0.73-0.76], 0.67 [0.65-0.68], 0.66 [0.70-0.73]; P<.001). Calibration plots showed excellent concordance between the predicted and actual SMM for the APEX scoring system and OB-CMI (both Hosmer-Lemeshow test P values=1.00, suggesting goodness-of-fit). CONCLUSION This study validated four risk-scoring systems to predict SMM. Both CMQCC and APEX scoring systems had good discrimination to predict SMM. The APEX score and the OB-CMI had goodness-of-fit. At ideal calculated cut-off points, the APEX score had the highest sensitivity of the four scores at 71%, indicating that better scoring systems are still needed for predicting SMM.
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Affiliation(s)
| | - George Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Tetsuya Kawakita
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
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Meredith ME, Steimle LN, Stanhope KK, Platner MH, Boulet SL. Racial/ethnic differences in pre-pregnancy conditions and adverse maternal outcomes in the nuMoM2b cohort: A population-based cohort study. PLoS One 2024; 19:e0306206. [PMID: 39133734 PMCID: PMC11318875 DOI: 10.1371/journal.pone.0306206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 06/12/2024] [Indexed: 08/15/2024] Open
Abstract
OBJECTIVES To determine how pre-existing conditions contribute to racial disparities in adverse maternal outcomes and incorporate these conditions into models to improve risk prediction for racial minority subgroups. STUDY DESIGN We used data from the "Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b)" observational cohort study. We defined multimorbidity as the co-occurrence of two or more pre-pregnancy conditions. The primary outcomes of interest were severe preeclampsia, postpartum readmission, and blood transfusion during pregnancy or up to 14 days postpartum. We used weighted Poisson regression with robust variance to estimate adjusted risk ratios and 95% confidence intervals, and we used mediation analysis to evaluate the contribution of the combined effects of pre-pregnancy conditions to racial/ethnic disparities. We also evaluated the predictive performance of our regression models by racial subgroup using the area under the receiver operating characteristic curve (AUC) metric. RESULTS In the nuMoM2b cohort (n = 8729), accounting for pre-existing conditions attenuated the association between non-Hispanic Black race/ethnicity and risk of severe preeclampsia. Cardiovascular and kidney conditions were associated with risk for severe preeclampsia among all women (aRR, 1.77; CI, 1.61-1.96, and aRR, 1.27; CI, 1.03-1.56 respectively). The mediation analysis results were not statistically significant; however, cardiovascular conditions explained 36.6% of the association between non-Hispanic Black race/ethnicity and severe preeclampsia (p = 0.07). The addition of pre-pregnancy conditions increased model performance for the prediction of severe preeclampsia. CONCLUSIONS Pre-existing conditions may explain some of the association between non-Hispanic Black race/ethnicity and severe preeclampsia. Specific pre-pregnancy conditions were associated with adverse maternal outcomes and the incorporation of comorbidities improved the performance of most risk prediction models.
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Affiliation(s)
- Meghan E. Meredith
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Lauren N. Steimle
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Kaitlyn K. Stanhope
- Department of Gynecology & Obstetrics, Emory University, Atlanta, Georgia, United States of America
| | - Marissa H. Platner
- Department of Gynecology & Obstetrics, Emory University, Atlanta, Georgia, United States of America
| | - Sheree L. Boulet
- Department of Gynecology & Obstetrics, Emory University, Atlanta, Georgia, United States of America
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Raktong W, Sawaddisan R, Peeyananjarassri K, Suwanrath C, Geater A. Predictors and a scoring model for maternal near-miss and maternal death in Southern Thailand: a case-control study. Arch Gynecol Obstet 2024; 310:1055-1062. [PMID: 38713295 DOI: 10.1007/s00404-024-07539-6] [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: 01/31/2024] [Accepted: 04/24/2024] [Indexed: 05/08/2024]
Abstract
PURPOSE To identify predictors and develop a scoring model to predict maternal near-miss (MNM) and maternal mortality. METHODS A case-control study of 1,420 women delivered between 2014 and 2020 was conducted. Cases were women with MNM or maternal death, controls were women who had uneventful deliveries directly after women in the cases group. Antenatal characteristics and complications were reviewed. Multivariate logistic regression and Akaike information criterion were used to identify predictors and develop a risk score for MNM and maternal mortality. RESULTS Predictors for MNM and maternal mortality (aOR and score for predictive model) were advanced age (aOR 1.73, 95% CI 1.25-2.39, 1), obesity (aOR 2.03, 95% CI 1.22-3.39, 1), parity ≥ 3 (aOR 1.75, 95% CI 1.27-2.41, 1), history of uterine curettage (aOR 5.13, 95% CI 2.47-10.66, 3), history of postpartum hemorrhage (PPH) (aOR 13.55, 95% CI 1.40-130.99, 5), anemia (aOR 5.53, 95% CI 3.65-8.38, 3), pregestational diabetes (aOR 5.29, 95% CI 1.27-21.99, 3), heart disease (aOR 13.40, 95%CI 4.42-40.61, 5), multiple pregnancy (aOR 5.57, 95% CI 2.00-15.50, 3), placenta previa and/or placenta-accreta spectrum (aOR 48.19, 95% CI 22.75-102.09, 8), gestational hypertension/preeclampsia without severe features (aOR 5.95, 95% CI 2.64-13.45, 4), and with severe features (aOR 16.64, 95% CI 9.17-30.19, 6), preterm delivery <37 weeks (aOR 1.65, 95%CI 1.06-2.58, 1) and < 34 weeks (aOR 2.71, 95% CI 1.59-4.62, 2). A cut-off score of ≥4 gave the highest chance of correctly classified women into high risk group with 74.4% sensitivity and 90.4% specificity. CONCLUSIONS We identified predictors and proposed a scoring model to predict MNM and maternal mortality with acceptable predictive performance.
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Affiliation(s)
- Wipawan Raktong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Rapphon Sawaddisan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
| | - Krantarat Peeyananjarassri
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Chitkasaem Suwanrath
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Alan Geater
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla, University, Songkhla, Thailand
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Zivin K, Zhang X, Tilea A, Hall SV, Admon LK, Vance AJ, Dalton VK. Perinatal Psychotherapy Use and Costs Before and After Federally Mandated Health Insurance Coverage. JAMA Netw Open 2024; 7:e2426802. [PMID: 39120900 PMCID: PMC11316231 DOI: 10.1001/jamanetworkopen.2024.26802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 06/12/2024] [Indexed: 08/10/2024] Open
Abstract
Importance Insurance coverage affects health care access for many delivering women diagnosed with perinatal mood and anxiety disorders (PMADs). The Mental Health Parity and Addiction Equity Act (MHPAEA; passed in 2008) and the Patient Protection and Affordable Care Act (ACA; passed in 2010) aimed to improve health care access. Objective To assess associations between MHPAEA and ACA implementation and psychotherapy use and costs among delivering women overall and with PMADs. Design, Setting, and Participants This cross-sectional study conducted interrupted time series analyses of private insurance data from January 1, 2007, to December 31, 2019, for delivering women aged 15 to 44 years, including those with PMADs, to assess changes in psychotherapy visits in the year before and the year after delivery. It estimated changes in any psychotherapy use and per-visit out-of-pocket costs (OOPCs) for psychotherapy associated with MHPAEA (January 2010) and ACA (January 2014) implementation. Data analyses were performed from August 2022 to May 2023. Exposures Implementation of the MHPAEA and ACA. Main Outcomes and Measures Any psychotherapy use and per-visit OOPCs for psychotherapy standardized to 2019 dollars. Results The study included 837 316 overall deliveries among 716 052 women (mean [SD] age, 31.2 [5.4] years; 7.6% Asian, 8.8% Black, 12.8% Hispanic, 64.1% White, and 6.7% unknown race and ethnicity). In the overall cohort, a nonsignificant step change was found in the delivering women who received psychotherapy after MHPAEA implementation of 0.09% (95% CI, -0.04% to 0.21%; P = .16) and a nonsignificant slope change of delivering women who received psychotherapy of 0.00% per month (95% CI, -0.02% to 0.01%; P = .69). A nonsignificant step change was found in delivering individuals who received psychotherapy after ACA implementation of 0.11% (95% CI, -0.01% to 0.22%; P = .07) and a significantly increased slope change of delivering individuals who received psychotherapy of 0.03% per month (95% CI, 0.00% to 0.05%; P = .02). Among those with PMADs, the MHPAEA was associated with an immediate increase (0.72%; 95% CI, 0.26% to 1.18%; P = .002) then sustained decrease (-0.05%; -0.09% to -0.02%; P = .001) in psychotherapy receipt; the ACA was associated with immediate (0.77%; 95% CI, 0.26% to 1.27%; P = .003) and sustained (0.07%; 95% CI, 0.02% to 0.12%; P = .005) monthly increases. In both populations, per-visit monthly psychotherapy OOPCs decreased (-$0.15; 95% CI, -$0.24 to -$0.07; P < .001 for overall and -$0.22; -$0.32 to -$0.12; P < .001 for the PMAD population) after MHPAEA passage with an immediate increase ($3.14 [95% CI, $1.56-$4.73]; P < .001 and $2.54 [95% CI, $0.54-$4.54]; P = .01) and steady monthly increase ($0.07 [95% CI, $0.02-$0.12]; P = .006 and $0.10 [95% CI, $0.03-$0.17]; P = .004) after ACA passage. Conclusions and Relevance This study found complementary and complex associations between passage of the MHPAEA and ACA and access to psychotherapy among delivering individuals. These findings indicate the value of continuing efforts to improve access to mental health treatment for this population.
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Affiliation(s)
- Kara Zivin
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Psychiatry, Michigan Medicine, Ann Arbor
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor
| | - Xiaosong Zhang
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor
| | - Anca Tilea
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor
| | - Stephanie V. Hall
- Department of Psychiatry, Michigan Medicine, Ann Arbor
- Department of Learning Health Sciences, Michigan Medicine, Ann Arbor
| | - Lindsay K. Admon
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor
| | - Ashlee J. Vance
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan
| | - Vanessa K. Dalton
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor
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11
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Chuang HM, Meng LC, Lin CW, Chen WW, Chen YY, Shang CY, Chen LK, Hsiao FY. Concomitant use of antidepressants and benzodiazepines during pregnancy and associated risk of congenital malformations: a population-based cohort study in Taiwan. Lancet Psychiatry 2024; 11:601-610. [PMID: 38968942 DOI: 10.1016/s2215-0366(24)00176-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/07/2024] [Accepted: 05/21/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Despite the frequent co-administration of antidepressants and benzodiazepines, the association between such concomitant use during pregnancy and the risk of congenital malformations remains inadequately explored. This study aims to examine the association between concomitant use of antidepressants and benzodiazepines during the first trimester and organ-specific congenital malformations. METHODS We conducted a population-based cohort study using Taiwan's National Birth Certificate Application database, the Maternal and Child Health database, and Taiwan's National Health Insurance database. Pregnant people aged 15-50 years with singleton births between Jan 1, 2004, and Dec 31, 2018, were included. Use of antidepressants and benzodiazepines was defined as at least one prescription during the first trimester, and concomitant use was defined as the overlapping prescription of both drugs with an overlapping prescription period. The primary outcomes were overall congenital malformations and eight organ-specific malformations, consisting of the nervous system, heart, respiratory system, oral cleft, digestive system, urinary system, genital system, and limb malformations. Logistic regression models with propensity score fine stratification weighting approach were used to control for measured confounders. Analyses controlling for confounding by indication and sibling comparison analyses were done to address unmeasured confounders. No individuals with lived experience participated in the research or writing process. FINDINGS The cohort included 2 634 021 singleton pregnancies, and 8599 (0·3%) individuals were concomitant users of antidepressants and benzodiazepines during the first trimester (mean age at delivery was 31·8 years [SD 5·2] for pregnancies with exposure to antidepressants and benzodiazepines vs 30·7 years [SD 4·9] for pregnancies without exposure). All study participants were female, and information about ethnicity was not available. Absolute risk of overall malformations was 3·81 per 100 pregnancies with exposure, compared with 2·87 per 100 pregnancies without exposure. The propensity score-weighted odds ratios (weighted ORs) did not suggest an increased risk for overall malformations (weighted OR 1·10, 95% CI 0·94-1·28), heart defects (1·01, 0·83-1·23), or any of the other organ-specific malformations, except for digestive system malformations, for which the weighted OR remained statistically significant after adjustment (1·63, 1·06-2·51). The absence of an increased risk for overall congenital malformations associated with concomitant use of antidepressants and benzodiazepines was supported by the analyses controlling for confounding by indication and sibling-matched comparisons. INTERPRETATION The findings of this study suggest that the concomitant use of antidepressants and benzodiazepines during the first trimester is not associated with a substantial increase in risk for most malformation subtypes. However, considering other potential adverse effects of using both medications concomitantly, a thorough assessment of the risks and benefits is crucial for clinical decision making. FUNDING National Science and Technology Council.
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Affiliation(s)
- Hui-Min Chuang
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Lin-Chieh Meng
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | | | - Yi-Yung Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chi-Yung Shang
- Department of Psychiatry, National Taiwan University Hospital, and College of Medicine, Taipei, Taiwan
| | - Liang-Kung Chen
- Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan; Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan; Taipei Municipal Gan-Dau Hospital (Managed by Taipei Veterans General Hospital), Taipei, Taiwan
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; School of Pharmacy, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.
