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Boghossian NS, Greenberg LT, Buzas JS, Rogowski J, Lorch SA, Passarella M, Saade GR, Phibbs CS. Severe Maternal Morbidity from Pregnancy through 1-year Postpartum. Am J Obstet Gynecol MFM 2024:101385. [PMID: 38768903 DOI: 10.1016/j.ajogmf.2024.101385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/13/2024] [Accepted: 04/14/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Few recent studies have examined the rate of severe maternal morbidity (SMM) occurring during the antenatal and/or the postpartum period through 42 days postpartum. However, little is known about the rate of SMM occurring beyond 42 days postpartum. OBJECTIVE To examine the distribution of SMM and its indicators during antenatal, delivery, and postpartum hospitalizations through 365 days postpartum, and to estimate the increase in SMM rate and its indicators after accounting for antenatal and postpartum SMM through 365 days postpartum. STUDY DESIGN We conducted a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from Michigan, Oregon, and South Carolina from 2008-2020. We examined the distribution of SMM, non-transfusion SMM, and SMM indicators during antenatal, delivery, and postpartum hospitalizations through 365 days postpartum. We subsequently examined "SMM cases added," which represent cases among unique individuals that are included by considering the antenatal and postpartum periods but that would be missed if only the delivery hospitalization cases were included. RESULTS A total of 64,661 (2.5%) individuals experienced SMM while 37,112 (1.4%) individuals experienced non-transfusion SMM during antenatal, delivery, and/or postpartum hospitalization. A total of 31% of SMM cases were added after accounting for SMM occurring during the antenatal or postpartum hospitalization through 365 days postpartum while 49% of non-transfusion SMM cases were added after accounting for non-transfusion SMM occurring during the antenatal or postpartum periods. SMM occurring between 43 and 365 days postpartum contributed to 12% of all SMM cases while non-transfusion SMM occurring between 43 and 365 days postpartum contributed to 19% of all non-transfusion SMM cases. CONCLUSION We showed that a total of 31% of SMM and 49% of non-transfusion SMM cases were added after accounting for SMM occurring during the antenatal or postpartum hospitalization through 365 days postpartum. Our findings highlight the importance of expanding the SMM definition beyond the delivery hospitalization to better capture the full period of increased risk, identify contributing factors, and design strategies to mitigate this risk. Only then, can we improve outcomes for mothers and subsequently the quality of life of their infants.
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Affiliation(s)
- Nansi S Boghossian
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC.
| | | | - Jeffrey S Buzas
- Department of Mathematics and Statistics, University of Vermont, Burlington, VT
| | - Jeannette Rogowski
- Department of Health Policy and Administration, The Pennsylvania State University, State College, PA
| | - Scott A Lorch
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Molly Passarella
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - George R Saade
- Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Ciaran S Phibbs
- Departments of Pediatrics and Health Policy, Stanford University School of Medicine, Stanford, CA; Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA
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Song BB, Mandelbaum RS, Anderson ZS, Masjedi AD, Harris CA, Violette CJ, Ouzounian JG, Matsuo K, Paulson RJ. Pregnancy following assisted reproductive technology in morbidly obese patients: assessment of feto-maternal outcomes. J Assist Reprod Genet 2024; 41:903-914. [PMID: 38381390 PMCID: PMC11052942 DOI: 10.1007/s10815-024-03065-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 02/12/2024] [Indexed: 02/22/2024] Open
Abstract
PURPOSE To examine feto-maternal characteristics and outcomes of morbidly obese pregnant patients who conceived with assisted reproductive technology (ART). METHODS This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample. Study population was 48,365 patients with ART pregnancy from January 2012 to September 2015, including non-obesity (n = 45,125, 93.3%), class I-II obesity (n = 2445, 5.1%), and class III obesity (n = 795, 1.6%). Severe maternal morbidity at delivery per the Centers for Disease and Control Prevention definition was assessed with multivariable binary logistic regression model. RESULTS Patients in the class III obesity group were more likely to have a hypertensive disorder (adjusted-odds ratio (aOR) 3.03, 95% confidence interval (CI) 2.61-3.52), diabetes mellitus (aOR 3.08, 95%CI 2.64-3.60), large for gestational age neonate (aOR 3.57, 95%CI 2.77-4.60), and intrauterine fetal demise (aOR 2.03, 95%CI 1.05-3.94) compared to those in the non-obesity group. Increased risks of hypertensive disease (aOR 1.35, 95%CI 1.14-1.60) and diabetes mellitus (aOR 1.39, 95%CI 1.17-1.66) in the class III obesity group remained robust even compared to the class I-II obesity group. After controlling for priori selected clinical, pregnancy, and delivery factors, patients with class III obesity were 70% more likely to have severe maternal morbidity at delivery compared to non-obese patients (8.2% vs 4.4%, aOR 1.70, 95%CI 1.30-2.22) whereas those with class I-II obesity were not (4.1% vs 4.4%, aOR 0.87, 95%CI 0.70-1.08). CONCLUSIONS The results of this national-level analysis in the United States suggested that morbidly obese pregnant patients conceived with ART have increased risks of adverse fetal and maternal outcomes.
