The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity

Describing Adverse Pregnancy Events and Pregnancy-Associated Death Among Veterans

Background: Veterans who use VA pregnancy benefits may be at high risk for adverse pregnancy outcomes; however, little is known about rates of adverse pregnancy events or pregnancy-associated death among Veterans. Methods: We conducted a retrospective cohort study using VA national administrative data for Veterans ages 18-45 with at least one pregnancy outcome between October 2009 and September 2016 and a VA primary care visit within one year prior to pregnancy. We identified adverse events during pregnancy and up to 42 days after pregnancy and all-cause mortality within one year of pregnancy and compared prevalence of adverse events by Veteran race/ethnicity using adjusted logistic regression. Results: Pregnancies among Black Veterans had 69% higher odds of any adverse event than those among White Veterans (aOR = 1.69, 95% CI: 1.43, 2.00). All-cause mortality during pregnancy or within one year of pregnancy was recorded for 18 pregnancies, resulting in an estimated overall pregnancy-associated mortality rate of 76 deaths per 100,000 live births. Conclusions: We identified high overall rates of adverse pregnancy events and pregnancy-associated death among Veterans using VA benefits. As in non-VA populations, there were stark racial disparities in adverse pregnancy events among Veterans.

Study protocol: a mixed-methods study of the implementation of doula care to address racial health equity in six state Medicaid programs

BACKGROUND

Racial inequities in severe maternal morbidity (SMM) and mortality constitute a public health crisis in the United States. Doula care, defined as care from birth workers who provide culturally appropriate, non-clinical support during pregnancy and postpartum, has been proposed as an intervention to help disrupt obstetric racism as a driver of adverse pregnancy outcomes in Black and other birthing persons of colour. Many state Medicaid programs are implementing doula programs to address the continued increase in SMM and mortality. Medicaid programs are poised to play a major role in addressing the needs of these populations with the goal of closing the racial gaps in SMM and mortality. This study will investigate the most effective ways that Medicaid programs can implement doula care to improve racial health equity.

METHODS

We describe the protocol for a mixed-methods study to understand how variation in implementation of doula programs in Medicaid may affect racial equity in pregnancy and postpartum health. Primary study outcomes include SMM, person-reported measures of respectful obstetric care, and receipt of evidence-based care for chronic conditions that are the primary causes of postpartum mortality (cardiovascular, mental health, and substance use conditions). Our research team includes doulas, university-based investigators, and Medicaid participants from six sites (Kentucky, Maryland, Michigan, Pennsylvania, South Carolina and Virginia) in the Medicaid Outcomes Distributed Research Network (MODRN). Study data will include policy analysis of doula program implementation, longitudinal data from a cohort of doulas, cross-sectional data from Medicaid beneficiaries, and Medicaid healthcare administrative data. Qualitative analysis will examine doula and beneficiary experiences with healthcare systems and Medicaid policies. Quantitative analyses (stratified by race groups) will use matching techniques to estimate the impact of using doula care on postpartum health outcomes, and will use time-series analyses to estimate the average treatment effect of doula programs on population postpartum health outcomes.

DISCUSSION

Findings will facilitate learning opportunities among Medicaid programs, doulas and Medicaid beneficiaries. Ultimately, we seek to understand the implementation and integration of doula care programs into Medicaid and how these processes may affect racial health equity. Study registration The study is registered with the Open Science Foundation ( https://doi.org/10.17605/OSF.IO/NXZUF ).

Predictors and a scoring model for maternal near-miss and maternal death in Southern Thailand: a case-control study

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.

How Much is too Much? High Utilization of Prenatal Care and Its Impact on Primary Cesarean Birth Among Women in the United States

INTRODUCTION

Nationally, cesarean birth is one of the most performed surgical procedures, yet cesarean births have been linked to an increased risk of delivery complications. Prenatal care (PNC) and education are possible strategies to reduce the number of cesarean births. However, there is scant research assessing the impact of these strategies on safely reducing primary cesarean births. This study evaluates the association between the adequacy of PNC utilization and primary cesarean birth.

METHODS

The analysis used 2018 birth certificate data, and the sample included nulliparous women with no reported pregnancy or delivery complications (N = 729,140). Logistic regression was used to model the association between the adequacy of PNC utilization and delivery method, as well as identify other factors associated with the delivery method.

RESULTS

Among women with a primary cesarean birth, 36.2% had received adequate plus PNC. After adjustment, there was no significant association between women receiving inadequate, intermediate, or adequate PNC and primary cesarean birth. However, women who received adequate plus PNC had an increased odds of having a primary cesarean birth compared to women with no PNC (OR, 1.23; 95% CI, 1.18-1.28).

DISCUSSION

Findings from this study highlight the need to further understand the role of PNC and its potential impact on the delivery method. Within the patient-provider relationship, healthcare providers have the unique opportunity to provide education and inform patients of the risks and benefits of all delivery options. Thus, there is an increased opportunity to safely reduce primary cesarean births.

The racial disparity of severe maternal morbidity across weeks of gestation: a cross-sectional analysis of the 2019 National Inpatient Sample

BACKGROUND

Severe maternal morbidity is increasing in the United States. Black women experience the highest rates of severe maternal morbidity and also of preterm births, which are associated with severe maternal morbidity. The racial disparity of severe maternal morbidity across weeks of gestation has not been well-studied.

OBJECTIVE

This study aimed to evaluate differences in severe maternal morbidity between Black and White birthing people by week of gestation. Differences may indicate periods of pregnancy when Black women are particularly vulnerable to severe maternal morbidity and may require additional interventions.

STUDY DESIGN

This was a cross-sectional study using the National Inpatient Sample from 2019. We used International Classification of Diseases codes from Centers for Disease Control and Prevention guidelines to identify severe maternal morbidity from delivery hospitalizations. We examined the rates of severe maternal morbidity in Black vs White women by week of gestation to evaluate periods of pregnancy when Black women experience additional risks of severe maternal morbidity while adjusting for age, region, medical comorbidities, and Medicaid enrollment. Severe maternal morbidity was analyzed while both including and excluding cases for which blood transfusion was the only indicator of severe maternal morbidity.

RESULTS

Overall, Black birthing people had twice the rate of severe maternal morbidity births compared with White birthing people (2.7% vs 1.3%; P<.0001) and were more likely to deliver preterm (14.7% vs 9.4%; P<.0001). The racial disparity of severe maternal morbidity was present throughout all weeks of gestation, with the largest gap observed at extremely and moderately preterm gestations (22-33 weeks). Rates of severe maternal morbidity for Black women peaked at 22 to 33 weeks' gestation and were lowest at term (≥37 weeks). Black women had a greater proportion of severe maternal morbidity cases due to blood transfusion (68.3% vs 64.5%; P<.01) and acute renal failure (11.1% vs 8.5%; P<.001).

CONCLUSION

Black women experience a substantially higher rate of severe maternal morbidity at preterm gestations (22-36 weeks) in addition to higher rates of preterm delivery. Even when accounting for age, medical comorbidities, and social determinants, Black birthing people have higher odds of severe maternal morbidity throughout pregnancy.

The relative impact of labor induction versus improved labor management: Before and after the ARRIVE (a randomized trial of induction vs. expectant management) trial

OBJECTIVE

To evaluate the association of labor induction on cesarean delivery and other maternal and neonatal outcomes in low-risk, full-term patients in community hospitals during a period of concerted effort to safely prevent cesarean delivery.

METHODS

We performed a retrospective cohort study using the California Maternal Data Center comprised linked discharge diagnoses and birth certificate data for all low-risk, nulliparous, term, singleton, vertex (NTSV) individuals between 39 and 41 weeks from three Sacramento Valley community hospitals from 2016 to 2022 (N = 10,821) during a period of state-wide efforts to safely reduce cesarean rates. Logistic regression was used to calculate odds ratios (ORs) and adjusted odds ratios (aORs) after labor induction in two time periods before and after the ARRIVE trial.

RESULTS

During the study period, labor induction increased from 14.7% to 23.1%. Controlling for maternal age, pre-pregnancy BMI, birthweight, maternal race and ethnicity, birthplace, English language, gestational age, Medicaid status, delivery year, and labor induction was associated with an increased aOR of 1.67 (95% CI 1.48-1.89) for cesarean delivery. We found a trend toward increased aOR of chorioamnionitis but no differences in blood transfusion, severe maternal morbidity, unexpected newborn complications, chorioamnionitis, operative vaginal delivery, maternal lacerations, and shoulder dystocia with labor induction. A decrease aOR of cesarean delivery was observed comparing all births in 2019-2021 to 2016-2018.

CONCLUSION

Labor induction was associated with an increased aOR for cesarean delivery both before and after the ARRIVE trial. A decreased aOR for cesarean delivery was observed during the period of statewide efforts to safely reduce cesarean delivery both with and without labor induction.

Comparing labour induction outcomes using misoprostol and dinoprostone in term pregnancies: A retrospective study at Kiambu Level 5 Hospital between 2018 and 2020

BACKGROUND

The Maternal and Perinatal Death Surveillance and Response (MPDSR) was introduced in Kenya in 2016 and implemented at Kiambu Level 5 Hospital (KL5H) three years later in 2019. During a routine MPDSR meeting at KL5H, committee members identified a possible link between the off-label use of 200mcg misoprostol tablets divided eight times to achieve the necessary dose for labour induction (25mcg) and maternal deaths. Following this, an administrative decision was made to switch from misoprostol to dinoprostone for the induction of labour in June of 2019. This study aimed to assess the overall impact of MPDSR as well as the effect of replacing misoprostol with dinoprostone on uterine rupture, maternal and neonatal deaths at KL5H.