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12
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Lui B, Khusid E, Tangel VE, Jiang SY, Abramovitz SE, Oxford CM, White RS. Disparities in postpartum readmission by patient- and hospital-level social risk factors in the United States: a retrospective multistate analysis, 2015-2020. Int J Obstet Anesth 2024; 59:103998. [PMID: 38719764 DOI: 10.1016/j.ijoa.2024.103998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Postpartum readmission is an area of focus for improving obstetric care and reducing costs. We examined disparities in all-cause 30-day postpartum readmission by patient- and hospital-level factors in the United States. METHODS We conducted a retrospective cohort study using 2015-2020 records from the State Inpatient Databases from four states. Generalized linear mixed models were constructed to estimate the effects of individual patient- and hospital-level factors on adjusted odds of 30-day readmission after controlling for confounders. Stratified analyses by delivery and anesthesia type (New York only) and interaction models were performed. RESULTS Black mothers were more likely than White mothers to be readmitted within 30-days postpartum (aOR 1.57, 95% CI 1.52 to 1.61). Mothers with public insurance had increased odds of readmission compared with those with private insurance (Medicare: aOR 2.13, 95% CI 1.95 to 2.32; Medicaid: aOR 1.14, 95% CI 1.11 to 1.17). Compared with mothers in the lowest income quartile, those in the highest quartile experienced a 14% lower odds of readmission (aOR 0.86, 95% CI 0.83 to 0.89). There were no significant associations between hospital-level characteristics and readmission. Black mothers were more likely to be readmitted regardless of delivery type and most combinations of delivery and anesthesia type. Black mothers from the highest income quartile were more likely to be readmitted than White mothers from the lowest income quartile. CONCLUSION Substantial disparities in 30-day postpartum readmissions by patient-level social factors were observed, particularly amongst Black mothers. Action is needed to address and mitigate disparities in postpartum readmission.
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Affiliation(s)
- B Lui
- Weill Cornell Medical College, Weill Cornell Medicine, New York, NY, USA
| | - E Khusid
- Weill Cornell Medical College, Weill Cornell Medicine, New York, NY, USA
| | - V E Tangel
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - S Y Jiang
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - S E Abramovitz
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - C M Oxford
- Department of Maternal and Fetal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - R S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
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13
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Shea L, Sadowsky M, Tao S, Rast J, Schendel D, Chesnokova A, Headen I. Perinatal and Postpartum Health Among People With Intellectual and Developmental Disabilities. JAMA Netw Open 2024; 7:e2428067. [PMID: 39145975 PMCID: PMC11327882 DOI: 10.1001/jamanetworkopen.2024.28067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024] Open
Abstract
Importance Small, geographically limited studies report that people with intellectual and developmental disabilities (IDD) have increased risk for serious pregnancy-related and birth-related challenges, including preeclampsia, preterm birth, and increased anxiety and depression, than their peers. United States-based population-level data among people with IDD are lacking. Objectives To identify perinatal and postpartum outcomes among a national, longitudinal sample of people with IDD enrolled in public health insurance, compare subgroups of people with IDD, and compare outcomes among people with IDD with those of peers without IDD. Design, Setting, and Participants This retrospective cohort study used national Medicaid claims from January 1, 2008, to December 31, 2019, for 55 440 birthing people with IDD and a random sample of 438 557 birthing people without IDD. Medicaid funds almost half of all births and is the largest behavioral health insurer in the US, covering a robust array of services for people with IDD. Statistical analysis was performed from July 2023 to June 2024. Exposure People who had a documented birth in Medicaid during the study years. Main Outcome and Measures Perinatal outcomes were compared across groups using univariate and multivariate logistic regression. The probability of postpartum anxiety and depression was estimated using Kaplan-Meier and Cox proportional hazards regression. Results The study sample included 55 440 birthing people with IDD (including 41 854 with intellectual disabilities [ID] and 13 586 with autism; mean [SD] age at first delivery, 24.9 [6.7] years) and a random sample of 438 557 birthing people without IDD (mean [SD] age at first delivery, 26.4 [6.3] years). People with IDD were younger at first observed delivery, had a lower prevalence of live births (66.6% vs 76.7%), and higher rates of obstetric conditions (gestational diabetes, 10.3% vs 9.9%; gestational hypertension, 8.7% vs 6.1%; preeclampsia, 6.1% vs 4.4%) and co-occurring physical conditions (heart failure, 1.4% vs 0.4%; hyperlipidemia, 5.3% vs 1.7%; ischemic heart disease, 1.5% vs 0.4%; obesity, 16.3% vs 7.4%) and mental health conditions (anxiety disorders, 27.9% vs 6.5%; depressive disorders, 32.1% vs 7.5%; posttraumatic stress disorder, 9.5% vs 1.2%) than people without IDD. The probability of postpartum anxiety (adjusted hazard ratio [AHR], 3.2 [95% CI, 2.9-3.4]) and postpartum depression (AHR, 2.4 [95% CI, 2.3-2.6]) was significantly higher among autistic people compared with people with ID only and people without IDD. Conclusions and Relevance In this retrospective cohort study, people with IDD had a younger mean age at first delivery, had lower prevalence of live births, and had poor obstetric, mental health, and medical outcomes compared with people without IDD, pointing toward a need for clinician training and timely delivery of maternal health care. Results highlight needed reproductive health education, increasing clinician knowledge, and expanding Medicaid to ensure access to care for people with IDD.
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Affiliation(s)
- Lindsay Shea
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania
| | - Molly Sadowsky
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania
| | - Sha Tao
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania
| | - Jessica Rast
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania
| | - Diana Schendel
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania
| | - Arina Chesnokova
- Division of Academic Specialists, University of Pennsylvania, Philadelphia
| | - Irene Headen
- Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
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Zacher Kjeldsen MM, Mægbæk ML, Liu X, Madsen MG, Bliddal M, Egsgaard S, Bang Madsen K, Munk-Olsen T. The HOPE cohort: cohort profile and evaluation of selection bias. Eur J Epidemiol 2024; 39:943-954. [PMID: 39158818 PMCID: PMC11410971 DOI: 10.1007/s10654-024-01150-4] [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: 01/05/2024] [Accepted: 08/07/2024] [Indexed: 08/20/2024]
Abstract
The HOPE cohort is a Danish nationwide cohort with ongoing follow-up, holding information on postpartum depression (PPD) symptoms and diagnoses on 170,218 childbirths (142,795 unique mothers). These data have been linked with extensive register data on health and socioeconomic information on the mothers, their partners, parents, and children. This cohort profile aimed to provide an overview of the data collection and content, describe characteristics, and evaluate potential selection bias. PPD screenings, using the Edinburgh Postnatal Depression Scale, were collected from 67 of the 98 Danish municipalities, covering the period January 2015 to December 2021. This data was linked with register data on PPD diagnoses (identified through medication prescriptions and hospital contacts) as well as background information. Cohort characteristics were compared to the source population, defined as all childbirths by women residing in Denmark during the same period (452,207 childbirths). Potential selection bias was evaluated by comparing odds ratios of five well-established associations between the cohort and the source population. The HOPE cohort holds information on 170,218 childbirths (38% of the source population) involving 142,795 unique mothers. The HOPE cohort only differed slightly from the source population on most characteristics examined, but larger differences were observed on specific characteristics with an underrepresentation of the youngest and oldest age groups, women with more than three children or twins/triplets, and women born outside Denmark. Similar associations were identified across the two populations within the five well-established associations. There was no indication of selection bias on the five examined associations, and the HOPE cohort is representative of the source population on important perinatal characteristics.
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Affiliation(s)
- Mette-Marie Zacher Kjeldsen
- NCRR-National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark.
- Department of Public Health, Aarhus University, Aarhus, Denmark.
- CIRRAU - Centre for Integrated Register-Based Research, Aarhus University, Aarhus, Denmark.
| | - Merete Lund Mægbæk
- NCRR-National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark
- CIRRAU - Centre for Integrated Register-Based Research, Aarhus University, Aarhus, Denmark
| | - Xiaoqin Liu
- NCRR-National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark
- CIRRAU - Centre for Integrated Register-Based Research, Aarhus University, Aarhus, Denmark
| | - Malene Galle Madsen
- NCRR-National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark
| | - Mette Bliddal
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sofie Egsgaard
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Child and Adolescent Psychiatric Unit, Region of Southern Denmark, Odense, Denmark
| | - Kathrine Bang Madsen
- NCRR-National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark
- CIRRAU - Centre for Integrated Register-Based Research, Aarhus University, Aarhus, Denmark
| | - Trine Munk-Olsen
- NCRR-National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Child and Adolescent Psychiatric Unit, Region of Southern Denmark, Odense, Denmark
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15
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Rueda Camino JA, Azcoaga-Lorenzo A, Noguero-Meseguer R, Joya-Seijo D, Angelina-García M, Trujillo D, Miranda C, Barba-Martín R. Incidence of pregnancy related pulmonary embolism in Spain 2016-2021: an observational population-based retrospective study. Rev Clin Esp 2024:S2254-8874(24)00103-6. [PMID: 39094786 DOI: 10.1016/j.rceng.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
OBJECTIVE This study aimed to estimate the overall and annual age-standardized incidence of pregnancy-related pulmonary embolism (PE) in Spain from 2016 to 2021, explore the distribution of PE events during pregnancy and the postpartum period, identify potential risk factors, and estimate mortality rates during hospital admission. METHODS In a retrospective, observational, population-based study, data from the Spanish National Hospital Discharge Database were analyzed to identify women with hospital episodes of pregnancy-related-PE. The primary outcome was the overall and annual age-standardized incidence of pregnancy-related-PE, with secondary aims including the distribution of events during pregnancy and postpartum and the calculation of age-standardized mortality rates during admission. RESULTS Among 2,178,805 births from 2016 to 2021, 522 women were diagnosed with pregnancy-related PE, yielding an overall age-standardized incidence of 2.83 cases per 10,000 births. A non-significant increasing trend was observed from 2.43 to 4.18 cases per 10,000 births (p = 0.06). Comorbidities were low, with a notable association between PE and SARS-CoV-2 infection during the last two years. The mortality rate among women with pregnancy-related PE was 2.8%, with a higher incidence of PE reported during the postpartum period. CONCLUSION The incidence of pregnancy-related-PE in Spain exhibits a non-significant increasing trend, with a significant risk of mortality. The association with SARS-CoV-2 infection underscores the importance of vigilant monitoring and management of pregnant women, particularly during pandemics. This study contributes specific data on the incidence and characteristics of pregnancy-related-PE in Spain, emphasizing the need to consider PE in the differential diagnosis and management strategies for pregnant and postpartum women.
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Affiliation(s)
- J A Rueda Camino
- Internal Medicine Department, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Madrid, Spain
| | - A Azcoaga-Lorenzo
- Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Madrid, Spain; Division of Population and Behavioural Sciences, School of Medicine, University of St Andrews, St Andrews, UK; Research Network On Chronicity, Primary Care and Prevention and Health Promotion, (ISCIII), Madrid, Spain
| | - R Noguero-Meseguer
- Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Madrid, Spain; Department of Gynecology and Obstetrics, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Universidad Rey Juan Carlos, Madrid
| | - D Joya-Seijo
- Internal Medicine Department, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Madrid, Spain; Universidad Rey Juan Carlos, Madrid
| | - M Angelina-García
- Internal Medicine Department, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Madrid, Spain
| | - D Trujillo
- Internal Medicine Department, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | - C Miranda
- Internal Medicine Department, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Madrid, Spain
| | - R Barba-Martín
- Internal Medicine Department, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Madrid, Spain; Grupo Gestión Sociedad Española Medicina Interna; Universidad Rey Juan Carlos, Madrid.
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16
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Lin YC, Lin CW, Meng LC, Huang ST, Chen YY, Wang SJ, Chan KA, Hsiao FY. Uses of antiseizure medication among pregnant women with epilepsy and risk of adverse obstetric outcomes: A group-based trajectory analysis. Epilepsia 2024. [PMID: 39077901 DOI: 10.1111/epi.18064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 07/03/2024] [Accepted: 07/10/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE This study was undertaken to examine the association between different patterns of antiseizure medication (ASM) use during pregnancy and adverse obstetric outcomes (preterm birth, low birth weight [LBW], and small for gestational age [SGA]). METHODS This retrospective cohort study used the Birth Certificate Application and National Health Insurance data in Taiwan (January 1, 2004 through December 31, 2018). We retrieved weekly ASM among pregnant women with epilepsy who were prepregnancy chronic users and used group-based trajectory modeling to identify distinct patterns of use. Logistic regressions were adopted to examine the association between patterns of ASM use and risk of preterm birth, LBW, and SGA. In addition, we revealed postnatal ASM utilization pattern among these prepregnancy chronic users as an exploratory study. RESULTS Of 2175 pregnant women with epilepsy, we identified four patterns of ASM use during pregnancy: frequent and continuous (64.87%), frequent but discontinuous (7.08%), intermittent (19.72%), and intermittent and discontinuous users (8.32%). Compared to frequent and continuous users, the adjusted odds ratios for preterm birth in frequent but discontinuous, intermittent, and intermittent and discontinuous users were .83 (95% confidence interval [CI] = .47-1.48), .71 (95% CI = .47-1.05), and .88 (95% CI = .52-1.49), respectively. Similar results were observed for LBW and SGA. In the exploratory study, we found that most of our study subjects maintained the same patterns before and after delivery. SIGNIFICANCE After considering duration and timing of exposure, our study did not find an association between four distinct patterns of ASM use and adverse obstetric outcomes among women with epilepsy. The findings suggested that optimal seizure control could be received for pregnant women with epilepsy after evaluating the risks and benefits.
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Affiliation(s)
- Yi-Chin Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | | | - Lin-Chieh Meng
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shih-Tsung Huang
- Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Yung Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center and College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - K Arnold Chan
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
- College of Medicine, National Taiwan University, Taipei, Taiwan
- TriNetX, London, UK
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- School of Pharmacy, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
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17
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Lee S, Seow CH, Nerenberg K, Bertazzon S, Leung Y, Huang V, Whitten T, Coward S, Panaccione R, Kaplan GG, Metcalfe A. Despite Increased Disease Activity, Women who Attended a Dedicated Inflammatory Bowel Disease and Pregnancy Clinic Had Infants With Higher Apgar Scores: A Population-Based Study. Inflamm Bowel Dis 2024; 30:1071-1079. [PMID: 37499061 DOI: 10.1093/ibd/izad147] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Attendance at a subspecialty pregnancy clinic for women with inflammatory bowel disease (IBD) improves disease-specific pregnancy knowledge. We examined the impact of attendance at a dedicated IBD-pregnancy clinic on IBD and perinatal outcomes. METHODS Using linked administrative databases in Alberta, Canada (2012-2019), we identified 1061 pregnant women with IBD who delivered singleton liveborn infants in-hospital who did (n = 314) and did not attend (n = 747) the clinic. Propensity score weighted multivariable log-binomial and multinomial logistic regression models were used to determine the risk of IBD and perinatal outcomes. RESULTS The median number of clinic visits was 3 (Q1-Q3, 3-5), with 34.7% completing a preconception consultation. A greater proportion of women who attended lived near the clinic, were nulliparous, had a disease flare prior to pregnancy, and were on maintenance IBD medication (P < .05). Women who attended had increased risks of a disease flare during pregnancy (adjusted risk ratio [aRR], 2.02; 95% CI, 1.45-2.82), an IBD-related emergency department visit during pregnancy (aRR, 2.66; 95% CI, 1.92-3.68), and cesarean delivery (aRR, 1.78; 95% CI, 1.23-2.57). Despite this, clinic attendees had a decreased risk of delivering an infant with a low Apgar score at 1 minute (risk ratio [RR], 0.49; 95% CI, 0.32-0.76) and 5 minutes (RR, 0.32; 95% CI, 0.12-0.87). CONCLUSIONS Women who attended a dedicated IBD-pregnancy clinic were more likely to have a disease flare prior to pregnancy, reflecting a more severe disease phenotype, but had similar perinatal outcomes and infants with better Apgar scores at birth. Our study suggests the value of these subspecialty clinics in providing enhanced IBD-specific prenatal care.