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Affiliation(s)
- Bonnie B Song
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD520, Los Angeles, CA, 90033, USA
| | - Rachel S Mandelbaum
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Zachary S Anderson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD520, Los Angeles, CA, 90033, USA
| | - Aaron D Masjedi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD520, Los Angeles, CA, 90033, USA
| | - Chelsey A Harris
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD520, Los Angeles, CA, 90033, USA
| | - Caroline J Violette
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD520, Los Angeles, CA, 90033, USA
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD520, Los Angeles, CA, 90033, USA.
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
| | - Richard J Paulson
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
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Osei-Poku GK, Prentice JC, Easter SR, Diop H. Delivery at an inadequate level of maternal care is associated with severe maternal morbidity. Am J Obstet Gynecol 2024:S0002-9378(24)00421-6. [PMID: 38432412 DOI: 10.1016/j.ajog.2024.02.308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Implementing levels of maternal care is one strategy proposed to reduce maternal morbidity and mortality. The levels of maternal care framework outline individual medical and obstetrical comorbidities, along with hospital resources required for individuals with these different comorbidities to deliver safely. The overall goal is to match individuals to hospitals so that all birthing people get appropriate resources and personnel during delivery to reduce maternal morbidity. OBJECTIVE This study examined the association between delivery in a hospital with an inappropriate level of maternal care and the risk of experiencing severe maternal morbidity. STUDY DESIGN The 40 birthing hospitals in Massachusetts were surveyed using the Centers for Disease Control and Prevention's Levels of Care Assessment Tool. We linked individual delivery hospitalizations from the Massachusetts Pregnancy to Early Life Longitudinal Data System to hospital-level data from the Levels of Care Assessment Tool surveys. Level of maternal care guidelines were used to outline 16 high-risk conditions warranting delivery at hospitals with resources beyond those considered basic (level I) obstetrical care. We then used the Levels of Care Assessment Tool assigned levels to determine if delivery occurred at a hospital that had the resources to meet an individual's needs (ie, if a patient received risk-appropriate care). We conducted our analyses in 2 stages. First, multivariable logistic regression models predicted if an individual delivered in a hospital that did not have the resources for their risk condition. The main explanatory variable of interest was if the hospital self-assessed their level of maternal care to be higher than the Levels of Care Assessment Tool assigned level. We then used logistic regression to examine the association between delivery at an inappropriate level hospital and the presence of severe maternal morbidity at delivery. RESULTS Among 64,441 deliveries in Massachusetts from January 1 to December 31, 2019, 33.2% (21,415/64,441) had 1 or more of the 16 high-risk conditions that require delivery at a center designated as a level I or higher. Of the 21,415 individuals with a high-risk condition, 13% (2793/21,415), equating to 4% (2793/64,441) of the entire sample, delivered at an inappropriate level of maternal care. Birthing individuals with high-risk conditions who delivered at a hospital with an inappropriate level had elevated odds (adjusted odds ratio, 3.34; 95% confidence interval, 2.24-4.96) of experiencing severe maternal morbidity after adjusting for patient comorbidities, demographics, average hospital severe maternal morbidity rate, hospital level of maternal care, and geographic region. CONCLUSION Birthing people who delivered in a hospital with risk-inappropriate resources were substantially more likely to experience severe maternal morbidity. Delivery in a hospital with a discrepancy in their self-assessment and the Levels of Care Assessment Tool assigned level substantially predicted delivery in a hospital with an inappropriate level of maternal care, suggesting inadequate knowledge of hospitals' resources and capabilities. Our data demonstrate the potential for the levels of maternal care paradigm to decrease severe maternal morbidity while highlighting the need for robust implementation and education to ensure everyone receives risk-appropriate care.