METHODS

We conducted a retrospective cohort study of women who gave birth at KL5H between January 2018 and December 2020. We defined the pre-intervention period as January 2018-June 2019, and the intervention period as July 2019-December 2020. We randomly selected the records of 411 mothers, 167 from the pre-intervention period and 208 from the intervention period, all of whom were induced. We used Bayes-Poisson Generalised Linear Models to fit the risk of uterine rupture, maternal and perinatal death. 12 semi-structured key person questionnaires was used to describe staff perspectives regarding the switch from misoprostol to dinoprostone. Inductive and deductive data analysis was done to capture the salient emerging themes.

RESULTS

We reviewed 411 patient records and carried out 12 key informant interviews. Mothers induced with misoprostol (IRR = 3.89; CI = 0.21-71.6) had an increased risk of death while mothers were less likely to die if they were induced with dinoprostone (IRR = 0.23; CI = 0.01-7.12) or had uterine rupture (IRR = 0.56; CI = 0.02-18.2). The risk of dying during childbearing increased during Jul 2019-Dec 2020 (IRR = 5.43, CI = 0.68-43.2) when the MPDSR activities were strengthened. Induction of labour (IRR = 1.01; CI = 0.06-17.1) had no effect on the risk of dying from childbirth in our setting. The qualitative results exposed that maternity unit staff preferred dinoprostone to misoprostol as it was thought to be more effective (fewer failed inductions) and safer, regardless of being more expensive compared to misoprostol.

CONCLUSION

While the period immediately following the implementation of MPDSR at KL5H was associated with an increased risk of death, the switch to dinoprostone for labour induction was associated with a lower risk of maternal and perinatal death. The use of dinoprostone, however, was linked to an increased risk of uterine rupture, possibly attributed to reduced labour monitoring given that staff held the belief that it is inherently safer than misoprostol. Consequently, even though the changeover was warranted, further investigation is needed to determine the reasons behind the rise in maternal mortalities, even though the MPDSR framework appeared to have been put in place to quell such an increase.

Trends and Disparities in Severe Maternal Morbidity Indicator Categories during Childbirth Hospitalization in California from 1997 to 2017

OBJECTIVE

Severe maternal morbidity (SMM) is increasing and characterized by substantial racial and ethnic disparities. Analyzing trends and disparities across time by etiologic or organ system groups instead of an aggregated index may inform specific, actionable pathways to equitable care. We explored trends and racial and ethnic disparities in seven SMM categories at childbirth hospitalization.

STUDY DESIGN

We analyzed California birth cohort data on all live and stillbirths ≥ 20 weeks' gestation from 1997 to 2017 (n = 10,580,096) using the Centers for Disease Control and Prevention's SMM index. Cases were categorized into seven nonmutually exclusive indicator categories (cardiac, renal, respiratory, hemorrhage, sepsis, other obstetric, and other medical SMM). We compared prevalence and trends in SMM indicator categories overall and by racial and ethnic group using logistic and linear regression.

RESULTS

SMM occurred in 1.16% of births and nontransfusion SMM in 0.54%. Hemorrhage SMM occurred most frequently (27 per 10,000 births), followed by other obstetric (11), respiratory (7), and sepsis, cardiac, and renal SMM (5). Hemorrhage, renal, respiratory, and sepsis SMM increased over time for all racial and ethnic groups. The largest disparities were for Black individuals, including over 3-fold increased odds of other medical SMM. Renal and sepsis morbidity had the largest relative increases over time (717 and 544%). Sepsis and hemorrhage SMM had the largest absolute changes over time (17 per 10,000 increase). Disparities increased over time for respiratory SMM among Black, U.S.-born Hispanic, and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals. Disparities decreased over time for sepsis SMM among Black individuals yet remained substantial.

CONCLUSION

Our research further supports the critical need to address SMM and disparities as a significant public health priority in the United States and suggests that examining SMM subgroups may reveal helpful nuance for understanding trends, disparities, and potential needs for intervention.

KEY POINTS

· By SMM subgroup, trends and racial and ethnic disparities varied yet Black individuals consistently had highest rates.. · Hemorrhage, renal, respiratory, and sepsis SMM significantly increased over time.. · Disparities increased for respiratory SMM among Black, U.S.-born Hispanic and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals..

Association of Maternal Body Mass Index and Maternal Morbidity And Mortality

OBJECTIVE

This study aimed to assess the association of maternal body mass index (BMI) with a composite of severe maternal outcomes.

STUDY DESIGN

Secondary analysis of a cohort of deliveries on randomly selected days at 25 hospitals from 2008 to 2011. Data on comorbid conditions, intrapartum events, and postpartum course were collected. The reference group (REF, BMI: 18.5-29.9kg/m2), obese (OB; BMI: 30-39.9kg/m2), morbidly obese (MO; BMI: 40-49.9kg/m2), and super morbidly obese (SMO; BMI ≥ 50kg/m2) women were compared. The composite of severe maternal outcomes was defined as death, intensive care unit (ICU) admission, ventilator use, deep venous thrombosis/pulmonary embolus (DVT/PE), sepsis, hemorrhage, disseminated intravascular coagulation (DIC), unplanned operative procedure, or stroke. Patients in the REF group were matched 1:1 with those in all other obesity groups based on propensity score using the baseline characteristics of age, race/ethnicity, previous cesarean, preexisting diabetes, chronic hypertension, parity, cigarette use, and insurance status. Multivariable Poisson's regression was used to estimate adjusted relative risks (aRRs) and 95% confidence intervals (CIs) for the association between BMI and the composite outcome. Because cesarean delivery may be in the causal pathway between obesity and adverse maternal outcomes, models were then adjusted for mode of delivery to evaluate potential mediation.

RESULTS

A total of 52,162 pregnant patients are included in the analysis. Risk of composite maternal outcomes was increased for SMO compared with REF but not for OB and MO [OB: aRR=1.06, 95% CI: 0.99-1.14; MO: aRR=1.10, 95% CI: 0.97-1.25; SMO: aRR=1.32, 95% CI: 1.02-1.70]. However, in the mediation analysis, cesarean appears to mediate 46% (95% CI: 31-50%) of the risk of severe morbidity for SMO compared with REF.

CONCLUSION

Super morbid obesity is significantly associated with increased serious maternal morbidity and mortality; however, cesarean appears to mediate this association. Obesity and morbid obesity are not associated with maternal morbidity and mortality.

KEY POINTS

· Super morbid obesity is associated with increased morbidity.. · Cesarean appears to mediate the association between super morbid obesity and morbidity.. · Obesity and morbid maternal obesity are not associated with morbidity..

Antihypertensive Medication Use before and during Pregnancy and the Risk of Severe Maternal Morbidity in Individuals with Prepregnancy Hypertension

OBJECTIVE

Our objective is to examine severe maternal morbidity (SMM) and patterns of antihypertensive medication use before and during pregnancy among individuals with chronic hypertension.

STUDY DESIGN

We examined 11,759 pregnancies resulting in a live birth or stillbirth to individuals with chronic hypertension and one or more antihypertensive prescription 6 months before pregnancy (Optum, 2007-17). We examined whether study outcomes were associated with the use of medication as compared to no use during pregnancy. In addition, patterns of medication use based on the Food and Drug Administration guidance and literature were evaluated. Medication use was divided into prepregnancy and during pregnancy use and classified as pregnancy recommended (PR) or not pregnancy recommended (nPR) or no medication use. SMM was defined per the Centers for Disease Control and Prevention definition of 21 indicators. Risk ratios (RR) reflecting the association of SMM with the use of antihypertensive medications were computed using modified Poisson regression with robust standard errors and adjusted for maternal age, education, and birth year.

RESULTS

Overall, 83% of individuals filled an antihypertensive prescription during pregnancy and 6.3% experienced SMM. The majority of individuals with a prescription prior to pregnancy had a prescription for the same medication in pregnancy. Individuals with any versus no medication use in pregnancy had increased adjusted RR (aRR) of SMM (1.18, 95% confidence interval [CI]: 0.96-1.44). Compared to the use of PR medications before and during pregnancy, aRRs were 1.42 (95% CI: 1.18-1.69, 12.4% of sample) for nPR use before and during pregnancy, 1.52 (1.23-1.86; 12.4%) for nPR (before) and PR (during) use, and 2.67 (1.73-4.15) for PR and nPR use. Patterns with no medication use during pregnancy were not statistically significant.

CONCLUSION

Pattern of antihypertensive medication use before and during pregnancy may be associated with an elevated risk of SMM. Further research is required to elucidate whether this association is related to the severity of hypertension, medication effectiveness, or suboptimal quality of care.

KEY POINTS

· Individuals with any medication use compared to no medication use in pregnancy had an increased risk of SMM.. · Specific medication use patterns were associated with an elevated risk of SMM.. · Pattern of antihypertensive medication use before and during pregnancy may be associated with an increased risk of SMM..