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Affiliation(s)
- Sangmin Lee
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, Alberta, Canada
| | - Kara Nerenberg
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Stefania Bertazzon
- Department of Geography, University of Calgary, Calgary, Alberta, Canada
| | - Yvette Leung
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vivian Huang
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tara Whitten
- Provincial Research Data Services, Alberta Health Services, Alberta, Canada
- Alberta Strategy for Patient Oriented Research Support Unit Data and Research Services Platform, Alberta, Canada
| | - Stephanie Coward
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Remo Panaccione
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, Alberta, Canada
| | - Amy Metcalfe
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
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18
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Arya S, Mahar A, Callum J, Haspel RL. Examining Injustices: Transfusion Medicine and Race. Transfus Med Rev 2024; 38:150822. [PMID: 38519336 DOI: 10.1016/j.tmrv.2024.150822] [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: 12/09/2023] [Revised: 02/01/2024] [Accepted: 02/12/2024] [Indexed: 03/24/2024]
Abstract
Race and ethnicity are sociopolitical and not biological constructs, and assertions that these population descriptors have scientific meaning has caused significant harm. A critical assessment of the transfusion medicine literature is an important aspect of promoting race-conscious as opposed to race-based medicine. Utilizing current definitions and health equity frameworks, this review will provide a critical appraisal of transfusion medicine studies at the intersection of race and healthcare disparities, with a focus on larger methodological challenges facing the transfusion medicine community. Moving forward, risk modelling accounting for upstream factors, patient input, as well as an expert consensus on how to critically conduct and evaluate this type of literature are needed. Further, when using race and ethnicity in research contexts, investigators must be aware of existing guidelines for such reporting.
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Affiliation(s)
- Sumedha Arya
- Canadian Blood Services, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Alyson Mahar
- School of Nursing and Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Jeannie Callum
- University of Toronto, Toronto, Ontario, Canada; Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | - Richard L Haspel
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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19
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Chaalan F, Minisha F, Zaidi Z, Babekar A, Saleh HAH, Shurbak ZSB, Al Baloushi M, Alnaama A, Ahmed H, Babarinsa I, Dewik NA, Pallivalapila A, Olagundoye V, Farrell T. Validation of a modified obstetric comorbidity index for prediction of postpartum adverse events including fetal morbidity - a retrospective cohort study from Qatar. BMC Pregnancy Childbirth 2024; 24:415. [PMID: 38851669 PMCID: PMC11161943 DOI: 10.1186/s12884-024-06612-x] [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: 12/08/2023] [Accepted: 05/29/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND The Obstetric Comorbidity Index (OBCMI) is an internationally validated scoring system for maternal risk factors intended to reliably predict the occurrence of severe maternal morbidity (SMM). This retrospective cohort study applied the OBCMI to pregnant women in Qatar to validate its performance in predicting SMM and cumulative fetal morbidity. METHODS Data from 1000 women who delivered in July 2021 in a large tertiary centre was extracted from medical records. The OBCMI index included maternal demographics, pre-existing comorbidities, and various current pregnancy risk factors such as hypertension, including preeclampsia, intrauterine fetal death, prolonged rupture of membranes and unbooked pregnancies. SMM was based on the ACOG consensus definition, and the cumulative fetal morbidity (CFM) included fetal distress in labour, low APGAR and umbilical artery (UA) pH, admission to neonatal intensive care (NICU), and hypoxic-ischemic encephalopathy (HIE). A c-statistic or area under curve (AUC) was calculated to determine the ability of OBCMI to predict SMM and CFM. RESULTS The median OBCMI score for the cohort was 1 (interquartile range- 0 to 2); 50% of women scored 0, while 85% (n = 842) had a score ranging from 0 to 2. Ten women (1%) scored ≥ 7; the highest score was 10. The incidence of SMM was 13%. According to the modified scoring system, the mean OBCMI score in those who developed SMM was 2.18 (± 2.20) compared to a mean of 1.04 (± 1.40) in those who did not (median 1, IQR:1-3 versus median 0, IQR: 0-2; p < 0.001). The incidence of CFM was 11.3%. The incidence of low APGAR score, HIE and NICU admission was nearly 1 in 1000. Around 5% of the babies had fetal distress in labour and low UA pH. For every 1 unit increase in OBCMI score, the odds of SMM increased by 44% (OR 1.44 95% CI 1.30-1.59; p < 0.001; AUC 0.66), and CFM increased by 28% (OR 1.28 95% CI 1.15-1.42; p < 0.001; AUC 0.61). A cut-off score of 4 had a high specificity (> 90%); 1 in 4 and 1 in 6 women with OBCMI score ≥ 4 developed SMM and CFM, respectively. CONCLUSION The OBCMI performed moderately well in predicting SMM in pregnant women of Qatar and can be effectively used as a risk assessment tool to red-flag high-risk cases so that appropriate and timely multidisciplinary care can be initiated to reduce SMM and maternal mortality. The index is also helpful in predicting fetal morbidity; however, further prospective studies are required to validate OBCMI for CFM.
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Affiliation(s)
- Fouad Chaalan
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Fathima Minisha
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar.
| | - Zehra Zaidi
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Alaa Babekar
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Huda Abullah Hussain Saleh
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
- Women's Wellness and Research Centre, Executive Director of Quality and Safety, Hamad Medical Corporation, Doha, Qatar
| | - Zeena Saeed Bu Shurbak
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Mariam Al Baloushi
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Alaa Alnaama
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Husham Ahmed
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Isaac Babarinsa
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Nader Al Dewik
- Department of Research, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Abdulrouf Pallivalapila
- Department of Research, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Victor Olagundoye
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Thomas Farrell
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
- Chair of Research, Department of Research, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
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Guseh S, Tworetzky W. Transforming congenital heart disease management: Advances in fetal cardiac interventions. Prenat Diagn 2024; 44:733-738. [PMID: 38768017 DOI: 10.1002/pd.6592] [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: 04/02/2024] [Revised: 05/03/2024] [Accepted: 05/06/2024] [Indexed: 05/22/2024]
Abstract
This review addresses the transformative advancements in fetal cardiac interventions (FCI) for congenital heart diseases (CHD), with a particular focus on aortic stenosis with evolving hypoplastic left heart syndrome, pulmonary atresia with an intact ventricular septum, and HLHS with an intact atrial septum (HLHS-IAS). We outline the specific FCI techniques employed, the refined criteria for selecting appropriate fetal and maternal candidates, and the promising yet varied outcomes associated with these procedures. Procedural strategies and clinical decision-making are examined as we take into account the fetal pathophysiology and the benefits and risks of early intervention. We highlight the role of multidisciplinary teams in improving technical success and managing immediate procedural complications, which have led to significant improvements in procedural outcomes. Additionally, the review discusses the long-term outcomes, challenges, and future research directions in FCI, emphasizing the necessity for continuous innovation and collaboration across specialties to advance the management of CHD. The integration of new technologies and research findings holds the promise of further enhancing FCI success rates and patient outcomes.
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Affiliation(s)
- Stephanie Guseh
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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21
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Lopez Laporte MA, Shahin J, Blotsky A, Malhamé I, Dayan N. Trends in maternal ICU admissions at a quaternary centre in Montreal, Canada, and impact of maternal age on critical care outcomes. Obstet Med 2024; 17:84-91. [PMID: 38784185 PMCID: PMC11110742 DOI: 10.1177/1753495x231184686] [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: 09/21/2022] [Accepted: 06/10/2023] [Indexed: 05/25/2024] Open
Abstract
Background Advancing maternal age is increasingly prevalent and is associated with severe maternal morbidity often requiring intensive care unit (ICU) admission. Objectives To describe maternal ICU admissions at a quaternary care hospital in Montreal, Canada, and evaluate the association between maternal age and composite of: need for invasive interventions, ICU stay > 48 h, or maternal death. Methods Chart review of ICU admissions during pregnancy/postpartum (2006-2016); logistic regressions to evaluate the impact of age on outcomes. Results With 5.1 ICU admissions per 1000 deliveries, we included 187 women (mean age 32 ± 6.3 years; 20 (10.7%) ≥ 40 years). The composite outcome occurred in 105 (56.2%) patients; there were two maternal deaths. Age ≥ 40 years increased the odds of invasive interventions (OR 4.03; 95% confidence interval [CI] 1.15-14.1) but not of the composite outcome (OR 2.30; 95% CI 0.66-8.02). Conclusion Peripartum women aged ≥ 40 years had worse outcomes in ICU, with an increased need for invasive interventions.
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Affiliation(s)
- Maria Agustina Lopez Laporte
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Jason Shahin
- Division of Respirology and Critical Care Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Andrea Blotsky
- Division of Respirology and Critical Care Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Isabelle Malhamé
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Natalie Dayan
- Division of General Internal Medicine and Critical Care Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
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Meng LC, Lin CW, Chuang HM, Chen YY, Shang CY, Wu CY, Chen LK, Hsiao FY. Prescription Patterns and Predisposing Factors of Benzodiazepine and Z-Hypnotic Use During Pregnancy: A Nationwide Cohort Study. Pharmacoepidemiol Drug Saf 2024; 33:e5847. [PMID: 38898542 DOI: 10.1002/pds.5847] [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: 02/27/2024] [Revised: 05/04/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE The use of benzodiazepines and Z-hypnotics during pregnancy has raised significant concerns in recent years. However, there are limited data that capture the prescription patterns and predisposing factors in use of these drugs, particularly among women who have been long-term users of benzodiazepines and Z-hypnotics before pregnancy. METHODS This population-based cohort study comprised 2 930 988 pregnancies between 2004 and 2018 in Taiwan. Women who were dispensed benzodiazepines or Z-hypnotics during pregnancy were identified and further stratified into groups based on their status before pregnancy: long-term users (with a supply of more than 180 days within a year), short-term users (with a supply of less than 180 days within a year), and nonusers. Trends in the use of benzodiazepines or Z-hypnotics and concomitant use with antidepressants or opioids were assessed. Logistic regression models were utilized to identify factors associated with use of these drugs during pregnancy, and interrupted time series analyses (ITSA) were employed to evaluate utilization patterns of these drugs across different pregnancy-related periods. RESULTS The overall prevalence of benzodiazepine and Z-hypnotic use was 3.5% during pregnancy. Among prepregnancy long-term users, an upward trend was observed. The concomitant use of antidepressants or opioids among exposed women increased threefold (from 8.6% to 23.1%) and sixfold (from 0.3% to 1.7%) from 2004 to 2018, respectively. Women with unhealthy lifestyle behaviors, such as alcohol abuse (OR 2.48; 95% CI, 2.02-3.03), drug abuse (OR 10.34; 95% CI, 8.46-12.64), and tobacco use (OR 2.19; 95% CI, 1.96-2.45), as well as those with psychiatric disorders like anxiety (OR 6.99; 95% CI, 6.77-7.22), insomnia (OR 15.99; 95% CI, 15.55-16.45), depression (OR 9.43; 95% CI, 9.07-9.80), and schizophrenia (OR 21.08; 95% CI, 18.76-23.69), and higher healthcare utilization, were more likely to use benzodiazepines or Z-hypnotics during pregnancy. ITSA revealed a sudden decrease in use of benzodiazepines and Z-hypnotics after recognition of pregnancy (level change -0.55 percentage point; 95% CI, -0.59 to -0.51). In contrast, exposures to benzodiazepines and Z-hypnotics increased significantly after delivery (level change 0.12 percentage point; 95% CI, 0.09 to 0.16). CONCLUSIONS In this cohort study, an increased trend of benzodiazepine and Z-hypnotic use during pregnancy among prepregnancy long-term users, as well as concomitant use with antidepressants or opioids were found. The findings have highlighted the existence of various risk factors associated with the use of these drugs during pregnancy. Utilization patterns varied across different stages of pregnancy, highlighting the need for prescription guidelines and educational services for women using these drugs during pregnancy.