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Affiliation(s)
- Godwin K Osei-Poku
- Division of Research and Analysis, Betsy Lehman Center for Patient Safety, Commonwealth of Massachusetts, Boston, MA.
| | - Julia C Prentice
- Division of Research and Analysis, Betsy Lehman Center for Patient Safety, Commonwealth of Massachusetts, Boston, MA; Department of Psychiatry, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA
| | - Sarah Rae Easter
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Hafsatou Diop
- Commissioners Office, Massachusetts Department of Public Health, Boston, MA
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Mitra M, Akobirshoev I, Valentine A, McKee K, McKee MM. Severe maternal morbidity in deaf or hard of hearing women in the United States. Prev Med 2024; 180:107883. [PMID: 38307211 DOI: 10.1016/j.ypmed.2024.107883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/04/2024]
Abstract
OBJECTIVE Prior studies on severe maternal morbidity (SMM) have often excluded women who are deaf or hard of hearing (DHH), even though they are at increased risk of pregnancy complications and adverse birth outcomes. This study compared rates of SMM during delivery and postpartum among DHH and non-DHH women. METHODS This nationally representative retrospective cohort study used hospital discharge data from the 2004-2020 Health Care and Cost Utilization Project Nationwide Inpatient Sample. The risk of SMM with and without blood transfusion during delivery and postpartum among DHH and non-DHH women were compared using modified Poisson regression analysis. The study was conducted in the United States in 2022-2023. RESULTS The cohort included 9351 births to DHH women for the study period, and 13,574,382 age-matched and delivery year-matched births to non-DHH women in a 1:3 case-control ratio. The main outcomes were SMM and non-transfusion SMM during delivery and postpartum. Relative risks were sequentially adjusted for sociodemographic characteristics, hospital-level characteristics, and clinical characteristics. In unadjusted analyses, DHH women were at 80% higher risk for SMM (RR = 1.81, 95% CI 1.63-2.02, p < 0.001) during delivery and postpartum compared to non-DHH women. Adjustment for socio-demographic and hospital characteristics attenuated risk for SMM (RR = 1.54, 95% CI 1.38-1.72, p < 0.001). Adjustment for the Elixhauser comorbidity score further attenuated the risk of SMM among DHH women (RR = 1.13, 95% CI 1.01-1.26, p < 0.05). CONCLUSION The findings of this study demonstrate a critical need for inclusive preconception, prenatal, and postpartum care that address conditions that increase the risk for SMM among DHH people.
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Affiliation(s)
- Monika Mitra
- Lurie Institute for Disability Policy, Heller School for Social Policy and Management, Brandeis University, 415 South St. MS 035, Waltham, MA 02453, USA.