Factors Associated with Maternal Morbidity among Black Women in the United States

OBJECTIVE

 Non-Hispanic Black people (NHBP) have a three-fold higher rate of maternal mortality compared to other racial groups. Racial disparities in maternal morbidity are well-described; however, there are substantial differences in cultural, economic, and social determinants of health among racial groups. We thus sought to study the at-risk, non-Hispanic Black population as its own cohort to identify factors most associated with severe maternal morbidity (SMM).

STUDY DESIGN

 This is a population-based retrospective case-control study of all live births in the United States between 2017 and 2019 using birth records obtained from the National Center for Health Statistics. The primary outcome for this study was to determine demographic, social, medical, and obstetric factors associated with maternal morbidity among NHBP who did and did not experience an SMM event. Multivariable logistic regression was used to estimate the adjusted odds ratio between each individual factor and the outcome of SMM among NHBP.

RESULTS

 Of the 1,624,744 NHBP who delivered between 2017 and 2019, 1.1% experienced an SMM event defined as a composite of blood product transfusion, eclamptic seizure, intensive care unit admission, unplanned hysterectomy, and uterine rupture. The rates of these individual SMM events per 10,000 deliveries were 50, 40, 20, 5, and 4 among NHBP, respectively. Among NHBP, factors associated in multivariable regression analysis with SMM in order of strength of association included cesarean delivery, earlier gestational age at delivery, preeclampsia, induction of labor, chronic hypertension, prior preterm birth, lower educational attainment, multifetal gestation, advanced maternal age, pregestational diabetes, and cigarette smoking. The population attributable fraction for cesarean delivery, preterm birth, and pregnancy-induced hypertensive disease for the outcome of SMM were 0.46, 0.23, and 0.07, respectively.

CONCLUSION

 The three factors most associated with SMM among NHBP are potentially avoidable or modifiable by aggressive screening, prevention, and treatment of preeclampsia and preterm birth as well as reducing cesarean rates in this population.

KEY POINTS

· The rate of SMM in NHBP may be modifiable.. · NHBP have a three-fold higher rate of maternal mortality.. · Preeclampsia, preterm birth, and cesarean sections are most associated with maternal morbidity..

Severe Maternal Morbidity among Women in the U. S. Military, 2003-2015

OBJECTIVE

This study aimed to assess trends and correlates of severe maternal morbidity at delivery among active duty women in the U.S. military, all of whom are guaranteed health care and full employment.

STUDY DESIGN

Linked military personnel and medical encounter data from the Department of Defense Birth and Infant Health Research program were used to identify a cohort of delivery hospitalizations among active duty military women from January 2003 through August 2015. Cases of severe maternal morbidity were identified by applying 21- and 20-condition algorithms (with and without blood transfusion) developed by the Centers for Disease Control and Prevention. Rates (per 10,000 delivery hospitalizations) were reported overall and by specific condition. Multivariable Poisson regression models estimated associations with demographic, clinical, and military characteristics.

RESULTS

Overall, 187,063 hospitalizations for live births were included for analyses. The overall 21- and 20-condition severe maternal morbidity rates were 111.7 (n = 2089) and 37.4 (n = 699) per 10,000 delivery hospitalizations, respectively. The 21-condition rate increased by 184% from 2003 to 2015; the 20-condition rate increased by 40%. Compared with non-Hispanic White women, the adjusted 21-condition rate of severe maternal morbidity was higher for Hispanic (adjusted rate ratio [aRR] = 1.28, 95% confidence interval [CI]: 1.13-1.46), non-Hispanic Black (aRR = 1.34, 95% CI: 1.21-1.49), Asian/Pacific Islander (aRR = 1.35, 95% CI: 1.13-1.61), and American Indian/Alaska Native (aRR = 1.39, 95% CI: 1.06-1.82) women. Rates also varied by age, clinical factors, and deployment history.

CONCLUSION

Active duty U.S. military women experienced an increase in severe maternal morbidity from 2003 to 2015 that followed national trends, despite protective factors such as stable employment and universal health care. Similar to other populations, military women of color were at higher risk for severe maternal morbidity relative to non-Hispanic White military women. Continued surveillance and further investigation into maternal health outcomes are critical for identifying areas of improvement in the Military Health System.

KEY POINTS

· Cesarean delivery and multiple birth were the strongest correlates of severe maternal morbidity in this population.. · Racial disparities persisted across indicators of severe maternal morbidity.. · Rates of disseminated intravascular coagulation were higher than those reported nationally..

Home Birth in the United States: An Evidence-Based Ethical Analysis

AbstractThe assumption in current U.S. mainstream medicine is that birthing requires hospitalization. In fact, while the American College of Obstetricians and Gynecologists supports the right of every birthing person to make a medically informed decision about their delivery, they do not recommend home birth owing to data indicating greater neonatal morbidity and mortality. In this article, we examine the evidence surrounding home birth in the United States and its current limitations, as well as the ethical considerations around birth setting.

Black/African American Women's Woes: Women's Perspectives of Black/African American Maternal Mortality in the USA

BACKGROUND

Despite advances in perinatal care in the USA, maternal mortality is on the rise, and maternal death is higher than in any other high-income country. Maternal mortality in the USA is a persistent public health concern. This issue disproportionately affects Black/African American women, with their likelihood of pregnancy-related death being three times more likely compared to White women. This study aimed to explore the resources needed for Black/African American women to address the relatively higher maternal mortality rates recorded for them.

METHODS

An anonymous link with demographic and open-ended questions was sent to US women 18 years and older to participate in the study. A total of 140 participants responded to the survey. We retained a final sample of 118 responses after eliminating responses with missing data. Descriptive statistics are reported for closed-ended items. Open-ended responses were analyzed using content analysis procedures, where we coded and categorized the data into themes.

RESULTS

Six themes were identified from the study data: (1) Diversity, Equity, and Inclusion (DEI) training for health providers focused on racial bias and discrimination, (2) Advocacy, (3) Provider selection, (4) Researching doctors and delivery hospitals to inform women's birthing decision-making, (5) Women's care-seeking behaviors, and (6) Addressing the Social Determinants of Health.

CONCLUSION

Based on the study's findings, we recommend DEI training for healthcare professionals providing direct care to pregnant and postpartum women, advocacy and resource-awareness training for pregnant Black/African American women and their spouses/partners, or a family member, to assist them in their pregnancy and birthing journeys.

Severe maternal morbidity by race and ethnicity before vs. during the COVID-19 pandemic

PURPOSE

To examine the change in racial disparity in severe maternal morbidity (SMM) during the COVID-19 pandemic and the associations between SARS-CoV-2 infection and SMM.

METHODS

This retrospective cohort study used linked databases of all livebirths delivered between 2018 and 2021 in South Carolina (n = 162,576). Exposures were 1) pre-pandemic and pandemic periods (before vs. March 2020 onwards); 2) SARS-CoV-2 infection, severity, and timing of first infection. Log-binomial regression models were used.

RESULTS

SMM rate was higher among pandemic childbirths than pre-pandemic period (p = 0.06). The risk of SMM among Hispanics was doubled from pre-pandemic to pandemic periods (adjusted relative risk (aRR)= 2.50, 95% CI: 1.27, 4.94). During pre-pandemic, compared to White women, Black women (aRR=1.37, 95% CI: 1.14-1.64), while Hispanics had lower risk of SMM (aRR=0.42, 95% CI: 0.24-0.73). During the pandemic, the Black-White difference in the risk of SMM persisted (aRR=1.24, 95% CI: 1.00-1.54) and Hispanic-White difference in SMM risk became insignificant (aRR=0.85, 95% CI: 0.54-1.34). SARS-CoV-2 infection, its severity, and the late diagnosis were associated with 1.78-5.06 times higher risk of SMM.

CONCLUSIONS

During pandemic, Black-White racial disparity in SMM persisted but the relative pre-pandemic advantage in SMM among Hispanic women over White women disappeared during the pandemic.

Adverse maternal outcomes associated with major fetal malformations after singleton live birth

BACKGROUND

Major fetal malformations complicate 2% to 5% of live births. It is unclear what effect fetal malformations have on severe maternal morbidity.

OBJECTIVE

This study aimed to compare maternal outcomes between individuals with a fetus with major or minor fetal malformations and those with a fetus without major or minor fetal malformations.

STUDY DESIGN

This was a secondary analysis of the Consortium on Safe Labor database. Our study was limited to the current analysis of pregnant individuals with a singleton live birth. Major fetal malformations based on the Centers for Disease Control and Prevention's criteria were defined. Fetal malformations that did not meet the criteria for major fetal malformations were categorized as minor fetal malformations. Our primary maternal outcome was severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Missing values were imputed by multiple imputation using the k-nearest neighbor imputation method. Poisson regression with robust error variance was used to obtain adjusted relative risks with 95% confidence intervals, controlling for confounders.