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Affiliation(s)
- Lin-Chieh Meng
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | - Hui-Min Chuang
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Taiwan Drug Relief Foundation, Taipei, Taiwan
| | - Yi-Yung Chen
- Department of Obstetrics and Gynecology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chi-Yung Shang
- Department of Psychiatry, National Taiwan University Hospital, and College of Medicine, Taipei, Taiwan
| | - Chia-Yi Wu
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
- Taiwanese Society of Suicidology, Taiwan Suicide Prevention Center, Taipei, Taiwan
| | - Liang-Kung Chen
- Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
- Taipei Municipal Gan-Dau Hospital Managed by Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- School of Pharmacy, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
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Choi A, Lee H, Jeong HE, Lee SY, Kwon JS, Han JY, Choe YJ, Shin JY. Association between exposure to antibiotics during pregnancy or early infancy and risk of autism spectrum disorder, intellectual disorder, language disorder, and epilepsy in children: population based cohort study. BMJ 2024; 385:e076885. [PMID: 38777351 PMCID: PMC11109903 DOI: 10.1136/bmj-2023-076885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To evaluate the association between antibiotic use during pregnancy or early infancy and the risk of neurodevelopmental disorders in children. DESIGN Nationwide population based cohort study and sibling analysis. SETTING Korea's National Health Insurance Service mother-child linked database, 2008-21. PARTICIPANTS All children live born between 2009 and 2020, followed up until 2021 to compare those with and without antibiotic exposure during pregnancy or early infancy (first six months of life). MAIN OUTCOMES MEASURES Autism spectrum disorder, intellectual disorder, language disorder, and epilepsy in children. After 1:1 propensity score matching based on many potential confounders, hazard ratios with 95% confidence interval were estimated using Cox proportional hazard models. A sibling analysis additionally accounted for unmeasured familial factors. RESULTS After propensity score matching, 1 961 744 children were identified for the pregnancy analysis and 1 609 774 children were identified for the early infancy analysis. Although antibiotic exposure during pregnancy was associated with increased risks of all four neurodevelopmental disorders in the overall cohort, these estimates were attenuated towards the null in the sibling analyses (hazard ratio for autism spectrum disorder 1.06, 95% confidence interval 1.01 to 1.12; intellectual disorder 1.00, 0.93 to 1.07; language disorder 1.05, 1.02 to 1.09; and epilepsy 1.03, 0.98 to 1.08). Likewise, no association was observed between antibiotic exposure during early infancy and autism spectrum disorder (hazard ratio 1.00, 0.96 to 1.03), intellectual disorder (1.07, 0.98 to 1.15), and language disorder (1.04, 1.00 to 1.08) in the sibling analyses; however, a small increased risk of epilepsy was observed (1.13, 1.09 to 1.18). The results generally remained consistent across several subgroup and sensitivity analyses, except for slightly elevated risks observed among children who used antibiotics during very early life and those who used antibiotics for more than 15 days. CONCLUSIONS In this large cohort study, antibiotic exposure during pregnancy or early infancy was not associated with an increased risk of autism spectrum disorder, intellectual disorder, or language disorder in children. However, elevated risks were observed in several subgroups such as children using antibiotics during very early life and those with long term antibiotic use, which warrants attention and further investigation. Moreover, antibiotic use during infancy was modestly associated with epilepsy, even after control for indications and familial factors. When prescribing antibiotics to pregnant women and infants, clinicians should carefully balance the benefits of use against potential risks.
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Affiliation(s)
- Ahhyung Choi
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, USA
| | - Hyesung Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Han Eol Jeong
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Seo-Young Lee
- Department of Neurology, College of Medicine, Kangwon National University, Chuncheon, South Korea
- Interdisciplinary Graduate Program in Medical Bigdata Convergence, Kangwon National University, Chuncheon, South Korea
| | - Jun Soo Kwon
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, South Korea
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, South Korea
- Institute of Human Behavioral Medicine, Seoul National University Medical Research Center, Seoul, South Korea
| | - Jung Yeol Han
- Korean Mothersafe Counselling Center, Department of Obstetrics and Gynecology, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Young June Choe
- Department of Pediatrics, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
- Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
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24
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Kearns RJ, Kyzayeva A, Halliday LOE, Lawlor DA, Shaw M, Nelson SM. Epidural analgesia during labour and severe maternal morbidity: population based study. BMJ 2024; 385:e077190. [PMID: 38777357 PMCID: PMC11109902 DOI: 10.1136/bmj-2023-077190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES To determine the effect of labour epidural on severe maternal morbidity (SMM) and to explore whether this effect might be greater in women with a medical indication for epidural analgesia during labour, or with preterm labour. DESIGN Population based study. SETTING All NHS hospitals in Scotland. PARTICIPANTS 567 216 women in labour at 24+0 to 42+6 weeks' gestation between 1 January 2007 and 31 December 2019, delivering vaginally or through unplanned caesarean section. MAIN OUTCOME MEASURES The primary outcome was SMM, defined as the presence of ≥1 of 21 conditions used by the US Centers for Disease Control and Prevention (CDC) as criteria for SMM, or a critical care admission, with either occurring at any point from date of delivery to 42 days post partum (described as SMM). Secondary outcomes included a composite of ≥1 of the 21 CDC conditions and critical care admission (SMM plus critical care admission), and respiratory morbidity. RESULTS Of the 567 216 women, 125 024 (22.0%) had epidural analgesia during labour. SMM occurred in 2412 women (4.3 per 1000 births, 95% confidence interval (CI) 4.1 to 4.4). Epidural analgesia was associated with a reduction in SMM (adjusted relative risk 0.65, 95% CI 0.50 to 0.85), SMM plus critical care admission (0.46, 0.29 to 0.73), and respiratory morbidity (0.42, 0.16 to 1.15), although the last of these was underpowered and had wide confidence intervals. Greater risk reductions in SMM were detected among women with a medical indication for epidural analgesia (0.50, 0.34 to 0.72) compared with those with no such indication (0.67, 0.43 to 1.03; P<0.001 for difference). More marked reductions in SMM were seen in women delivering preterm (0.53, 0.37 to 0.76) compared with those delivering at term or post term (1.09, 0.98 to 1.21; P<0.001 for difference). The observed reduced risk of SMM with epidural analgesia was increasingly noticeable as gestational age at birth decreased in the whole cohort, and in women with a medical indication for epidural analgesia. CONCLUSION Epidural analgesia during labour was associated with a 35% reduction in SMM, and showed a more pronounced effect in women with medical indications for epidural analgesia and with preterm births. Expanding access to epidural analgesia for all women during labour, and particularly for those at greatest risk, could improve maternal health.
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Affiliation(s)
- Rachel J Kearns
- Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Aizhan Kyzayeva
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Lucy O E Halliday
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Deborah A Lawlor
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Science, University of Bristol, Bristol, UK
| | - Martin Shaw
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
- Department of Medical Physics and Bioengineering, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Scott M Nelson
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
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25
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Clapp MA, James KE, Mccoy TH, Perlis RH, Kaimal AJ. The Application of a Standard Risk Threshold for the Stratification of Maternal Morbidity among Population Subgroups. Am J Perinatol 2024; 41:e1235-e1240. [PMID: 36608698 DOI: 10.1055/a-2008-8598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The aim of this study was to determine if a universally applied risk score threshold for severe maternal morbidity (SMM) resulted in different performance characteristics among subgroups of the population. STUDY DESIGN This is a retrospective cohort study of deliveries that occurred between July 1, 2016, and June 30, 2020, in a single health system. We examined the performance of a validated comorbidity score to stratify SMM risk in our cohort. We considered the risk score that was associated with the highest decile of predicted risk as a "screen positive" for morbidity. We then used this same threshold to calculate the sensitivity and positive predictive value (PPV) of this "highest risk" designation among subgroups of the overall cohort based on the following characteristics: age, race/ethnicity, parity, gestational age, and planned mode of delivery. RESULTS In the overall cohort of 53,982 women, the C-statistic was 0.755 (95% confidence interval [CI], 0.741-0.769) and calibration plot demonstrated that the risk score was well calibrated. The model performed less well in the following groups: non-White or Hispanic (C-statistic, 0.734; 95% CI, 0.712-0.755), nulliparas (C-statistic, 0.735; 95% CI, 0.716-0.754), term deliveries (C-statistic, 0.712; 95% CI, 0.694-0.729), and planned vaginal delivery (C-statistic, 0.728; 95% CI, 0.709-0.747). There were differences in the PPVs by gestational age (7.8% term and 29.7% preterm) and by planned mode of delivery (8.7% vaginal and 17.7% cesarean delivery). Sensitivities were lower in women who were <35 years (36.6%), non-White or Hispanic (40.7%), nulliparous (38.9%), and those having a planned vaginal delivery (40.9%) than their counterparts. CONCLUSION The performance of a risk score for SMM can vary by population subgroups when using standard thresholds derived from the overall cohort. If applied without such considerations, such thresholds may be less likely to identify certain subgroups of the population that may be at increased risk of SMM. KEY POINTS · Predictive risk models are helpful at condensing complex information into an interpretable output.. · Model performance may vary among different population subgroups.. · Prediction models should be examined for their potential to exacerbate underlying disparities..
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Affiliation(s)
- Mark A Clapp
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kaitlyn E James
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas H Mccoy
- Center for Quantitative Health, Massachusetts General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Roy H Perlis
- Center for Quantitative Health, Massachusetts General Hospital, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Anjali J Kaimal
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
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Feng AH, Stanhope KK, Jamieson DJ, Boulet SL. Postpartum Psychiatric Outcomes following Severe Maternal Morbidity in an Urban Safety-Net Hospital. Am J Perinatol 2024; 41:e809-e817. [PMID: 36130668 DOI: 10.1055/a-1948-3093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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..
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Affiliation(s)
- Alayna H Feng
- Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
| | - Kaitlyn K Stanhope
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
| | - Denise J Jamieson
- Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
| | - Sheree L Boulet
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
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Peahl AF, Pennathur H, Zacharek N, Naccarato A, Heberle-Rose H, Goodman J, Smith RD, Cohn A, Stout MJ, Fendrick AM, Moniz MH. Retrospective Use of Patients' Characteristics to Assess Variation in Prenatal Care Utilization. Am J Perinatol 2024; 41:e2529-e2538. [PMID: 37579763 DOI: 10.1055/s-0043-1771505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
OBJECTIVE We used patients' medical and psychosocial risk factors to explore prenatal care utilization and health outcomes to inform prenatal care tailoring. STUDY DESIGN This retrospective cohort study assessed patients who gave birth at an academic institution from January 1 to December 31, 2018, using electronic health record (EHR) data. Patients were categorized into four phenotypes based on medical/psychosocial risk factors available in the EHR: Completely low risk; High psychosocial risk only; High medical risk only; and Completely high risk. We examined patient characteristics, visit utilization, nonvisit utilization (e.g., phone calls), and outcomes (e.g., preterm birth, preeclampsia) across groups. RESULTS Of 4,681 patients, the majority were age 18 to 35 (3,697, 79.0%), White (3,326, 70.9%), multiparous (3,263, 69.7%), and Completely high risk (2,752, 58.8%). More Black and Hispanic patients had psychosocial risk factors than White patients. Patients with psychosocial risk factors had fewer prenatal visits (10, interquartile range [IQR]: 8-12) than those without (11, IQR: 9-12). Patients with psychosocial risk factors experienced less time in prenatal care, more phone calls, and fewer EHR messages across the same medical risk group. Rates of preterm birth and gestational hypertension were incrementally higher with additional medical/psychosocial risk factors. CONCLUSION Data readily available in the EHR can assess the compounding influence of medical/psychosocial risk factor on patients' care utilization and outcomes. KEY POINTS · Medical and psychosocial needs in pregnancy can inform patient phenotypes and are associated with prenatal care use and outcomes.. · Patient phenotypes are associated with prenatal care use and outcomes.. · Patients with high psychosocial risk spent less time in prenatal care and had more phone calls in pregnancy.. · Tailored prenatal care models may proactively address differences in patient's needs..
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Affiliation(s)
- Alex F Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
- Department of Obstetrics and Gynecology, University of Michigan Program on Women's Healthcare Effectiveness Research, Ann Arbor, Michigan
| | - Harini Pennathur
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Nicholas Zacharek
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Amanda Naccarato
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Hannah Heberle-Rose
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Jordan Goodman
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Roger D Smith
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Amy Cohn
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
- University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Molly J Stout
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - A Mark Fendrick
- University of Michigan School of Public Health, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Michelle H Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
- Department of Obstetrics and Gynecology, University of Michigan Program on Women's Healthcare Effectiveness Research, Ann Arbor, Michigan
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Gulersen M, Alvarez A, Suarez F, Kouba I, Rochelson B, Combs A, Nimaroff M, Blitz MJ. Risk of Severe Maternal Morbidity Associated with Maternal Comorbidity Burden and Social Vulnerability. Am J Perinatol 2024; 41:e3333-e3340. [PMID: 38057088 DOI: 10.1055/a-2223-3602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVE We evaluated the associations of the obstetric comorbidity index (OB-CMI) and social vulnerability index (SVI) with severe maternal morbidity (SMM). STUDY DESIGN Multicenter retrospective cohort study of all patients who delivered (gestational age > 20 weeks) within a university health system from January 1, 2019, to December 31, 2021. OB-CMI scores were assigned to patients using clinical documentation and diagnosis codes. SVI scores, released by the Centers for Disease Control and Prevention (CDC), were assigned to patients based on census tracts. The primary outcome was SMM, based on the 21 CDC indicators. Mixed-effects logistic regression was used to model the odds of SMM as a function of OB-CMI and SVI while adjusting for maternal race and ethnicity, insurance type, preferred language, and parity. RESULTS In total, 73,518 deliveries were analyzed. The prevalence of SMM was 4% (n = 2,923). An association between OB-CMI and SMM was observed (p < 0.001), where OB-CMI score categories of 1, 2, 3, and ≥4 were associated with higher odds of SMM compared with an OB-CMI score category of 0. In the adjusted model, there was evidence of an interaction between OB-CMI and maternal race and ethnicity (p = 0.01). After adjusting for potential confounders, including SVI, non-Hispanic Black patients had the highest odds of SMM among patients with an OB-CMI score category of 1 and ≥4 compared with non-Hispanic White patients with an OB-CMI score of 0 (adjusted odds ratio [aOR] = 2.76, 95% confidence interval [CI]: 2.08-3.66 and aOR = 10.07, 95% CI: 8.42-12.03, respectively). The association between SVI and SMM was not significant on adjusted analysis. CONCLUSION OB-CMI was significantly associated with SMM, with higher score categories associated with higher odds of SMM. A significant interaction between OB-CMI and maternal race and ethnicity was identified, revealing racial disparities in the odds of SMM within each higher OB-CMI score category. SVI was not associated with SMM after adjusting for confounders. KEY POINTS · OB-CMI was significantly associated with SMM.. · Racial disparities were seen within each OB-CMI score group.. · SVI was not associated with SMM on adjusted analysis..