RESULTS

Of 216,881 deliveries, there were 201,860 cases (93.1%) with no congenital malformation, 12,106 cases (5.6%) with minor fetal malformations, and 2845 cases (1.3%) with major fetal malformations. Compared with individuals with no fetal malformation, those with major fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.2%; adjusted relative risk, 1.51; 95% confidence interval, 1.07-2.12), postpartum hemorrhage (3.6% vs 6.9%; adjusted relative risk, 1.76; 95% confidence interval, 1.50-2.06), preeclampsia (5.1% vs 8.3%; adjusted relative risk, 1.48; 95% confidence interval, 1.31-1.67), and cesarean delivery (26.7% vs 42.3%; adjusted relative risk, 1.51; 95% confidence interval, 1.45-1.58). Compared with individuals with no fetal malformation, those with minor fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.4%; adjusted relative risk, 1.73; 95% confidence interval, 1.48-2.02), maternal death (0.01% vs 0.03%; adjusted relative risk, 4.50; 95% confidence interval, 1.18-17.19), postpartum hemorrhage (3.6% vs 6.1%; adjusted relative risk, 1.54; 95% confidence interval, 1.41-1.68), preeclampsia (5.1% vs 8.6%; adjusted relative risk, 1.50; 95% confidence interval, 1.41-1.60), superimposed preeclampsia (1.2% vs 2.4%; adjusted relative risk, 1.25; 95% confidence interval, 1.14-1.38), cesarean delivery (26.7% vs 39.6%; adjusted relative risk, 1.38; 95% confidence interval, 1.35-1.41), chorioamnionitis (3.0% vs 4.7%; adjusted relative risk, 1.41; 95% confidence interval, 1.29-1.53), and postpartum endometritis (0.6% vs 1.0%; adjusted relative risk, 1.58; 95% confidence interval, 1.31-1.90).

CONCLUSION

Major and minor congenital fetal malformations are independent risk factors for severe maternal morbidity and other pregnancy complications.

Role of Maternal Age in Increasing Severe Maternal Morbidity Rates in the United States

OBJECTIVE

To evaluate a commonly proposed explanation for increasing rates of severe maternal morbidity (SMM) in the United States: shifts in the birthing population to older maternal ages, a known risk factor for SMM.

METHODS

We conducted a cross-sectional analysis comparing delivery hospitalizations from two time points (2008-2009 to 2017-2018) using hospital discharge data from the National Inpatient Sample. We used demographic decomposition techniques to evaluate whether increasing rates of SMM and nontransfusion SMM were explained by population-level increases in maternal age or changes in age-specific rates. Analyses were stratified by race and ethnicity.

RESULTS

Rates of SMM and nontransfusion SMM significantly increased in the United States between 2008 and 2018 from 135.6 to 170.5 and 58.8 to 67.9 per 10,000 delivery hospitalizations, respectively, with increases observed for nearly all racial and ethnic groups. Over this same period, the proportion of births to people younger than age 25 years decreased and births to people of advanced maternal age (35 years and older) increased, with the largest increases occurring among people identified as non-Hispanic American Indian/Alaskan Native (9.8-13.0%), non-Hispanic Black (10.7-14.4%), and Hispanic (12.1-17.1%). Decomposition analyses indicated that the changing maternal age distribution had little effect on SMM trends. Rather, increases in SMM and nontransfusion SMM were primarily driven by increases in age-specific SMM rates, including rising rates among younger people. Contributions of maternal age shifts were minimal for all racial and ethnic groups except among non-Hispanic Black people, for which 17-34% of the rise in SMM was due to increasing maternal age.

CONCLUSION

Except among certain racial groups, increases in U.S. population-level SMM rates over the past decade were due to increases in age-specific rates rather than shifts to older maternal age among the birthing population. Increasing SMM rates across the maternal age spectrum could indicate worsening prepregnancy health status of the birthing population.

Disparities by race/ethnicity in unplanned cesarean birth among healthy nulliparas: a secondary analysis of the nuMoM2b dataset

BACKGROUND

Racial disparities exist in maternal morbidity and mortality, with most of these events occurring in healthy pregnant people. A known driver of these outcomes is unplanned cesarean birth. Less understood is to what extent maternal presenting race/ethnicity is associated with unplanned cesarean birth in healthy laboring people, and if there are differences by race/ethnicity in intrapartum decision-making prior to cesarean birth.

METHODS

This secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b) dataset involved nulliparas with no significant health complications at pregnancy onset who had a trial of labor at ≥ 37 weeks with a singleton, non-anomalous fetus in cephalic presentation (N = 5,095). Logistic regression models were used to examine associations between participant-identified presenting race/ethnicity and unplanned cesarean birth. Participant-identified presenting race/ethnicity was used to capture the influence of racism on participant's healthcare experiences.

RESULTS

Unplanned cesarean birth occurred in 19.6% of labors. Rates were significantly higher among Black- (24.1%) and Hispanic- (24.7%) compared to white-presenting participants (17.4%). In adjusted models, white participants had 0.57 (97.5% CI [0.45-0.73], p < 0.001) lower odds of unplanned cesarean birth compared to Black-presenting participants, while Hispanic-presenting had similar odds as Black-presenting people. The primary indication for cesarean birth among Black- and Hispanic- compared to white-presenting people was non-reassuring fetal heart rate in the setting of spontaneous labor onset.

CONCLUSIONS

Among healthy nulliparas with a trial of labor, white-presenting compared to Black or Hispanic-presenting race/ethnicity was associated with decreased odds of unplanned cesarean birth, even after adjustment for pertinent clinical factors. Future research and interventions should consider how healthcare providers' perception of maternal race/ethnicity may bias care decisions, leading to increased use of surgical birth in low-risk laboring people and racial disparities in birth outcomes.

Severe Maternal Morbidity in Georgia, 2009-2020

BACKGROUND

The increasing focus of population surveillance and research on maternal-and not only fetal and infant-health outcomes is long overdue. The United States maternal mortality rate is higher than any other high-income country, and Georgia is among the highest rates in the country. Severe maternal morbidity (SMM) is conceived of as a "near miss" for maternal mortality, is 50 times more common than maternal death, and efforts to systematically monitor SMM rates in populations have increased in recent years. Much of the current population-based research on SMM has occurred in coastal states or large cities, despite substantial geographical variation with higher maternal and infant health burdens in the Southeast and rural regions.

METHODS

This population-based study uses hospital discharge records linked to vital statistics to describe the epidemiology of SMM in Georgia between 2009 and 2020.

RESULTS

Georgia had a higher SMM rate than the United States overall (189.2 vs. 144 per 10,000 deliveries in Georgia in 2014, the most recent year with US estimates). SMM was higher among racially minoritized pregnant persons and those at the extremes of age, of lower socioeconomic status, and with comorbid chronic conditions. SMM rates were 5 to 6 times greater for pregnant people delivering infants <1500 grams or <32 weeks' gestation as compared with those delivering normal weight or term infants. Since 2015, SMM has increased in Georgia.

CONCLUSION

SMM represents a collection of life-threatening emergencies that are unevenly distributed in the population and require increased attention. This descriptive analysis provides initial guidance for programmatic interventions intending to reduce the burden of SMM and, subsequently, maternal mortality in the US South.

Racial Disparities in Severe Maternal Morbidity in an Integrated Health Care System, Southern California, 2008-2017

OBJECTIVE

The study's objectives were to examine rates of severe maternal morbidity (SMM) over a 10-year period and assess racial/ethnic disparities in SMM among insured women in a large, integrated health care system in Southern California.

METHODS

We included Kaiser Permanente Southern California (KPSC) health plan members who gave birth at ≥20 weeks' gestation in a KPSC-owned hospital during 2008-2017. An SMM case was defined as presence of one or more indicators of an SMM event during a birth hospitalization, identified using maternal electronic health records. Crude SMM rates/10,000 births were calculated by year and maternal race/ethnicity. Modified Poisson regression models were used to assess the association between race/ethnicity and SMM adjusted for other maternal demographics, pregnancy characteristics, and preexisting conditions.

RESULTS

We identified 5,915 SMM cases among 335,310 births. Crude SMM rates increased from 94.7 per 10,000 in 2008 to 192.6 in 2015 and 249.5 in 2017. Non-Hispanic Black (adjusted risk ratio [aRR] 1.52; 95% confidence interval [CI] 1.37-1.69), Asian/Pacific Islander (aRR 1.29, 95% CI 1.18-1.41), and Hispanic (aRR 1.18, 95% CI 1.10-1.27) women had greater likelihood of SMM than non-Hispanic White women. After further adjusting for preexisting health conditions, differences in SMM by race/ethnicity remained.

CONCLUSIONS

SMM rates increased during 2008-2017 and women of racial and ethnic minority groups, particularly non-Hispanic Black women, were more likely to experience an SMM event than non-Hispanic White women. Multilevel approaches to understanding structural and social factors that may be associated with racial and ethnic disparities in SMM are needed to develop and test effective interventions to reduce SMM.

Does Delayed Fertility Explain the Rise in Comorbidities Among the Birthing Population?

Background: The increasing prevalence of preexisting health conditions among pregnant people is often attributed to the concurrent rise in maternal age. However, the link between advanced maternal age (AMA) and increases in chronic conditions among the birthing population has not been systematically documented at the population level. Materials and Methods: This retrospective population-based cohort study was based on linked hospitalization discharge and birth certificate data for live birth deliveries in California from 1991 to 2012. Decomposition techniques evaluated whether changes in the prevalence of selected preexisting health conditions during delivery (autoimmune conditions, chronic hypertension, cardiac disease, diabetes, and renal disease) were explained by population-level increases in maternal age. Analyses further adjusted for maternal education, plurality, insurance status, and availability of paternal information on the birth certificate. Results: Between 1991 and 2012, there were more than 11.5 million live birth deliveries in California. AMA (≥35 years) increased nearly 70% over this period. The prevalence of autoimmune conditions, chronic hypertension, diabetes, and renal disease rose among the birthing population, while cardiac disease declined. The prevalence of all conditions was higher for AMA, but changes in maternal age accounted for only 5.3%, 8.4%, 13.9%, and 0.4%, of the increase in autoimmune conditions, chronic hypertension, diabetes, and renal disease, respectively. Conclusion: While AMA was associated with higher rates of preexisting health conditions, it contributed little to the increase in autoimmune conditions, chronic hypertension, and diabetes and nothing to the rise in renal disease during childbirth.

Obstetric Care Consensus #11, Pregnancy at age 35 years or older

Centers for Disease Control and Prevention data from 2020 demonstrate the continued upward trend in the mean age of pregnant individuals in the United States. Observational studies demonstrate that pregnancy in older individuals is associated with increased risks of adverse pregnancy outcomes-for both the pregnant patient and the fetus-that might differ from those found in younger pregnant populations, even in healthy individuals with no other comorbidities. There are several studies that suggest that advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality. This document seeks to provide evidence-based clinical recommendations for minimizing adverse outcomes associated with pregnancy with anticipated delivery at an advanced maternal age. The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals cannot be overstated. However, this document focuses on and addresses the unique differences in pregnancy-related care for women and all those seeking obstetrical care with anticipated delivery at the age of 35 years or older within the framework of routine pregnancy care. This Obstetric Care Consensus document was developed using an a priori protocol in conjunction with the authors listed above.

Extracorporeal Membrane Oxygenation During Pregnancy

In the last 2 decades, the use of venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) during pregnancy and the postpartum period has increased, mirroring the increased utilization in nonpregnant individuals worldwide. VV ECMO provides respiratory support for patients with acute respiratory distress syndrome (ARDS) who fail conventional mechanical ventilation. With the COVID-19 pandemic, the use of VV ECMO has increased dramatically and data during pregnancy and the postpartum period are overall reassuring. In contrast, VA ECMO provides both respiratory and cardiovascular support. Data on the use of VA ECMO during pregnancy are extremely limited.

Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity

Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.

Linked birth cohort files for perinatal health research: California as a model for methodology and implementation

PURPOSE

Rigorous perinatal epidemiologic research depends on population-based parental and neonatal sociodemographic and clinical data. Here we describe the creation of linked birth cohort files, an enriched data source that combines information from vital records with maternal delivery and infant hospital encounter records.

METHODS

Probabilistic linkage techniques were used to link vital records (i.e., birth and fetal death certificates) from the California Department of Public Health with hospital inpatient, ambulatory surgery and emergency department encounter data for mothers and infants from the California Department of Health Care Access and Information.

RESULTS

From 2012 to 2018, 95% of live birth records were successfully linked to maternal and newborn hospital records while 85% of fetal death records were linked to a maternal delivery record. Overall, 93% of postnatal hospital encounters of infants (i.e., <1 year old) were matched to a linked record.

CONCLUSIONS

The linked birth cohort files is a rich resource opening many possibilities for understanding perinatal health outcomes and opportunities for linkage to longitudinal, social determinant, and environmental data. To optimally use this file for research, analysts should evaluate possible shortcomings or biases of the data sources being linked.

The association between severe maternal morbidity and mortality and race/ethnicity with community type in Maryland

BACKGROUND

Severe maternal morbidity and mortality are increasing in the United States with continued healthcare disparities among Non-Hispanic Black women. However, there is sparse data on the disparities of severe maternal morbidity and mortality by race/ethnicity as it relates to community type.

OBJECTIVE

To determine whether residing in rural communities increases the racial/ethnic disparities in severe maternal morbidity and mortality.

DESIGN

This study is a cross-sectional analysis of women admitted for delivery from 2015 to 2020. A total of 204,140 adults who self-identified as women, were admitted for delivery, who resided in Maryland, and were between the ages 15 and 54 were included in our analysis. Community type was defined as either rural or urban.

METHODS

A multivariable logistic regression, which included an interaction term between race/ethnicity and community type, was used to assess the effect of community type on the relationship between race/ethnicity and severe maternal morbidity and mortality. Data were obtained from the Maryland Health Service Cost Review Commission database. The primary outcome was a composite, binary variable of severe maternal morbidity and mortality. Exposures of interest were residence in either rural or urban counties in Maryland and race/ethnicity.

RESULTS

Our study found that after adjusting for confounders, odds of severe maternal morbidity and mortality were 65% higher in Non-Hispanic Black women (odds ratio 1.65, 95% confidence interval: 1.46-1.88, p < 0.001) and 54% higher in Non-Hispanic Asian women (odds ratio 1.54, 95% confidence interval: 1.24-1.90, p < 0.001) compared to Non-Hispanic White women. The interaction term used to determine whether community type modified the relationship between race/ethnicity and severe maternal morbidity and mortality was not statistically significant for any race/ethnicity (Non-Hispanic Black women, p = 0.60; Non-Hispanic Asian women, p = 0.91; Hispanic women, p = 0.15; Other/Unknown race/ethnicity, p = 0.54).

CONCLUSION

Although our study confirmed the known disparities in maternal outcomes by race/ethnicity, we found that residing in rural communities did not increase racial/ethnic disparities.

Investigating the impact of structural racism on black birthing people - associations between racialized economic segregation, incarceration inequality, and severe maternal morbidity

Black birthing people are twice as likely to experience severe maternal morbidity (SMM) as their white counterparts. Structural racism provides a framework for understanding root causes of perinatal health disparities. Our objective was to investigate associations between measures of structural racism and severe maternal morbidity (SMM) among Black birthing people in the US. We linked delivery hospitalizations for Black birthing people in the National Inpatient Sample (2008-2011) with data from the American Community Survey 5-year estimates and the Vera Institute of Justice Incarceration Trends datasets (2008-2011). Structural racism measures included the Index of Concentration at the Extremes for race and income (i.e., racialized economic segregation) and Black-white incarceration inequality, assessed as quintiles by hospital county. Multilevel logistic regression assessed the relationship between these county-level indicators of structural racism and SMM. Black birthing people delivering in quintiles 5 (concentrated deprivation; OR = 1.45, 95% CI = 1.16-1.81) and 3 (OR = 1.27, 95% CI = 1.04-1.56) experienced increased odds of SMM compared to those in quintile 1 (concentrated privilege). After adjusting for individual characteristics, obstetric comorbidities, and hospital characteristics the odds of SMM remained elevated for Black birthing people delivering in quintiles 5 (aOR = 1.32, 95% CI = 1.02-1.71) and 3 (aOR = 1.24, 95% CI = 1.02-1.51). Delivering in the quintile with the highest incarceration inequality (Q5) was not significantly associated with SMM (aOR = 0.95, 95% CI = 0.72-1.25) compared to those delivering in counties with the lowest incarceration inequality (Q1). In this national-level study, racialized economic segregation was associated with SMM among Black birthing people. Our findings highlight the need to promote maternal and perinatal health equity through actionable policies that prioritize investment in communities experiencing deprivation.

Implementing American College of Obstetricians and Gynecologists Outpatient Antepartum Testing Recommendations: Can Your Clinic Handle It?

OBJECTIVE

 This study was conducted to determine the difference in the number of pregnancies that would qualify for outpatient fetal testing between our current academic practice and that of the 2021 American College of Obstetricians and Gynecologists (ACOG) antepartum recommendations.

STUDY DESIGN

 We performed a retrospective study of all pregnancies that delivered and received prenatal care at our institution between January 1, 2019, and May 31, 2021. The timing and amount of outpatient antepartum testing was determined for each patient. Our current antepartum testing guidelines (clinic protocol) were compared with the 2021 ACOG recommendations (ACOG protocol). Statistical analysis was performed with descriptive statistics and z scoring to compare the total amount of antepartum testing utilized with each protocol.

RESULTS

 A total of 1,335 pregnancies were included in the study. With the ACOG protocol, an additional 310 (23.2%) of pregnancies would qualify for antepartum testing (57.8% with ACOG protocol vs. 34.6% with clinic protocol). Most of the increased testing was due to maternal age with additional risk factors, hypertensive disorders, diabetes, prepregnancy body mass index ≥ 35, and complex fetal anomalies or aneuploidies. Overall, the ACOG protocol would require an additional 570 antepartum tests (z-score = 4.04, p = 0.000005) over the study period, which is equivalent to 19 additional tests per month and 5 per week. Only nine stillbirths occurred during this time, of which two would have had antepartum testing with both protocols, one would have only had testing per ACOG, and two would have had testing individualized per ACOG.

CONCLUSION

 More pregnancies would require outpatient antenatal testing with adoption of the ACOG protocol. A 23% increase in testing would equate to five additional antepartum tests per week. Although this study cannot assess the clinical impact of additional testing, minimal scheduling resources are needed to accommodate this increase.

KEY POINTS

· Most pregnancies have risk factors for stillbirth.. · Most pregnancies qualify for fetal testing per ACOG.. · More resources are needed for this increased testing..

Risk factors and pregnancy outcomes vary among Asian American, Native Hawaiian, and Pacific Islander individuals giving birth in California

OBJECTIVE

To compare frequencies of risk factors and pregnancy outcomes in ethnic groups versus the combined total of Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations.