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Affiliation(s)
- Moti Gulersen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alejandro Alvarez
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New Hyde Park, New York
| | - Fernando Suarez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Insaf Kouba
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, South Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Bay Shore, New York
| | - Burton Rochelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Adriann Combs
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Michael Nimaroff
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Matthew J Blitz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, South Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Bay Shore, New York
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Varvoutis MS, Wein LE, Sugrue R, Darwin KC, Vaught AJ, Meng ML, Hughes BL, Grotegut CA, Federspiel JJ. Pregnancy-Associated Extracorporeal Membrane Oxygenation in the United States. Am J Perinatol 2024; 41:e1248-e1256. [PMID: 36608702 PMCID: PMC10425568 DOI: 10.1055/a-2008-8462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The use of extracorporeal membrane oxygenation (ECMO) therapy has increased in the adult population. Studies from the H1N1 influenza pandemic suggest that ECMO deployment in pregnancy is associated with favorable outcomes. With increasing numbers of pregnant women affected by COVID-19 (coronavirus disease 2019) and potentially requiring this life-saving therapy, we sought to compare comorbidities, costs, and outcomes between pregnancy- and nonpregnancy-associated ECMO therapy among reproductive-aged female patients. STUDY DESIGN We used the 2013 to 2019 National Readmissions Database. Diagnosis and procedural coding were used to identify ECMO deployment, potential indications, comorbid conditions, and pregnancy outcomes. The primary outcome was in-hospital mortality during the patient's initial ECMO stay. Secondary outcomes included length of stay and hospital charges/costs, occurrence of thromboembolic or bleeding complications during ECMO hospitalization, and mortality and readmissions up to 330 days following ECMO stay. Univariate and multivariate regression models were used to model the associations between pregnancy status and outcomes. RESULTS The sample included 324 pregnancy-associated hospitalizations and 3,805 nonpregnancy-associated hospitalizations, corresponding to national estimates of 665 and 7,653 over the study period, respectively. Pregnancy-associated ECMO had lower incidence of in-hospital death (adjusted odds ratio [aOR]: 0.56, 95% confidence interval [CI]: 0.41-0.75) and bleeding complications (aOR: 0.67, 95% CI: 0.49-0.93). Length of stay was significantly shorter (adjusted rate ratio (aRR): 0.86, 95% CI: 0.77-0.96) and total hospital costs were less (aRR: 0.83, 95% CI: 0.75-0.93). Differences in the incidence of thromboembolic events (aOR: 1.04, 95% CI: 0.78-1.38) were not statistically significant. CONCLUSION Pregnancy-associated ECMO therapy had lower incidence of in-hospital death, bleeding complications, total inpatient cost, and length of stay when compared with nonpregnancy-associated ECMO therapy without increased thromboembolic complications. Pregnancy-associated ECMO therapy should be offered to eligible patients. KEY POINTS · Pregnancy-related ECMO use was compared with nonpregnant use.. · Outcomes were equal or favored pregnancy-related deployment.. · These data may be useful when considering ECMO use in pregnancy..
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Affiliation(s)
- Megan S. Varvoutis
- Department of Obstetrics and Gynecology, West Virginia University, Morgantown, WV, USA
| | - Lauren E. Wein
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Ronan Sugrue
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Kristin C. Darwin
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Arthur J. Vaught
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Brenna L. Hughes
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Chad A. Grotegut
- Department of Obstetrics and Gynecology, Wake Forest University, Winston-Salem, NC, USA
| | - Jerome J. Federspiel
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Halliday L, Shaw M, Kyzayeva A, Lawlor DA, Nelson SM, Kearns RJ. Socio-economic disadvantage and utilisation of labour epidural analgesia in Scotland: a population-based study †. Anaesthesia 2024; 79:473-485. [PMID: 38359539 DOI: 10.1111/anae.16236] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 02/17/2024]
Abstract
Socio-economic deprivation is associated with adverse maternal and childhood outcomes. Epidural analgesia, the gold standard for labour analgesia, may improve maternal well-being. We assessed the association of socio-economic status with utilisation of epidural analgesia and whether this differed when epidural analgesia was advisable for maternal safety. This was a population-based study of NHS data for all women in labour in Scotland between 1 January 2007 and 23 October 2020, excluding elective caesarean sections. Socio-economic status deciles were defined using the Scottish Index of Multiple Deprivation. Medical conditions for which epidural analgesia is advisable for maternal safety (medical indications) and contraindications were defined according to national guidelines. Of 593,230 patients in labour, 131,521 (22.2%) received epidural analgesia. Those from the most deprived areas were 16% less likely to receive epidural analgesia than the most affluent (relative risk 0.84 [95%CI 0.82-0.85]), with the inter-decile mean change in receiving epidural analgesia estimated at -2% ([95%CI -2.2% to -1.7%]). Among the 21,219 deliveries with a documented medical indication for epidural analgesia, the socio-economic gradient persisted (relative risk 0.79 [95%CI 0.75-0.84], inter-decile mean change in receiving epidural analgesia -2.5% [95%CI -3.1% to -2.0%]). Women in the most deprived areas with a medical indication for epidural analgesia were still less likely (absolute risk 0.23 [95%CI 0.22-0.24]) to receive epidural analgesia than women from the most advantaged decile without a medical indication (absolute risk 0.25 [95%CI 0.24-0.25]). Socio-economic deprivation is associated with lower utilisation of epidural analgesia, even when epidural analgesia is advisable for maternal safety. Ensuring equitable access to an intervention that alleviates pain and potentially reduces adverse outcomes is crucial.
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Affiliation(s)
- L Halliday
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - M Shaw
- Department of Medical Physics, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - A Kyzayeva
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - D A Lawlor
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol, UK
| | - S M Nelson
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - R J Kearns
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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Ing C, Silber JH, Lackraj D, Olfson M, Miles C, Reiter JG, Jain S, Chihuri S, Guo L, Gyamfi-Bannerman C, Wall M, Li G. Behavioural disorders after prenatal exposure to anaesthesia for maternal surgery. Br J Anaesth 2024; 132:899-910. [PMID: 38423824 DOI: 10.1016/j.bja.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/27/2023] [Accepted: 01/16/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The association between prenatal exposure to general anaesthesia for maternal surgery during pregnancy and subsequent risk of disruptive or internalising behavioural disorder diagnosis in the child has not been well-defined. METHODS A nationwide sample of pregnant women linked to their liveborn infants was evaluated using the Medicaid Analytic eXtract (MAX, 1999-2013). Multivariate matching was used to match each child prenatally exposed to general anaesthesia owing to maternal appendectomy or cholecystectomy during pregnancy with five unexposed children. The primary outcome was diagnosis of a disruptive or internalising behavioural disorder in children. Secondary outcomes included diagnoses for a range of other neuropsychiatric disorders. RESULTS We matched 34,271 prenatally exposed children with 171,355 unexposed children in the database. Prenatally exposed children were more likely than unexposed children to receive a diagnosis of a disruptive or internalising behavioural disorder (hazard ratio [HR], 1.31; 95% confidence interval [CI], 1.23-1.40). For secondary outcomes, increased hazards of disruptive (HR, 1.32; 95% CI, 1.24-1.41) and internalising (HR, 1.36; 95% CI, 1.20-1.53) behavioural disorders were identified, and also increased hazards of attention-deficit/hyperactivity disorder (HR, 1.32; 95% CI, 1.22-1.43), behavioural disorders (HR, 1.28; 95% CI, 1.14-1.42), developmental speech or language disorders (HR, 1.16; 95% CI, 1.05-1.28), and autism (HR, 1.31; 95% CI, 1.05-1.64). CONCLUSIONS Prenatal exposure to general anaesthesia is associated with a 31% increased risk for a subsequent diagnosis of a disruptive or internalising behavioural disorder in children. Caution is advised when making any clinical decisions regarding care of pregnant women, as avoidance of necessary surgery during pregnancy can have detrimental effects on mothers and their children.
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Affiliation(s)
- Caleb Ing
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, New York, NY, USA.
| | - Jeffrey H Silber
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Deven Lackraj
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Mark Olfson
- Department of Epidemiology, Mailman School of Public Health, New York, NY, USA; Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Caleb Miles
- Department of Biostatistics, Mailman School of Public Health, New York, NY, USA
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Siddharth Jain
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stanford Chihuri
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Ling Guo
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA
| | - Melanie Wall
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Department of Biostatistics, Mailman School of Public Health, New York, NY, USA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, New York, NY, USA
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Pohl N, Bauer M, Pancaro C, Cassidy R, Engoren M. Characteristics and Outcomes of Obstetric Sepsis by Three Sets of Clinical Diagnostic Criteria: A Retrospective Study. Am J Perinatol 2024; 41:e3035-e3044. [PMID: 37793431 DOI: 10.1055/a-2185-3931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
OBJECTIVE Pregnancy-related mortality in the United States is the highest of all developed nations with a reported rate of 17 deaths per 100,000 live births in 2014 to 2017. Sepsis-related mortality is a major component of pregnancy-related mortality. Similar to nonpregnancy-related sepsis, the criteria for pregnancy-related sepsis are evolving. The purposes of this study were to compare three criteria for sepsis (Sepsis-2, Sepsis-3, California Maternal Quality Care Collaborative [CMQCC]) with one another and to determine patient outcomes using those three sets of criteria. STUDY DESIGN Using the electronic medical record, we obtained granular data on all patients at University of Michigan Medical Center from July 10, 2009 to September 4, 2019 with suspected sepsis (blood cultures and administration of antibiotics) during pregnancy until the 42nd postpartum day. Agreement between the three criteria were assessed with kappa and shown by a Venn diagram. Groups were compared using standardized differences and chi square, rank sum, or independent t-tests. RESULTS Of the 228 patients having sepsis by any criteria, 191 (83%) patients met the criteria for Sepsis-2, 131 (57%) for Sepsis-3, and 62 (27%) met criteria according to CMQCC. Agreement between the three criteria ranged from kappa = 0.13 (95% confidence interval [CI]: 0.09, 0.18) to kappa = 0.31 (95% CI: 0.23, 0.39). Patients who met CMQCC criteria tended to have more comorbidities and higher APACHE II (Acute Physiology And Chronic Health Evaluation) scores. Mortality (by 90 days) among the groups was low with 10 (4%) patients dying. Patients meeting criteria for CMQCC sepsis had higher mortality than the non-CMQCC patients with sepsis (10 vs. 2%, standardized difference = 0.31, p = 0.027). CONCLUSION The agreement among Sepsis-2, Sepsis-3, and CMQCC diagnostic criteria is weak. CMQCC criteria identifies patients with sepsis at higher risk of death. KEY POINTS · Agreements (kappa) between the three criteria are poor.. · CMQCC sepsis patients have more comorbidities.. · Endometritis was the most common cause of sepsis.. · CMQCC mortality was 10%; non-CMQCC mortality was 2%..
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Affiliation(s)
- Nicole Pohl
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Melissa Bauer
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Carlo Pancaro
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Ruth Cassidy
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Milo Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
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Difazio RL, Strout TD, Dorste A, Berry JG, Vessey JA. Tools used to measure the impact of comorbidities on surgical outcomes in children with complex chronic conditions: A scoping review. Dev Med Child Neurol 2024. [PMID: 38679854 DOI: 10.1111/dmcn.15943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/13/2024] [Accepted: 03/21/2024] [Indexed: 05/01/2024]
Abstract
AIM To identify and describe assessment tools used to measure the impact of comorbidities on postoperative outcomes in children with complex chronic conditions (CCC). METHOD This was a scoping review using five electronic databases. The search was conducted in March 2022 by a medical librarian. There were no date or language restrictions. Included studies were full-text articles published in peer-reviewed journals that described a tool used to measure the impact of comorbidities in children with CCC to assess postoperative outcomes. A standardized data charting tool was used. RESULTS A total of 2157 articles were retrieved. Five studies reporting on six comorbidity measures met inclusion criteria. All were cohort studies and were secondary analyses of data from an administrative database (n = 4) or a patient registry (n = 1). Sample sizes ranged from 645 to 25 747 participants. One paper described the assessment of reliability. Only one form of validity - predictive validity - was assessed in three papers for five measures. INTERPRETATION Findings from this scoping review revealed a paucity of comorbidity assessment tools validated for use with children with CCC; significant conceptual and measurement challenges exist in the current scientific literature.
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Affiliation(s)
- Rachel L Difazio
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Tania D Strout
- Department of Emergency Medicine, Maine Medical Center, Portland, ME, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Anna Dorste
- Medical Library, Boston Children's Hospital, Boston, MA, USA
| | - Jay G Berry
- Harvard Medical School, Harvard University, Boston, MA, USA
- Complex Care, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Judith A Vessey
- Medical, Surgical, and Behavioral Health Nursing Programs, Boston Children's Hospital, Boston, MA, USA
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Jarlenski M, Cole E, McClure C, Sanders S, Smalls M, Méndez DD. Implementation and early effects of medicaid policy interventions to promote racial equity in pregnancy and early childhood outcomes in Pennsylvania: protocol for a mixed methods study. BMC Health Serv Res 2024; 24:498. [PMID: 38649983 PMCID: PMC11036682 DOI: 10.1186/s12913-024-10982-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/10/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND There are large racial inequities in pregnancy and early childhood health within state Medicaid programs in the United States. To date, few Medicaid policy interventions have explicitly focused on improving health in Black populations. Pennsylvania Medicaid has adopted two policy interventions to incentivize racial health equity in managed care (equity payment program) and obstetric service delivery (equity focused obstetric bundle). Our research team will conduct a mixed-methods study to investigate the implementation and early effects of these two policy interventions on pregnancy and infant health equity. METHODS Qualitative interviews will be conducted with Medicaid managed care administrators and obstetric and pediatric providers, and focus groups will be conducted among Medicaid beneficiaries. Quantitative data on healthcare utilization, healthcare quality, and health outcomes among pregnant and parenting people will be extracted from administrative Medicaid healthcare data. Primary outcomes are stakeholder perspectives on policy intervention implementation (qualitative) and timely prenatal care, pregnancy and birth outcomes, and well-child visits (quantitative). Template analysis methods will be applied to qualitative data. Quantitative analyses will use an interrupted time series design to examine changes over time in outcomes among Black people, relative to people of other races, before and after adoption of the Pennsylvania Medicaid equity-focused policy interventions. DISCUSSION Findings from this study are expected to advance knowledge about how Medicaid programs can best implement policy interventions to promote racial equity in pregnancy and early childhood health.
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Affiliation(s)
- Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, 130 DeSoto St, A619, 15261, Pittsburgh, PA, USA.
| | - Evan Cole
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, 130 DeSoto St, A619, 15261, Pittsburgh, PA, USA
| | - Christine McClure
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, 130 DeSoto St, A619, 15261, Pittsburgh, PA, USA
| | - Sarah Sanders
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Marquita Smalls
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Dara D Méndez
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
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Beck DC, Tabb K, Tilea A, Vance AJ, Hall S, Schroeder A, Zivin K. Diagnosed behavioral health conditions during the perinatal period among a commercially insured population by race/ethnicity, 2008-2020. Front Public Health 2024; 12:1345442. [PMID: 38515598 PMCID: PMC10954808 DOI: 10.3389/fpubh.2024.1345442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/19/2024] [Indexed: 03/23/2024] Open
Abstract
Objective We sought to examine trends in diagnosed behavioral health (BH) conditions [mental health (MH) disorders or substance use disorders (SUD)] among pregnant and postpartum individuals between 2008-2020. We then explored the relationship between BH conditions and race/ethnicity, acknowledging race/ethnicity as a social construct that influences health disparities. Methods This study included delivering individuals, aged 15-44 years, and continuously enrolled in a single commercial health insurance plan for 1 year before and 1 year following delivery between 2008-2020. We used BH conditions as our outcome based on relevant ICD 9/10 codes documented during pregnancy or the postpartum year. Results In adjusted analyses, white individuals experienced the highest rates of BH conditions, followed by Black, Hispanic, and Asian individuals, respectively. Asian individuals had the largest increase in BH rates, increasing 292%. White individuals had the smallest increase of 192%. The trend remained unchanged even after adjusting for age and Bateman comorbidity score, the trend remained unchanged. Conclusions The prevalence of diagnosed BH conditions among individuals in the perinatal and postpartum periods increased over time. As national efforts continue to work toward improving perinatal BH, solutions must incorporate the needs of diverse populations to avert preventable morbidity and mortality.
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Affiliation(s)
- Dana C. Beck
- School of Nursing, University of California, Los Angeles, Los Angeles, CA, United States
| | - Karen Tabb
- School of Social Work, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Anca Tilea
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| | - Ashlee J. Vance
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, MI, United States
| | - Stephanie Hall
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Amy Schroeder
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Kara Zivin
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
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Lopez A, Wen T, Patel N, Booker WA, D'Alton ME, Friedman AM. Trends in and outcomes of delivery hospitalizations with lupus and antiphospholipid syndrome. Int J Gynaecol Obstet 2024; 164:1001-1009. [PMID: 37789684 DOI: 10.1002/ijgo.15171] [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: 02/03/2023] [Revised: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVE To assess trends and outcomes associated with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) during US delivery hospitalizations. STUDY DESIGN The National Inpatient Sample from 2000 to 2019 was used for this repeated cross-sectional analysis. We identified delivery hospitalizations with and without SLE. Temporal trends in SLE during delivery hospitalizations were determined using joinpoint regression. Adjusted logistic regression models accounting for demographic, clinical, and hospital factors were used to determine adjusted odds ratios (aORs) for adverse outcomes based on the presence or absence of SLE. RESULTS Of an estimated 76 698 775 delivery hospitalizations identified in the NIS, 79386 (0.10%) had an associated diagnosis of SLE. Over the study period, SLE increased from 6.7 to 14.6 cases per 10 000 delivery hospitalizations (average annual percent change 4.5%, 95% CI 4.0-5.1). Deliveries with SLE had greater odds of non-transfusion severe morbidity (aOR 2.21, 95% CI 2.00, 2.44) and underwent a larger absolute increase in morbidity risk over the study period. SLE was associated with a range of other adverse outcomes including preterm delivery, eclampsia, cesarean delivery, and blood transfusion. CONCLUSION The proportion of deliveries to women with SLE has increased over time in the US, and SLE and APS are associated with a broad range of adverse outcomes.
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Affiliation(s)
- Ashley Lopez
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | - Timothy Wen
- Department of Obstetrics and Gynecology, University of California-San Francisco, San Francisco, California, USA
| | - Naomi Patel
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
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Nielsen TC, Nassar N, Shand AW, Jones HF, Han VX, Patel S, Guastella AJ, Dale RC, Lain SJ. Association between cumulative maternal exposures related to inflammation and child attention-deficit/hyperactivity disorder: A cohort study. Paediatr Perinat Epidemiol 2024; 38:241-250. [PMID: 38009577 DOI: 10.1111/ppe.13022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Preclinical studies suggest synergistic effects of maternal inflammatory exposures on offspring neurodevelopment, but human studies have been limited. OBJECTIVES To examine the cumulative association and potential interactions between seven maternal exposures related to inflammation and child attention-deficit/hyperactivity disorder (ADHD). METHODS We conducted a population-based cohort study of children born from July 2001 to December 2011 in New South Wales, Australia, and followed up until December 2014. Seven maternal exposures were identified from birth data and hospital admissions during pregnancy: autoimmune disease, asthma, hospitalization for infection, mood or anxiety disorder, smoking, hypertension, and diabetes. Child ADHD was identified from stimulant prescription records. Multivariable Cox regression assessed the association between individual and cumulative exposures and ADHD and potential interaction between exposures, controlling for potential confounders. RESULTS The cohort included 908,770 children, one-third (281,724) with one or more maternal exposures. ADHD was identified in 16,297 children (incidence 3.5 per 1000 person-years) with median age of 7 (interquartile range 2) years at first treatment. Each exposure was independently associated with ADHD, and risk increased with additional exposures: one exposure (hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.54, 1.65), two exposures (HR 2.25, 95% CI 2.13, 2.37), and three or more exposures (HR 3.28, 95% CI 2.95, 3.64). Positive interaction was found between smoking and infection. The largest effect size was found for cumulative exposure of asthma, infection, mood or anxiety disorder, and smoking (HR 6.12, 95% CI 3.47, 10.70). CONCLUSIONS This study identifies cumulative effects of multiple maternal exposures related to inflammation on ADHD, most potentially preventable or modifiable. Future studies should incorporate biomarkers of maternal inflammation and consider gene-environment interactions.
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Affiliation(s)
- Timothy C Nielsen
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Natasha Nassar
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Antonia W Shand
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Hannah F Jones
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Starship Children's Hospital, Centre for Brain Research, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Velda X Han
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore City, Singapore
| | - Shrujna Patel
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Adam J Guastella
- Children's Hospital Westmead Clinical School, Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Russell C Dale
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Samantha J Lain
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Suarez EA, Bateman BT, Straub L, Hernández-Díaz S, Jones HE, Gray KJ, Connery HS, Davis JM, Lester B, Terplan M, Zhu Y, Vine SM, Mogun H, Huybrechts KF. First Trimester Use of Buprenorphine or Methadone and the Risk of Congenital Malformations. JAMA Intern Med 2024; 184:242-251. [PMID: 38252426 PMCID: PMC10804281 DOI: 10.1001/jamainternmed.2023.6986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/12/2023] [Indexed: 01/23/2024]
Abstract
Importance Use of buprenorphine or methadone to treat opioid use disorder is recommended in pregnancy; however, their teratogenic potential is largely unknown. Objective To compare the risk of congenital malformations following in utero exposure to buprenorphine vs methadone. Design, Setting, and Participants This population-based cohort study used health care utilization data from publicly insured Medicaid beneficiaries in the US from 2000 to 2018. A total of 13 360 pregnancies with enrollment from 90 days prior to pregnancy start through 1 month after delivery and first trimester use of buprenorphine or methadone were included and linked to infants. Data were analyzed from July to December 2022. Exposure A pharmacy dispensing of buprenorphine or a code for administration of methadone in the first trimester. Main Outcomes and Measures Primary outcomes included major malformations overall and malformations previously associated with opioids (any cardiac malformations, ventricular septal defect, secundum atrial septal defect/nonprematurity-related patent foramen ovale, neural tube defects, clubfoot, and oral clefts). Secondary outcomes included other organ system-specific malformations. Risk differences and risk ratios (RRs) were estimated comparing buprenorphine with methadone, adjusting for confounders with propensity score overlap weights. Results The cohort included 9514 pregnancies with first-trimester buprenorphine exposure (mean [SD] maternal age, 28.4 [4.6] years) and 3846 with methadone exposure (mean [SD] maternal age, 28.8 [4.7] years). The risk of malformations overall was 50.9 (95% CI, 46.5-55.3) per 1000 pregnancies for buprenorphine and 60.6 (95% CI, 53.0-68.1) per 1000 pregnancies for methadone. After confounding adjustment, buprenorphine was associated with a lower risk of malformations compared with methadone (RR, 0.82; 95% CI, 0.69-0.97). Risk was lower with buprenorphine for cardiac malformations (RR, 0.63; 95% CI, 0.47-0.85), including both ventricular septal defect (RR, 0.62; 95% CI, 0.39-0.98) and secundum atrial septal defect/nonprematurity-related patent foramen ovale (RR, 0.54; 95% CI, 0.30-0.97), oral clefts (RR, 0.65; 95% CI, 0.35-1.19), and clubfoot (RR, 0.55; 95% CI, 0.32-0.94). Results for neural tube defects were uncertain given low event counts. In secondary analyses, buprenorphine was associated with a decreased risk of central nervous system, urinary, and limb malformations but a greater risk of gastrointestinal malformations compared with methadone. These findings were consistent in sensitivity and bias analyses. Conclusions and Relevance In this cohort study, the risk of most malformations previously associated with opioid exposure was lower in buprenorphine-exposed infants compared with methadone-exposed infants, independent of measured confounders. Malformation risk is one factor that informs the individualized patient decision regarding medications for opioid use disorder in pregnancy.
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Affiliation(s)
- Elizabeth A. Suarez
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Center for Pharmacoepidemiology and Treatment Science, Rutgers Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Loreen Straub
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Hendrée E. Jones
- UNC Horizons Program, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Kathryn J. Gray
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Hilary S. Connery
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Jonathan M. Davis
- Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute, Boston, Massachusetts
| | - Barry Lester
- Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University and Women and Infants Hospital, Providence, Rhode Island
| | | | - Yanmin Zhu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Seanna M. Vine
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Addae-Konadu KL, Wein LE, Federspiel JJ, Hughes BL, Dotters-Katz S. Postpartum Pyelonephritis and Risk of Severe Maternal Morbidity. Am J Perinatol 2024; 41:337-342. [PMID: 34710940 PMCID: PMC9046458 DOI: 10.1055/a-1682-3171] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Pyelonephritis is the most common nonobstetric cause for hospitalization during pregnancy. The maternal and obstetric complications associated with antepartum pyelonephritis are well described. However, it is not clear whether these risks extend into the postpartum period. The primary objective of this study was to describe the morbidity associated with postpartum pyelonephritis, by comparing the morbidity associated with pyelonephritis in the postpartum period to morbidity seen during pregnancy or delivery. STUDY DESIGN A retrospective cohort study was performed using the Nationwide Readmissions Database (NRD), an all-payor sample of discharges from approximately 60% of U.S. hospitalizations. Discharges between October 2015 and December 2018 were included. Maternity-associated hospitalizations, diagnosis of pyelonephritis, comorbid conditions, and incidence of severe maternal morbidity were identified using International Classification of Disease-10th Revision (ICD-10) diagnosis and procedure codes. Bivariate statistics, weighted to account for the complex survey methods in the NRD, were used to evaluate the association between antepartum, delivery, and postpartum hospital stays associated with pyelonephritis and maternal morbidity. Weighted regression models were used to evaluate the association between admission timing and maternal outcomes. RESULTS A total of 32,850 pyelonephritis admissions were identified, corresponding to a national estimate of 61,837 admissions. Of these, 1,465 (2.4%) were postpartum, 55,056 (89.0%) were antepartum, and 5,317 (8.6%) involved a delivery stay. Rates of severe maternal morbidity were higher in the postpartum group than the antepartum or delivery hospitalization groups (59.5 vs. 12.9 and 15.8%, respectively, p < 0.001); when compared with antepartum hospitalizations, the adjusted relative risk for composite severe maternal morbidity for postpartum hospitalizations was 4.68 (95% confidence interval [CI]: 4.33, 5.05). Most of this difference was driven by rates of sepsis (53.2 vs. 11.0 vs. 10.9%). CONCLUSION Though relatively uncommon, postpartum hospitalizations for pyelonephritis are associated with higher rates of severe maternal morbidity, driven by differential rates of sepsis, than are antepartum or delivery-associated hospitalizations.
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Affiliation(s)
- Kateena L Addae-Konadu
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Lauren E Wein
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Jerome J Federspiel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Brenna L Hughes
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Sarah Dotters-Katz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
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Hall SV, Zivin K, Piatt GA, Weaver A, Tilea A, Zhang X, Moyer CA. Racial Disparities in Diagnosis of Postpartum Mood and Anxiety Disorders Among Symptomatic Medicaid Enrollees, 2012-2015. Psychiatr Serv 2024; 75:115-123. [PMID: 37752825 DOI: 10.1176/appi.ps.20230094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE This study quantified the prevalence of postpartum mood and anxiety disorder (PMAD) diagnoses among symptomatic Michigan Medicaid enrollees and explored factors associated with receiving a diagnosis. METHODS Data sources comprised Michigan Medicaid administrative claims and Phase 7 Michigan Pregnancy Risk Assessment Monitoring System (MI-PRAMS) survey responses, linked at the individual level. Participants were continuously enrolled in Michigan Medicaid, delivered a live birth (2012-2015), responded to the survey, and screened positive for PMAD symptoms on the adapted two-item Patient Health Questionnaire. Unadjusted and adjusted weighted logistic regression analyses were used to predict the likelihood of having a PMAD diagnosis (for the overall sample and stratified by race). RESULTS The weighted analytic cohort represented 24,353 deliveries across the 4-year study. Only 19.8% of respondents with symptoms of PMAD had a PMAD diagnosis between delivery and 3 months afterward. Black respondents were less likely to have PMAD diagnoses (adjusted odds ratio [AOR]=0.23, 95% CI=0.11-0.49) compared with White respondents. Among White respondents, no covariates were significantly associated with having a diagnosis. However, among Black respondents, more comorbid conditions and more life stressors were statistically significantly associated with having a diagnosis (AOR=3.18, 95% CI=1.27-7.96 and AOR=3.12, 95% CI=1.10-8.88, respectively). CONCLUSIONS Rate of PMAD diagnosis receipt differed by race and was low overall. Black respondents were less likely than White respondents to receive a diagnosis. Patient characteristics influencing diagnosis receipt also differed by race, indicating that strategies to improve detection of these disorders require a tailored approach.