METHODS

Using linked birth and fetal death certificate and maternal hospital discharge data (California 2007-2018), we estimated frequencies of 15 clinical and sociodemographic exposures and 11 pregnancy outcomes. Variability across 15 AANHPI groups was compared using a heat map and compared to frequencies for the total group (n = 904,232).

RESULTS

AANHPI groups varied significantly from each other and the combined total regarding indicators of social disadvantage (e.g., range for high school-level educational or less: 6.4% Korean-55.8% Samoan) and sociodemographic factors (e.g., maternal age <20 years: 0.2% Chinese-8.8% Guamanian) that are related to adverse pregnancy outcomes. Perinatal outcomes varied significantly (e.g., severe maternal morbidity: 1.2% Korean-1.9% Filipino). No single group consistently had risk factors or outcome prevalence at the extremes, i.e., no group was consistently better or worse off across examined factors.

CONCLUSIONS

Substantial variability in perinatal risk factors and outcomes exists across AANHPI groups. Aggregation into "AANHPI" is not appropriate for outcome reporting.

A Systematic Review of Severe Maternal Morbidity in High-Income Countries

With declining maternal mortality rates in high-income countries (HICs), severe maternal morbidity (SMM) is becoming an important quality measure of maternal care. However, there is no international consensus on the definition and types of SMM. This study aims to critically analyze published literature on SMM in HICs. The objectives are to compare definitions and criteria used to identify SMM and identify the main causes and risk factors contributing to SMM in HICs. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases were searched for articles published between 2010 and 2022, results were filtered, and 10 studies were critically appraised. Six of the articles discussed SMM identification criteria and proposed definition modifications. Longer hospital stays and admission to the intensive care unit (ICU) were suggested as additional criteria. Disease-based criteria were shown to be superior to organ dysfunction criteria. Seven articles detailed common types of SMM as severe hemorrhage, hypertensive disorders, and preeclampsia/eclampsia. Six articles described SMM risk factors, of which advanced maternal age and cesarean delivery were the most common. This literature review identified disease-based criteria and Canadian study criteria as promising measures of SMM. It also identified several causes and risk factors of SMM common between HICs. These findings can help physicians identify women at risk of SMM. The study is however limited to eight HICs and 10 studies. Further research should aim to investigate how these criteria compare with previous sources of criteria and discern the association of weight and race risk factors with SMM.

Severe Maternal Morbidity in Pregnancies Complicated by Fetal Congenital Heart Disease

Background

Maternal risk factors for fetal congenital heart disease (CHD) may also be associated with delivery complications in the mother.

Objectives

This study aimed to determine the prevalence of and risk factors for severe maternal morbidity (SMM) and maternal hospital transfer in pregnancies complicated by fetal CHD.

Methods

A population-based retrospective cohort study utilizing linked Ohio birth certificates and birth defect data for all live births from 2011 to 2015 was performed. The primary outcome was composite SMM. Secondary outcome was maternal hospital transfer prior to delivery. Pregnancies with isolated fetal CHD were compared to pregnancies with no fetal anomalies and isolated fetal cleft lip/palate (CLP).

Results

A total of 682,929 mothers with live births were included. Of these, 5,844 (0.85%) mothers had fetal CHD, and 963 (0.14%) had fetal CLP. SMM in pregnancies with fetal CHD was higher than that in those with no anomalies (3.6% vs 1.9%, P < 0.001) or CLP (3.6% vs 1.9%, P = 0.006). After adjusting for known risk factors, fetal CHD remained independently associated with SMM when compared to no fetal anomalies (adjusted relative risk [adjRR]: 1.81, 95% CI: 1.58-2.08) and CLP (adjRR: 1.81, 95% CI: 1.12-2.92). Maternal hospital transfer occurred more frequently in fetal CHD cases vs for those without fetal anomalies with an increased adjusted risk (adjRR: 3.65, 95% CI: 3.14-4.25).

Conclusions

Pregnancies with isolated fetal CHD have increased risk of SMM and maternal hospital transfer after adjusting for known risk factors. This may inform delivery planning for mothers with fetal CHD. Understanding the biological mechanisms may provide insight into other adverse perinatal outcomes in this population.

Pregnancy at Age 35 Years or Older: ACOG Obstetric Care Consensus No. 11

SUMMARY

Centers for Disease Control and Prevention data from 2020 demonstrate the continued upward trend in the mean age of pregnant individuals in the United States. Observational studies demonstrate that pregnancy in older individuals is associated with increased risks of adverse pregnancy outcomes-for both the pregnant patient and the fetus-that might differ from those in a younger pregnant population, even in healthy individuals with no other comorbidities. There are several studies that suggest advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality. This document seeks to provide evidence-based clinical recommendations for minimizing adverse outcomes associated with pregnancy with anticipated delivery at an advanced maternal age. The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals cannot be overstated. However, this document focuses on and addresses the unique differences in pregnancy-related care for women and all those seeking obstetric care with anticipated delivery at age 35 years or older within the framework of routine pregnancy care. This Obstetric Care Consensus document was developed using an a priori protocol in conjunction with the authors listed above.

Trends in Severe Maternal Morbidity in the US Across the Transition to ICD-10-CM/PCS From 2012-2019

IMPORTANCE

Surveillance of severe maternal morbidity (SMM) is critical for monitoring maternal health and evaluating clinical quality improvement efforts.

OBJECTIVE

To evaluate national and state trends in SMM rates from 2012 to 2019 and potential disruptions associated with the transition to International Classification of Diseases, 10th Revision, Clinical Modification and Procedure Coding System (ICD-10-CM/PCS) in October 2015.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional analysis examined delivery hospitalizations from 2012 through 2019 in the Healthcare Cost and Utilization Project's National Inpatient Sample and State Inpatient Databases, an all-payer compendium of hospital discharge records from community, nonrehabilitation hospitals. Trends were evaluated using segmented linear binomial regression models that allowed for discontinuities across the ICD-10-CM/PCS transition. Analyses were completed from April 2021 through March 2022.

EXPOSURES

Time, ICD-10-CM/PCS coding system, and state.

MAIN OUTCOMES AND MEASURES

SMM rates, excluding blood transfusion, per 10 000 delivery hospitalizations, overall and by indicator.

RESULTS

From 2012 to 2019, there were 5 964 315 delivery hospitalizations in the national sample representing a weighted total of 29.8 million deliveries with a mean (SD) maternal age of 28.6 (5.9) years. SMM rates increased from 69.5 per 10 000 in 2012 to 79.7 per 10 000 in 2019 (rate difference [RD], 10.2; 95% CI, 5.8 to 14.6) without a significant change across the ICD-10-CM/PCS transition (RD, -3.2; 95% CI, -6.9 to 0.6). Of 20 SMM indicators, rates for 10 indicators significantly increased while 3 significantly decreased; 5 of these changes were associated with ICD-10-CM/PCS transition. Acute kidney failure had the largest increase, from 6.4 to 15.3 per 10 000 delivery hospitalizations (RD, 8.9; 95% CI, 7.5 to 10.3) with no change associated with ICD transition (RD, -0.1; 95% CI, -1.2 to 1.1). Disseminated intravascular coagulation had the largest decrease from 31.3 to 21.2 per 10 000 (RD, 10.2; 95% CI, -12.8 to -7.5), with a significant drop associated with ICD transition (RD, -7.9; 95% CI, -10.2 to -5.6). State SMM rates significantly decreased for 1 state and significantly increased for 21 states from 2012 to 2019 and associations with ICD transition varied.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, overall US SMM rates increased from 2012 to 2019, which was not associated with the ICD-10-CM/PCS transition. However, data for certain indicators and states may not be comparable across coding systems; efforts are needed to understand SMM increases and state variation.

Sexual and/or gender minority disparities in obstetrical and birth outcomes

BACKGROUND

Many sexual and/or gender minority individuals build families through pregnancy and childbirth, but it is unknown whether they experience different clinical outcomes than those who are not sexual and/or gender minority individuals.

OBJECTIVE

To evaluate obstetrical and birth outcomes comparing couples who are likely sexual and/or gender minority patients compared with those who are not likely to be sexual and/or gender minority patients.

STUDY DESIGN

We performed a population-based cohort study of live birth hospitalizations during 2016 to 2019 linked to birth certificates in California. California changed its birth certificate in 2016 to include gender-neutral fields such as "parent giving birth" and "parent not giving birth," with options for each role to specify "mother," "father," or "parent." We classified birthing patients in mother-mother partnerships and those who identified as a father in any partnership as likely sexual and/or gender minority and classified birthing patients in mother-father partnerships as likely not sexual and/or gender minority. We used multivariable modified Poisson regression models to estimate the risk ratios for associations between likely sexual and/or gender minority parental structures and outcomes. The models were adjusted for sociodemographic factors, comorbidities, and multifetal gestation selected by causal diagrams. We replicated the analyses after excluding multifetal gestations.