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Affiliation(s)
- Stephanie V Hall
- Department of Psychiatry (Hall, Zivin), Department of Learning Health Sciences (Hall, Piatt, Moyer), Department of Obstetrics and Gynecology (Zivin, Tilea, Zhang), and School of Social Work (Weaver), University of Michigan, Ann Arbor
| | - Kara Zivin
- Department of Psychiatry (Hall, Zivin), Department of Learning Health Sciences (Hall, Piatt, Moyer), Department of Obstetrics and Gynecology (Zivin, Tilea, Zhang), and School of Social Work (Weaver), University of Michigan, Ann Arbor
| | - Gretchen A Piatt
- Department of Psychiatry (Hall, Zivin), Department of Learning Health Sciences (Hall, Piatt, Moyer), Department of Obstetrics and Gynecology (Zivin, Tilea, Zhang), and School of Social Work (Weaver), University of Michigan, Ann Arbor
| | - Addie Weaver
- Department of Psychiatry (Hall, Zivin), Department of Learning Health Sciences (Hall, Piatt, Moyer), Department of Obstetrics and Gynecology (Zivin, Tilea, Zhang), and School of Social Work (Weaver), University of Michigan, Ann Arbor
| | - Anca Tilea
- Department of Psychiatry (Hall, Zivin), Department of Learning Health Sciences (Hall, Piatt, Moyer), Department of Obstetrics and Gynecology (Zivin, Tilea, Zhang), and School of Social Work (Weaver), University of Michigan, Ann Arbor
| | - Xiaosong Zhang
- Department of Psychiatry (Hall, Zivin), Department of Learning Health Sciences (Hall, Piatt, Moyer), Department of Obstetrics and Gynecology (Zivin, Tilea, Zhang), and School of Social Work (Weaver), University of Michigan, Ann Arbor
| | - Cheryl A Moyer
- Department of Psychiatry (Hall, Zivin), Department of Learning Health Sciences (Hall, Piatt, Moyer), Department of Obstetrics and Gynecology (Zivin, Tilea, Zhang), and School of Social Work (Weaver), University of Michigan, Ann Arbor
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Yonekura H, Mazda Y, Noguchi S, Tsunobuchi H, Kawakami K. Anesthesia practice for Cesarean delivery in Japan: a retrospective cohort study. Can J Anaesth 2024; 71:175-186. [PMID: 37957438 DOI: 10.1007/s12630-023-02633-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 11/15/2023] Open
Abstract
PURPOSE General anesthesia for Cesarean delivery affects maternal and neonatal outcomes. We aimed to evaluate temporal trends in anesthesia management for Cesarean deliveries over 16 years and analyze interinstitutional variations in general anesthesia use in Japan. METHODS In this retrospective cohort study, we obtained patient data from the nationwide health insurance claims database containing data for ten million individuals. We included patients who underwent Cesarean delivery between 1 January 2005 and 31 August 2021. The primary outcome was the use of general anesthesia. We evaluated institutional variations in general anesthesia use in medical facilities using two-level hierarchical logistic regression analyses with median odds ratios and intraclass correlation coefficients. RESULTS The cohort included 86,793 patients who underwent 102,617 Cesarean deliveries at 2,496 institutions. General anesthesia was used in 3.7% (95% confidence interval [CI], 3.6 to 3.9) of all Cesarean deliveries. The temporal trend in the use of general anesthesia decreased gradually from 10.8% in 2005 to 2.9% in 2021 (P for trend < 0.001). The adjusted median odds ratio for medical facilities was 6.1 (95% CI, 5.9 to 6.7), and the intraclass correlation coefficient was 0.52 (95% CI, 0.51 to 0.55). CONCLUSION Although the rate of general anesthesia use for Cesarean delivery in Japan decreased gradually from 2005 to 2021, general anesthesia was used in 3.7% of all Cesarean deliveries. The use of general anesthesia varied significantly across institutions, and 52% of the overall variations in general anesthesia practice can be explained by differences between facilities.
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Affiliation(s)
- Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, 3-6-10 Otoubashi, Nakagawa-Ku, Nagoya City, Aichi, 454-8509, Japan.
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.
| | - Yusuke Mazda
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Shohei Noguchi
- Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Hironaka Tsunobuchi
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
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Maharjan S, Goswami S, Rong Y, Kirby T, Smith D, Brett CX, Pittman EL, Bhattacharya K. Risk Factors for Severe Maternal Morbidity Among Women Enrolled in Mississippi Medicaid. JAMA Netw Open 2024; 7:e2350750. [PMID: 38190184 PMCID: PMC10774990 DOI: 10.1001/jamanetworkopen.2023.50750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Importance Mississippi has one of the highest rates of severe maternal morbidity (SMM) in the US, and SMMs have been reported to be more frequent among Medicaid-insured women. A substantial proportion of pregnant women in Mississippi are covered by Medicaid; hence, there is a need to identify potential risk factors for SMM in this population. Objective To examine the associations of health care access and clinical and sociodemographic characteristics with SMM events among Mississippi Medicaid-enrolled women who had a live birth. Design, Setting, and Participants A nested case-control study was conducted using 2018 to 2021 Mississippi Medicaid administrative claims database. The study included Medicaid beneficiaries aged 12 to 55 years who had a live birth and were continuously enrolled throughout their pregnancy period and 12 months after delivery. Individuals in the case group had SMM events and were matched to controls on their delivery date using incidence density sampling. Data analysis was performed from June to September 2022. Exposure Risk factors examined in the study included sociodemographic factors (age and race), health care access (distance from delivery center, social vulnerability index, and level of maternity care), and clinical factors (maternal comorbidity index, first-trimester pregnancy-related visits, and postpartum care). Main Outcomes and Measures The main outcome of the study was an SMM event. Adjusted odds ratio (aORs) and 95% CIs were calculated using conditional logistic regression. Results Among 13 485 Mississippi Medicaid-enrolled women (mean [SD] age, 25.0 [5.6] years; 8601 [63.8%] Black; 4419 [32.8%] White; 465 [3.4%] other race [American Indian, Asian, Hispanic, multiracial, and unknown]) who had a live birth, 410 (3.0%) were in the case group (mean [SD] age, 26.8 [6.4] years; 289 [70.5%] Black; 112 [27.3%] White; 9 [2.2%] other race) and 820 were in the matched control group (mean [SD] age, 24.9 [5.7] years; 518 [63.2%] Black; 282 [34.4%] White; 20 [2.4%] other race). Black individuals (aOR, 1.44; 95% CI, 1.08-1.93) and those with higher maternal comorbidity index (aOR, 1.27; 95% CI, 1.16-1.40) had higher odds of experiencing SMM compared with White individuals and those with lower maternal comorbidity index, respectively. Likewise, an increase of 100 miles (160 km) in distance between beneficiaries' residence to the delivery center was associated with higher odds of experiencing SMM (aOR, 1.14; 95% CI, 1.07-1.20). Conclusions and Relevance The study findings hold substantial implications for identifying high-risk individuals within Medicaid programs and call for the development of targeted multicomponent, multilevel interventions for improving maternal health outcomes in this highly vulnerable population.
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Affiliation(s)
- Shishir Maharjan
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University
- Center for Pharmaceutical Marketing and Management, University of Mississippi School of Pharmacy, University
| | - Swarnali Goswami
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University
- Center for Pharmaceutical Marketing and Management, University of Mississippi School of Pharmacy, University
- Now with Complete Health Economics and Outcomes Solutions, LLC, Chalfont, Pennsylvania
| | - Yiran Rong
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University
- Center for Pharmaceutical Marketing and Management, University of Mississippi School of Pharmacy, University
- Now with MedTech Epidemiology and Real-World Data Sciences, Johnson and Johnson, New Brunswick, New Jersey
| | | | | | | | - Eric L. Pittman
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University
- Center for Pharmaceutical Marketing and Management, University of Mississippi School of Pharmacy, University
| | - Kaustuv Bhattacharya
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University
- Center for Pharmaceutical Marketing and Management, University of Mississippi School of Pharmacy, University
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Levaillant M, Garabédian C, Legendre G, Soula J, Hamel JF, Vallet B, Lamer A. In France, the organization of perinatal care has a direct influence on the outcome of the mother and the newborn: Contribution from a French nationwide study. Int J Gynaecol Obstet 2024; 164:210-218. [PMID: 37485702 DOI: 10.1002/ijgo.15004] [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: 03/03/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE To investigate maternal and neonatal outcomes after a delivery in France in 2019, according to hospital characteristics and the impact of distance and time of travel on mother and newborn. METHODS All parturients above 18 years of age who delivered in 2019 and were identified in the French health insurance database were included, with their newborns, in this retrospective cohort study. Main outcome measures were Severe Maternal Morbidity score and the Neonatal Adverse Outcome Indicator (NAOI). RESULTS Among the 733 052 pregnancies included, 10 829 presented a severe maternal morbidity (1.48%) and 77 237 had a neonatal adverse outcome (10.4%). Factors associated with an unfavorable maternal or neonatal outcome were Obstetric Comorbidity Index, primiparity, and cesarean or instrumental delivery. Prematurity was associated with less severe maternal morbidity but more neonatal adverse outcomes. Time of travel above 30 min was associated with a higher NAOI rate. CONCLUSIONS Results suggest the efficiency of regionalization of perinatal care in France, although a difference in both outcomes persists according to unit volume, suggesting the need for a further step in concentrating perinatal care. Perinatal care organization should focus on mapping the territory with high-level, high-volume maternity throughout the territory; this suggests closing down high-volume units and improving low-volume ones to maintain coherent mapping.
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Affiliation(s)
- Mathieu Levaillant
- Université Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
- Methodology and Biostatistics Department, Angers University Hospital, University of Angers, Angers, France
| | | | - Guillaume Legendre
- Faculté de Santé, Département de Médecine, CHU d'Angers, Angers, France
- Service de Gynécologie-Obstétrique, CHU d'Angers, Angers, France
| | - Julien Soula
- Université Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Jean-François Hamel
- Methodology and Biostatistics Department, Angers University Hospital, University of Angers, Angers, France
- UMR_S1085, University of Angers, CHU Angers, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), Angers, France
| | - Benoît Vallet
- Université Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Antoine Lamer
- Université Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
- F2RSM Psy - Fédération Régionale de Recherche en Psychiatrie et Santé Mentale Hauts-de-France, Lille, France
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Palladino R, Balsamo F, Mercogliano M, Sorrentino M, Monzani M, Egidio R, Piscitelli A, Borrelli A, Bifulco G, Triassi M. Impact of SARS-CoV-2 Positivity on Delivery Outcomes for Pregnant Women between 2020 and 2021: A Single-Center Population-Based Analysis. J Clin Med 2023; 12:7709. [PMID: 38137777 PMCID: PMC10744135 DOI: 10.3390/jcm12247709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Despite the existing body of evidence, there is still limited knowledge about the impact of SARS-CoV-2 positivity on delivery outcomes. We aimed to assess the impact of SARS-CoV-2 infection in women who gave birth at the University Hospital "Federico II" of Naples, Italy, between 2020 and 2021. We conducted a retrospective single-center population-based observational study to assess the differences in the caesarean section and preterm labor rates and the length of stay between women who tested positive for SARS-CoV-2 and those who tested negative at the time of labor. We further stratified the analyses considering the time period, dividing them into three-month intervals, and changes in SARS-CoV-2 as the most prevalent variant. The study included 5236 women with 353 positive cases. After vaccination availability, only 4% had undergone a complete vaccination cycle. The Obstetric Comorbidity Index was higher than 0 in 41% of the sample. When compared with negative women, positive ones had 80% increased odds of caesarean section, and it was confirmed by adjusting for the SARS-CoV-2 variant. No significant differences were found in preterm birth risks. The length of stay was 11% higher in positive cases but was not significant after adjusting for the SARS-CoV-2 variant. When considering only positive women in the seventh study period (July-September 2021), they had a 61% decrease in the odds of receiving a caesarean section compared to the fourth (October-December 2020). Guidelines should be implemented to improve the safety and efficiency of the delivery process, considering the transition of SARS-CoV-2 from pandemic to endemic. Furthermore, these guidelines should aim to improve the management of airborne infections in pregnant women.
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Affiliation(s)
- Raffaele Palladino
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
- Department of Primary Care and Public Health, Imperial College School of Public Health, London SW7 2BX, UK
- Interdepartmental Research Center in Healthcare Management and Innovation in Healthcare (CIRMIS), University “Federico II” of Naples, 80131 Naples, Italy
| | - Federica Balsamo
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
| | - Michelangelo Mercogliano
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
| | - Michele Sorrentino
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
| | - Marco Monzani
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
| | - Rosanna Egidio
- Clinical Directorate, Academic Hospital “Federico II” of Naples, 80131 Naples, Italy
| | - Antonella Piscitelli
- Azienda Ospedaliera di Rilievo Nazionale (AORN) Dei Colli, Vincenzo Monaldi Hospital, 80122 Naples, Italy
| | - Anna Borrelli
- Clinical Directorate, Academic Hospital “Federico II” of Naples, 80131 Naples, Italy
| | - Giuseppe Bifulco
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
| | - Maria Triassi
- Department of Public Health, University “Federico II” of Naples, 80131 Naples, Italy (M.M.); (M.S.); (M.M.); (G.B.)