RESULTS

In the final birthing patient sample, 1,483,119 were mothers with father partners, 2572 were mothers with mother partners, and 498 were fathers with any partner. Compared with birthing patients in mother-father partnerships, birthing patients in mother-mother partnerships experienced significantly higher rates of multifetal gestation (adjusted risk ratio, 3.9; 95% confidence interval, 3.4-4.4), labor induction (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3), postpartum hemorrhage (adjusted risk ratio, 1.4; 95% confidence interval, 1.3-1.6), severe morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.2-1.8), and nontransfusion severe morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.1-1.9). Severe morbidity was identified following the Centers for Disease Control and Prevention "severe maternal morbidity" index. Gestational diabetes mellitus, hypertensive disorders of pregnancy, cesarean delivery, preterm birth (<37 weeks' gestation), low birthweight (<2500 g), and low Apgar score (<7 at 5 minutes) did not significantly differ in the multivariable analyses. No outcomes significantly differed between father birthing patients in any partnership and birthing patients in mother-father partnerships in either crude or multivariable analyses, though the risk of multifetal gestation was nonsignificantly higher (adjusted risk ratio, 1.5; 95% confidence interval, 0.9-2.7). The adjusted risk ratios for the outcomes were similar after restriction to singleton gestations.

CONCLUSION

Birthing mothers with mother partners experienced disparities in several obstetrical and birth outcomes independent of sociodemographic factors, comorbidities, and multifetal gestation. Birthing fathers in any partnership were not at a significantly elevated risk of any adverse obstetrical or birth outcome considered in this study.

Interpregnancy weight change: associations with severe maternal morbidity and neonatal outcomes

BACKGROUND

Prepregnancy body mass index and gestational weight gain have been linked with severe maternal morbidity, suggesting that weight change between pregnancies may also play a role, as it does for neonatal outcomes.

OBJECTIVE

This study assessed the association of changes in prepregnancy body mass index between 2 consecutive singleton pregnancies with the outcomes of severe maternal morbidity, stillbirth, and small- and large-for-gestational-age infants in the subsequent pregnancy.

STUDY DESIGN

This observational study was based on birth records from 1,111,032 consecutive pregnancies linked to hospital discharge records in California (2007-2017). Interpregnancy body mass index change between the beginning of an index pregnancy and the beginning of the subsequent pregnancy was calculated from self-reported weight and height. Severe maternal morbidity was defined based on the Centers for Disease Control and Prevention index, including and excluding transfusion-only cases. We used multivariable log-binomial regression models to estimate adjusted risks, overall and stratified by prepregnancy body mass index at index birth.

RESULTS

Substantial interpregnancy body mass index gain (≥4 kg/m2) was associated with severe maternal morbidity in crude but not adjusted analyses. Substantial interpregnancy body mass index loss (>2 kg/m2) was associated with increased risk of severe maternal morbidity (adjusted relative risk, 1.13; 95% confidence interval (1.07-1.19), and both substantial loss (adjusted relative risk, 1.11 [1.02-1.19]) and gain (≥4 kg/m2; adjusted relative risk, 1.09 [1.02-1.17]) were associated with nontransfusion severe maternal morbidity. Substantial loss (adjusted relative risk, 1.17 [1.05-1.31]) and gain (1.26 [1.14-1.40]) were associated with stillbirth. Body mass index gain was positively associated with large-for-gestational-age infants and inversely associated with small-for-gestational-age infants.

CONCLUSION

Substantial interpregnancy body mass index changes were associated with modestly increased risk of severe maternal morbidity, stillbirth, and small- and large-for-gestational-age infants.

Women's experiences of surviving severe obstetric complications: a qualitative inquiry in southern Ghana

Women who survive severe obstetric complications (SOC) have health and well-being issues even up to 1 year postpartum and have challenges in their quality-of-life (QoL). However, little is known about their predicaments. This study aimed to describe the impact of severe obstetric complications on women’s QoL and well-being after surviving severe obstetric complications. Using the WHO standards for near-miss, twelve (12) women who survived severe obstetric complications were recruited between January and March 2019. The study adopted a qualitative approach with an exploratory descriptive design to explore the experiences of women who survived SOC in Southern Ghana. The participants were purposively sampled and were interviewed face to face in their homes and healthcare facility after discharge from the Hospital. Recorded interviews were transcribed and analyzed. Two (2) major themes and nine (9) sub-themes emerged. The findings revealed that women who suffered SOC are unable to perform functional activities, have financial constraints, residual hypertension, signs and symptoms of anaemia, pain, and mostly have difficulty in sleeping due to fear of death when they fall asleep. Anxiety, sadness, and emotional trauma was a common phenomenon. The study findings offer insights and directions on measures to improve the care and QoL of women who have survived severe obstetric complications in Ghana.

Obstetric comorbidity scores and disparities in severe maternal morbidity across marginalized groups

BACKGROUND

A recently developed obstetrical comorbidity scoring system enables the comparison of severe maternal morbidity rates independent of health status at the time of birth hospitalization. However, the scoring system has not been evaluated in racial-ethnic and socioeconomic groups or used to assess disparities in severe maternal morbidity.

OBJECTIVE

This study aimed to evaluate the performance of an obstetrical comorbidity scoring system when applied across racial-ethnic and socioeconomic groups and to determine the effect of comorbidity score risk adjustment on disparities in severe maternal morbidity.

STUDY DESIGN

We analyzed a population-based cohort of live births that occurred in California during 2011 through 2017 with linked birth certificates and birth hospitalization discharge data (n=3,308,554). We updated a previously developed comorbidity scoring system to include the International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modifications diagnosis codes and applied the scoring system to subpopulations (groups) defined by race-ethnicity, nativity, payment method, and educational attainment. We then calculated the risk-adjusted rates of severe maternal morbidity (including and excluding blood transfusion-only cases) for each group and estimated the disparities for these outcomes before and after adjustment for the comorbidity score using logistic regression.

RESULTS

The obstetric comorbidity scores performed consistently across groups (C-statistics ranged from 0.68 to 0.76; calibration curves demonstrated overall excellent prediction of absolute risk). All non-White groups had significantly elevated rates of severe maternal morbidity before and after risk adjustment for comorbidities when compared with the White group (1.3% before, 1.3% after) (American Indian-Alaska Native: 2.1% before, 1.8% after; Asian: 1.5% before, 1.7% after; Black: 2.5% before, 2.0% after; Latinx: 1.6% before, 1.7% after; Pacific Islander: 2.2% before, 1.9% after; and multi-race groups: 1.7% before, 1.6% after). Risk adjustment also modestly increased disparities for the foreign-born group and government insurance groups. Higher educational attainment was associated with decreased severe maternal morbidity rates, which was largely unaffected by comorbidity risk adjustment. The pattern of results was the same whether or not transfusion-only cases were included as severe maternal morbidity.

CONCLUSION

These results support the use of an updated comorbidity scoring system to assess disparities in severe maternal morbidity. Disparities in severe maternal morbidity decreased in magnitude for some racial-ethnic and socioeconomic groups and increased in magnitude for other groups after adjustment for the comorbidity score.

Antepartum severe maternal morbidity: A population-based study of risk factors and delivery outcomes

BACKGROUND

Severe maternal morbidity (SMM) is a key indicator of maternal health. Generally explored without distinction by the timing of the event, it mainly reflects postpartum SMM. Although antepartum (pre-labour) SMM presents specific challenges in its need to optimise the risk-benefit balance for both mother and foetus, its features remain inadequately explored.

OBJECTIVES

We explored risk factors of antepartum SMM and described adverse delivery and neonatal outcomes associated with antepartum SMM.

METHODS

We designed a population-based nested case-control study based on data from the EPIMOMS study (119 maternity hospitals of 6 French regions, 2012-2013, N = 182,309 deliveries in the source cohort). This study included all women with antepartum SMM (cases, n = 601) compared to a randomly selected sample of women who gave birth without SMM in the same hospitals (controls, n = 3651). Antepartum SMM risk factors were identified with multivariable logistic regression following imputations for missing data.

RESULTS

Antepartum SMM complicated 0.33% (95% confidence interval [CI] 0.30, 0.36) of pregnancies. Antepartum SMM risk factors were maternal age ≥35 years (adjusted odds ratio [OR] 1.55, 95% CI 1.22, 1.97), increased body mass index (OR for 5 kg/m² increase, 1.24, 95% CI 1.14, 1.36), maternal birth in sub-Saharan Africa (OR 1.80, 95% CI 1.29, 2.53), pre-existing medical condition (OR 2.56, 95% CI 1.99, 3.30), nulliparity (OR 2.26, 95% CI 1.83, 2.80), previous pregnancy-related hypertensive disorders (OR 4.94, 95% CI 3.36, 7.26), multiple pregnancy (OR 5.79, 95% CI 3.75, 7.26), irregular prenatal care (OR 1.86, 95% CI 1.27, 2.72). For women with antepartum SMM, preterm delivery, neonatal mortality and transfer to the neonatal intensive care unit were 10 times more frequent than for controls. Emergency caesarean and general anaesthesia were more frequent in women with antepartum SMM.

CONCLUSIONS

Antepartum SMM is rare but associated with increased rates of adverse delivery and neonatal outcomes.

An Exploratory Spatiotemporal Analysis of Socio-Environmental Patterns in Severe Maternal Morbidity

OBJECTIVES

Severe Maternal Morbidity (SMM) is a group of pregnancy complications in which a woman nearly dies. Despite its increasing prevalence, little research has evaluated geographic patterns of SMM and the underlying social determinants that influence excess risk. This study examined the spatial clustering of SMM across South Carolina, US, and its associations with place-based social and environmental factors.

METHODS

Hospitalized deliveries from 2012 to 2017 were analyzed using Kulldorff's spatial scan statistic to locate areas with abnormally high rates of SMM. SMM patients inside and outside risk clusters were compared using Generalized Estimating Equations (GEE) to determine underlying individual and community-level risk factors.

RESULTS

GEE models revealed that the odds of living in a high-risk SMM21 (SMM including blood transfusions) cluster was 2.49 times higher among Black patients (p < .001) compared to those outside of a high-risk cluster. Women residing in a high-risk SMM20 (SMM excluding blood transfusions) cluster were 1.38 times more likely to experience the most number of extremely hot days and 1.70 times more likely to present with obesity than women in a low-risk SMM cluster (p < .001).

CONCLUSIONS

This study is the first to characterize the geographic clustering of SMM risk in the US. Our geospatial approach contributes a novel understanding to factors which influence SMM beyond patient-level characteristics and identifies the impact of hot ambient temperature on maternal morbidity. Findings address an important literature gap surrounding place-based risk factors by explaining the contextual social and built environmental factors that drive SMM risk.

Risk of recurrent severe maternal morbidity in an urban safety net health system

BACKGROUND

Rates of severe maternal morbidity (SMM) are steadily increasing in the US and are highest among women who are Black, publicly insured, or deliver at a safety net hospital. There is limited information on the risk of SMM recurrence in subsequent births, particularly among socially vulnerable women.

OBJECTIVE

To estimate the risk of SMM recurrence among a singleton births in a large, public hospital system.

STUDY DESIGN

We conducted a population-based cohort study using electronic medical record data on deliveries occurring at an urban public hospital between 2011 and 2020. We included all women with two singleton deliveries at ≥20 weeks gestation (live or stillborn) during the study period and assessed SMM recorded at delivery or within 42 days postpartum. We used generalized linear models to estimate adjusted risk ratios (aRR), adjusted risk differences (aRD) and 95% confidence intervals (CI) for SMM at the subsequent birth, controlling for age, parity, self-reported race/ethnicity, insurance type, chronic hypertension and diabetes, and obesity at the index delivery.

RESULTS

Between 2011 and 2020, there were 26,994 singleton deliveries to 21,638 women. Among 4,368 women with two singleton births at ≥20 weeks gestation, 4.8% (n=211) had SMM at the index birth, and 5.7% (n=250) had SMM at the subsequent birth. SMM at the index birth was associated with an over 3-fold increased risk of SMM in a subsequent pregnancy (aRR 3.65, 95% CI: 2.65-5.03) and an excess risk of 12.9 per 100 deliveries (aRD 12.9, 95% CI: 7.7-18.1).

CONCLUSIONS

The results of our study suggest that women who experienced SMM in a prior birth are at increased risk for SMM recurrence and may warrant additional monitoring in subsequent pregnancies.

A Comprehensive Analysis of the Costs of Severe Maternal Morbidity

INTRODUCTION

The objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases.

METHODS

California linked birth certificate-patient discharge data for 2009 through 2011 (n = 1,262,862) with complete costs and LOS were used in a secondary data analysis. Cost-to-charge ratios were used to estimate costs from charges, adjusting for inflation. Physician payments were estimated from the mean payments for specific diagnosis-related groups. Generalized linear models estimated the association between SMM and costs and LOS.

RESULTS

Excluding readmissions and physician costs, SMM was associated with a 60% increase in hospital costs (marginal effect [ME], $3,550) and a 33% increase in LOS (ME 0.9 days). These increased to 70% (ME $5,806) and 46% (ME 1.3 days) when physician costs and readmissions were included. The effects of SMM were roughly one-half as large for patients who only required a blood transfusion (49% [ME $4,056] and 31% [ME 0.9 days]) as for patients who had another indicator for SMM (93% [ME $7,664] and 62% [ME 1.7 days]).

CONCLUSIONS

Postpartum hospital readmissions and physician costs are important and previously unreported contributors to the costs of SMM. Excess costs and LOS associated with SMM vary considerably by indication. Cost effects were larger than the LOS effects, indicating that SMM increases treatment intensity beyond increasing LOS, and decreasing SMM may have broader health and cost benefits than previously understood.

Development and Validation of an Obstetric Comorbidity Risk Score for Clinical Use

Background: A comorbidity summary score may support early and systematic identification of women at high risk for adverse obstetric outcomes. The objective of this study was to conduct the initial development and validation of an obstetrics comorbidity risk score for automated implementation in the electronic health record (EHR) for clinical use. Methods: The score was developed and validated using EHR data for a retrospective cohort of pregnancies with delivery between 2010 and 2018 at Kaiser Permanente Northern California, an integrated health care system. The outcome used for model development consisted of adverse obstetric events from delivery hospitalization (e.g., eclampsia, hemorrhage, death). Candidate predictors included maternal age, parity, multiple gestation, and any maternal diagnoses assigned in health care encounters in the 12 months before admission for delivery. We used penalized regression for variable selection, logistic regression to fit the model, and internal validation for model evaluation. We also evaluated prenatal model performance at 18 weeks of pregnancy. Results: The development cohort (n = 227,405 pregnancies) had an outcome rate of 3.8% and the validation cohort (n = 41,683) had an outcome rate of 2.9%. Of 276 candidate predictors, 37 were included in the final model. The final model had a validation c-statistic of 0.72 (95% confidence interval [CI] 0.70-0.73). When evaluated at 18 weeks of pregnancy, discrimination was modestly diminished (c-statistic 0.68 [95% CI 0.67-0.70]). Conclusions: The obstetric comorbidity score demonstrated good discrimination for adverse obstetric outcomes. After additional appropriate validation, the score can be automated in the EHR to support early identification of high-risk women and assist efforts to ensure risk-appropriate maternal care.

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

OBJECTIVES

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

DESIGN, SETTING AND PARTICIPANTS

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

PRIMARY OUTCOME

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

RESULTS

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

CONCLUSION

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

Pre-pregnancy Obesity and the Risk of Peripartum Cardiomyopathy

OBJECTIVE

The aim of this study is to evaluate the contribution of pre-pregnancy obesity and overweight to peripartum cardiomyopathy.

STUDY DESIGN

This population-based study used linked birth record and maternal hospital discharge data from live births in California during 2007 to 2012 (n = 2,548,380). All women who had a diagnosis of peripartum cardiomyopathy during the childbirth hospitalization or who were diagnosed with peripartum cardiomyopathy during a postpartum hospital readmission within 5 months of birth were identified as cases. Pre-pregnancy body mass index (BMI, kg/m²) was classified as normal weight (18.5-24.9), overweight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2 (35.0-39.9), and obesity class 3 (≥40). Because of small numbers, we excluded women with underweight BMI, and in some analyses, we combined obesity classes into one group. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) expressing associations between BMI and peripartum cardiomyopathy, adjusted for maternal age, race/ethnicity, education, health care payer, parity, plurality, and comorbidities.

RESULTS

The overall prevalence of peripartum cardiomyopathy during hospital admissions was 1.3 per 10,000 live births (n = 320). Unadjusted ORs were 1.32 (95% CI: 1.01-1.74) for women with overweight BMI and 2.03 (95% CI: 1.57-2.62) for women with obesity, compared with women with normal pre-pregnancy BMI. Adjusted ORs were 1.26 (95% CI: 0.95-1.66) for overweight women and 1.38 (95% CI: 1.04-1.84) for women with obesity. The ORs suggested a dose-response relationship with increasing levels of obesity, but the 95% CIs for the specific classes of obesity included 1.00.

CONCLUSION

Pre-pregnancy obesity was associated with an increased risk of peripartum cardiomyopathy. These findings underscore the importance of BMI during pregnancy. There is a need to recognize the increased risk of peripartum cardiomyopathy in women with high BMI, especially in the late postpartum period.

KEY POINTS

· Pre-pregnancy obesity affects maternal health.. · Effects may extend to peripartum cardiomyopathy.. · The risk includes peripartum cardiomyopathy that emerges postpartum..

Costs of Severe Maternal Morbidity in U.S. Commercially Insured and Medicaid Populations: An Updated Analysis

Background: The most common reason for hospitalization in the United States is childbirth. The costs of childbirth are substantial. Materials and Methods: This was a retrospective cohort study of hospital deliveries identified in the MarketScan^® Commercial and Medicaid health insurance claim databases. Women with an inpatient birth in the calendar year 2016 were included. Severe maternal morbidity (SMM) was identified using the Centers for Disease Control and Prevention algorithm of 21 International Classification of Diseases-10 codes. Mean costs and cost ratios for women with and without SMM were reported. Generalized linear models were used to analyze demographic and clinical variables influencing delivery costs. Results: We identified 1,486 women in the Commercial population, who had a birth in 2016 and met the criteria for SMM. The total mean per-patient costs of care for women with and without SMM were $50,212 and $23,795, respectively. In the Medicaid population there were 29,763 births, of which 342 met the criteria for SMM. The total mean per-patient costs of care for women with and without SMM were $26,513 and $9,652, respectively. A multifetal gestation, a cesarean delivery, maternal age, and pregnancy-related complications were independently predictive of increased delivery costs in both Commercial and Medicaid populations. Conclusions: The occurrence of SMM was associated with an increase in maternity-related costs of 111% in the Commercial and 175% in the Medicaid population. Some of the factors associated with increased delivery hospitalization costs could be treated or avoided.