- Interdepartmental Research Center in Healthcare Management and Innovation in Healthcare (CIRMIS), University “Federico II” of Naples, 80131 Naples, Italy
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Craig AM, Campbell A, Snow SC, Spates TN, Goldstein SA, Denoble AE, Meng ML, Schroder JN, Flores KP, Agarwal R, Ward CC, Federspiel JJ. Maternal and Pregnancy Outcomes Following Heart Transplantation in the United States. JACC. HEART FAILURE 2023; 11:1666-1674. [PMID: 37804312 PMCID: PMC10841668 DOI: 10.1016/j.jchf.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/25/2023] [Accepted: 08/03/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Improved survival following heart transplantation (HT) has led to more recipients contemplating pregnancy, but data on outcomes are limited. OBJECTIVES The authors used a national data set to investigate and describe outcomes of pregnancies and deliveries in the United States in HT recipients. METHODS Diagnosis and procedure codes from the 2010-2020 Nationwide Readmissions Database identified delivery hospitalizations, history of HT, comorbid conditions, and outcomes. The authors compared rates of severe maternal morbidity (SMM), nontransfusion SMM, cardiovascular SMM (cSMM), and preterm birth from delivery hospitalization between HT recipients and no-HT recipients. The authors evaluated readmission to 330 days postpartum. Logistic and proportional hazard regressions were performed, adjusting for age, socioeconomic and facility characteristics, and clinical comorbidities. RESULTS Among 19,399,521 deliveries, 105 were HT recipients. Compared with no-HT, HT recipients were at higher risk for all SMM (24.8% vs 1.7%), nontransfusion SMM (20.8% vs 0.7%), cSMM (7.3% vs 0.12%), and preterm birth (43.3% vs 8.2%), all P < 0.001. In adjusted analyses, HT recipients had 16-fold greater odds of SMM, 28-fold greater odds of nontransfusion SMM, 38-fold greater odds of cSMM, and 7-fold greater odds of preterm birth. HT recipients had higher morbidity rates during delivery hospitalization and higher readmission rates within 1 year following delivery (26.9% vs 3.8%; adjusted HR: 6.03 [95% CI: 3.73-9.75]). CONCLUSIONS Delivery with history of HT is associated with significantly increased rates of SMM, preterm birth, and hospital readmission. These results provide data regarding pregnancy outcomes for use when counseling patients with HT history who are considering pregnancy or who are pregnant.
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Affiliation(s)
- Amanda M Craig
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina.
| | - Alexa Campbell
- Duke University School of Medicine, Durham, North Carolina
| | - Sarah C Snow
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Toi N Spates
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Sarah A Goldstein
- Division of Cardiology, Department of Medicine, Yale University, New Haven, Connecticut
| | - Anna E Denoble
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut
| | - Marie-Louise Meng
- Division of Women's Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Karen P Flores
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Richa Agarwal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Cary C Ward
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jerome J Federspiel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
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Du R, Ali MM, Sung YS, Pandit AA, Payakachat N, Ounpraseuth ST, Magann EF, Eswaran H. Maternal comorbidity index and severe maternal morbidity among medicaid covered pregnant women in a US Southern rural state. J Matern Fetal Neonatal Med 2023; 36:2167073. [PMID: 36683016 DOI: 10.1080/14767058.2023.2167073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The rates of SMM have been steadily increasing in Arkansas, a southern rural state, which has the 5th highest maternal death rate among the US states. The aims of the study were to test the functionality of the Bateman index in association to SMM, in clustering the risks of pregnancies to SMM, and to study the predictability of SMM using the Bateman index. STUDY DESIGN From the ANGELS database, 72,183 pregnancies covered by Medicaid in Arkansas between 2013 and 2016 were included in this study. The expanded CDC ICD-9/ICD-10 criteria were used to identify SMM. The Bateman comorbidity index was applied in quantifying the comorbidity burden for a pregnancy. Multivariable logistic regressions, KMeans method, and five widely used predictive models were applied respectively for each of the study aims. RESULTS SMM prevalence remained persistently high among Arkansas women covered by Medicaid (195 per 10,000 deliveries) during the study period. Using the Bateman comorbidity index score, the study population was divided into four groups, with a monotonically increasing odds of SMM from a lower score group to a higher score group. The association between the index score and the occurrence of SMM is confirmed with statistical significance: relative to Bateman score falling in 0-1, adjusted Odds Ratios and 95% CIs are: 2.1 (1.78, 2.46) for score in 2-5; 5.08 (3.81, 6.79) for score in 6-9; and 8.53 (4.57, 15.92) for score ≥10. Noticeably, more than one-third of SMM cases were detected from the studied pregnancies that did not have any of the comorbid conditions identified. In the prediction analyses, we observed minimal predictability of SMM using the comorbidity index: the calculated c-statistics ranged between 62% and 67%; the Precision-Recall AUC values are <7% for internal validation and <9% for external validation procedures. CONCLUSIONS The comorbidity index can be used in quantifying the risk of SMM and can help cluster the study population into risk tiers of SMM, especially in rural states where there are disproportionately higher rates of SMM; however, the predictive value of the comorbidity index for SMM is inappreciable.
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Affiliation(s)
- Ruofei Du
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mir M Ali
- Institute for Digital Health & Innovation, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Yi-Shan Sung
- Institute for Digital Health & Innovation, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ambrish A Pandit
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nalin Payakachat
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Songthip T Ounpraseuth
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Everett F Magann
- Department of Obstetrics & Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hari Eswaran
- Institute for Digital Health & Innovation, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Declercq ER, Cabral HJ, Liu CL, Amutah-Onukagha N, Meadows A, Cui X, Diop H. Prior Hospitalization, Severe Maternal Morbidity, and Pregnancy-Associated Deaths in Massachusetts From 2002 to 2019. Obstet Gynecol 2023; 142:1423-1430. [PMID: 37797329 PMCID: PMC10843823 DOI: 10.1097/aog.0000000000005398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 07/28/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To examine demographic and clinical precursors to pregnancy-associated deaths overall and when pregnancy-related deaths are excluded. METHODS We conducted a retrospective cohort study based on a Massachusetts population-based data system linking data from live birth and fetal death certificates to corresponding delivery hospital discharge records and a birthing individual's nonbirth hospital contacts and associated death records. Exposures included maternal demographics, severe maternal morbidity (without transfusion), hospitalizations in the 3 years before pregnancy, comorbidities during pregnancy, and opioid use. In cases of postpartum deaths, hospitalization between delivery and death was examined. The primary outcome measure was pregnancy-associated death , defined as death during pregnancy or up to 1 year postpartum. RESULTS There were 1,291,626 deliveries between 2002 and 2019, of which 384 were linked to pregnancy-associated deaths. Pregnancy-associated but not pregnancy-related deaths (per 100,000 deliveries) were highest for birthing people with opioid use before pregnancy (498.3), severe maternal morbidity (387.3), a comorbidity (106.3), or a prior hospitalization (88.9). In multivariable analysis, the adjusted risk ratios associated with severe maternal morbidity (9.37, 95% CI, 6.14-14.31) and opioid use (6.49, 95%, CI, 3.71-11.35) were highest. Individuals with pregnancy-associated deaths were also more likely to have been hospitalized before or during pregnancy (2.30, 95% CI, 1.62-3.26). Among postpartum deaths, more than two-thirds (69.9%) of birthing people had a hospital contact after delivery and before their death. CONCLUSION Severe maternal morbidity and opioid use disorder were precursors to pregnancy-associated deaths. Individuals with pregnancy-associated but not pregnancy-related deaths experienced a history of hospital contacts during and after pregnancy before death.
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Affiliation(s)
- Eugene R Declercq
- Boston University School of Public Health, the Department of Public Health and Community Medicine, Tufts University School of Medicine, and the Massachusetts Department of Public Health, Boston, and Evalogic Services, Inc., Newton, Massachusetts; and the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, San Diego, California
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White RS, Tangel VE, Lui B, Jiang SY, Pryor KO, Abramovitz SE. Racial and Ethnic Disparities in Delivery In-Hospital Mortality or Maternal End-Organ Injury: A Multistate Analysis, 2007-2020. J Womens Health (Larchmt) 2023; 32:1292-1307. [PMID: 37819719 DOI: 10.1089/jwh.2023.0245] [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] [Indexed: 10/13/2023] Open
Abstract
Background: In the United States, Black maternal mortality is 2-4 × higher than that of White maternal mortality, with differences also present in severe maternal morbidity and other measures. However, limited research has comprehensively studied multilevel social determinants of health, and their confounding and effect modification on obstetrical outcomes. Materials and Methods: We performed a retrospective multistate analysis of adult inpatient delivery hospitalizations (Florida, Kentucky, Maryland, New Jersey, New York, North Carolina, and Washington) between 2007 and 2020. Multilevel multivariable models were used to test the confounder-adjusted association for race/ethnicity and the binary outcomes (1) in-hospital mortality or maternal end-organ injury and (2) in-hospital mortality only. Stratified analyses were performed to test effect modification. Results: The confounder-adjusted odds ratio showed that Black (1.33, 95% confidence interval [CI]: 1.30-1.36) and Hispanic (1.14, 95% CI: 1.11-1.18) as compared with White patients were more likely to die in-hospital or experience maternal end-organ injury. For Black and Hispanic patients, stratified analysis showed that findings remained significant in almost all homogeneous strata. After statistical adjustment, Black as compared with White patients were more likely to die in-hospital (1.49, 95% CI: 1.21-1.82). Conclusions: Black and Hispanic patients had higher adjusted odds of in-patient mortality and end-organ damage after birth than White patients. Race and ethnicity serve as strong predictors of health care inequality, and differences in outcomes may reflect broader structural racism and individual implicit bias. Proposed solutions require immense and multifaceted active efforts to restructure how obstetrical care is provided on the societal, hospital, and patient level.
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Affiliation(s)
- Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Virginia E Tangel
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Briana Lui
- Weill Cornell Medical College, Weill Cornell Medicine, New York, New York, USA
| | - Silis Y Jiang
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Kane O Pryor
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Sharon E Abramovitz
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
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Zivin K, Zhang X, Tilea A, Clark SJ, Hall SV. Relationship between Depression and Anxiety during Pregnancy, Delivery-Related Outcomes, and Healthcare Utilization in Michigan Medicaid, 2012-2021. Healthcare (Basel) 2023; 11:2921. [PMID: 37998413 PMCID: PMC10671817 DOI: 10.3390/healthcare11222921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023] Open
Abstract
To evaluate associations between depression and/or anxiety disorders during pregnancy (DAP), delivery-related outcomes, and healthcare utilization among individuals with Michigan Medicaid-funded deliveries. We conducted a retrospective delivery-level analysis comparing delivery-related outcomes and healthcare utilization among individuals with and without DAP between January 2012 and September 2021. We used generalized estimating equation models assessing cesarean and preterm delivery; 30-day readmission after delivery; severe maternal morbidity within 42 days of delivery; and ambulatory, inpatient, emergency department or observation (ED), psychotherapy, or substance use disorders (SUD) visits during pregnancy. We adjusted models for age, race/ethnicity, urbanicity, federal poverty level, and obstetric comorbidities. Among 170,002 Michigan Medicaid enrollees with 218,890 deliveries, 29,665 (13.6%) had diagnoses of DAP. Compared to those without DAP, individuals with DAP were more often White, rural dwelling, had lower income, and had more comorbidities. In adjusted models, deliveries with DAP had higher odds of cesarean and preterm delivery OR = 1.02, 95% CI: [1.00, 1.05] and OR = 1.15, 95% CI: [1.11, 1.19] respectively), readmission within 30 days postpartum (OR = 1.14, 95% CI: [1.07, 1.22]), SMM within 42 days (OR = 1.27, 95% CI: [1.18, 1.38]), and utilization compared to those without DAP diagnoses (ambulatory: OR = 7.75, 95% CI: [6.75, 8.88], inpatient: OR = 1.13, 95% CI: [1.11, 1.15], ED: OR = 1.86, 95% CI: [1.80, 1.92], psychotherapy: OR = 172.8, 95% CI: [160.10, 186.58], and SUD: OR = 5.6, 95% CI: [5.37, 5.85]). Among delivering individuals in Michigan Medicaid, DAP had significant associations with adverse delivery-related outcomes and greater healthcare use. Early detection and intervention to address mental illness during pregnancy may help mitigate burdens of these complex yet treatable disorders.
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Affiliation(s)
- Kara Zivin
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI 48109, USA
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Xiaosong Zhang
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Anca Tilea
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Sarah J. Clark
- Ambulatory Care Program, Department of Pediatrics, Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Stephanie V. Hall
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI 48109, USA
- Department of Learning Health Sciences, Michigan Medicine, Ann Arbor, MI 48109, USA
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Chaturvedi R, Lui B, Tangel VE, Abramovitz SE, Pryor KO, Lim KG, White RS. United States rural residence is associated with increased acute maternal end-organ injury or mortality after birth: a retrospective multi-state analysis, 2007-2018. Int J Obstet Anesth 2023; 56:103916. [PMID: 37625988 DOI: 10.1016/j.ijoa.2023.103916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 06/22/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Geographic-based healthcare determinants and choice of anesthesia have been shown to be associated with maternal morbidity and mortality. We explored whether differences in maternal outcomes based on maternal residence, and anesthesia type for cesarean and vaginal birth, exist. METHODS This study was a retrospective multi-state analysis; patient residence was the predictor variable of interest and a composite binary measure of maternal end-organ injury or inpatient mortality was the primary outcome. Our secondary outcomes included a binary measure of anesthesia type for cesarean birth (general vs. neuraxial [NA]) and NA analgesia for vaginal birth (no NA vs. NA). Our predictor variable of interest was patient residency (reference category central metropolitan areas of >1 million population), fringe large metropolitan county, medium metropolitan, small metropolitan, micropolitan, and non-metropolitan or micropolitan county. RESULTS Women residing in micropolitan (OR 1.17; 95% CI 1.09 to 1.27) and non-metropolitan or micropolitan counties (OR 1.14; 95% CI 1.04 to 1.24) had the highest adjusted increased odds of adverse maternal outcomes. Those residing in suburban, medium, and small metropolitan areas underwent general anesthesia less often during cesarean births than those residing in urban areas. Patients residing in micropolitan rural (OR 2.07; 95% CI 2.02 to 2.12) and non-metropolitan or micropolitan (2.25; 95% CI 2.16 to 2.34) counties underwent vaginal births without NA analgesia more than twice as often as those residing in urban areas. CONCLUSIONS Rural-urban disparities in maternal end-organ damage and mortality exist and anesthesia choice may play an important role in these disparate outcomes.
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Affiliation(s)
- R Chaturvedi
- New York Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - B Lui
- Weill Cornell Medical College, Weill Cornell Medicine, New York, NY, USA
| | - V E Tangel
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - S E Abramovitz
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - K O Pryor
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - K G Lim
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - R S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
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