| | - Ilhom Akobirshoev
- Lurie Institute for Disability Policy, Heller School for Social Policy and Management, Brandeis University, 415 South St. MS 035, Waltham, MA 02453, USA
| | - Anne Valentine
- Lurie Institute for Disability Policy, Heller School for Social Policy and Management, Brandeis University, 415 South St. MS 035, Waltham, MA 02453, USA
| | - Kimberly McKee
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael M McKee
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
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Albright CM, Sienas L, Pike M, Walker S, Hitti J. Racial Disparity in Severe Maternal Morbidity Associated with Hypertensive Disorders in Washington State: A Retrospective Cohort Study. Matern Child Health J 2024:10.1007/s10995-024-03920-8. [PMID: 38407715 DOI: 10.1007/s10995-024-03920-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVES To evaluate the relationship between hypertensive (HTN) disorders and severe maternal morbidity (SMM). To understand whether there is differential prevalence of HTN disorders by race and whether the relationship between HTN disorders and SMM is modified by race and ethnicity. METHODS We performed a retrospective cohort study using patient-level rates of SMM for pregnancies at all 61 non-military hospitals in Washington State from 10/2015 to 9/2016. Data were obtained from the Washington State Comprehensive Hospital Abstract Reporting System. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated to evaluate the association of HTN disorders and SMM (with and without transfusion) overall and by race. The population-attributable fraction of HTN disorders on SMM within each racial/ethnic group was calculated. RESULTS Of 76,965 deliveries, 864 (1.1%) had any SMM diagnosis or procedure. All racial and ethnic minorities, except white and Asian, were disproportionally affected by preeclampsia with severe features (SF) and SMM. Overall, and within each racial/ethnic group, the SMM rate was higher among pregnancies with any HTN disorder compared to no HTN disorder (2.8 vs. 0.9%, OR 3.1, 95% CI 2.7-3.6). Race and ethnicity significantly modified the association. Overall and within each racial/ethnic group, there was a dose-response relationship between the type of HTN disorder and SMM, with more severe HTN disorders leading to a greater risk of SMM. The population-attributable fraction of HTN disorders on SMM was 20.6% for Black individuals versus 17.5% overall. The findings were similar when reclassifying transfusion-only SMM as no SMM. CONCLUSIONS In Washington, HTN disorders are associated with SMM in a dose-dependent fashion with the greatest impact among Black individuals.
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Affiliation(s)
- Catherine M Albright
- Department of Obstetrics/Gynecology, University of Washington Medical Center, Seattle, WA, USA.
| | | | - Mindy Pike
- Department of Obstetrics/Gynecology, University of Washington Medical Center, Seattle, WA, USA
| | - Suzan Walker
- Department of Obstetrics/Gynecology, University of Washington Medical Center, Seattle, WA, USA
| | - Jane Hitti
- Department of Obstetrics/Gynecology, University of Washington Medical Center, Seattle, WA, USA
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Baykemagn FT, Abreha GF, Zelelow YB, Berhe AK, Kahsay AB. Global burden of potentially life-threatening maternal conditions: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:11. [PMID: 38166681 PMCID: PMC10759711 DOI: 10.1186/s12884-023-06199-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Potentially life-threatening maternal conditions (PLTCs) is an important proxy indicator of maternal mortality and the quality of maternal health services. It is helpful to monitor the rates of severe maternal morbidity to evaluate the quality of maternal care, particularly in low- and lower-middle-income countries. This study aims to systematically identify and synthesize available evidence on PLTCs. METHODS We searched studies in English from 2009‒2023 in PubMed, the National Library of Medicine (NLM) Gateway, the POPLINE database, and the Science Direct website. The study team independently reviewed the illegibility criteria of the articles. Two reviewers independently appraised the included articles using the Joanna Briggs Instrument for observational studies. Disputes between the reviewers were resolved by consensus with a third reviewer. Meta-analysis was conducted in Stata version 16. The pooled proportion of PLTCs was calculated using the random effects model. The heterogeneity test was performed using the Cochrane Q test, and its level was determined using the I2 statistical result. Using Egger's test, the publication bias was assessed. RESULT Thirty-two cross-sectional, five case-control, and seven cohort studies published from 2009 to 2023 were included in the meta-analysis. The highest proportion of PLTC was 17.55% (95% CI: 15.51, 19.79) in Ethiopia, and the lowest was 0.83% (95% CI: 0.73, 0.95) in Iraq. The pooled proportion of PLTC was 6.98% (95% CI: 5.98-7.98). In the subgroup analysis, the pooled prevalence varied based on country income level: in low-income 13.44% (95% CI: 11.88-15.00) I2 = 89.90%, low-middle income 7.42% (95% CI: 5.99-8.86) I2 = 99.71%, upper-middle income 6.35% (95% CI: 4.21-8.50) I2 = 99.92%, and high-income 2.67% (95% CI: 2.34-2.99) I2 = 99.57%. Similarly, it varied based on the diagnosis criteria; WHO diagnosis criteria used 7.77% (95% CI: 6.10-9.44) I2 = 99.96% at P = 0.00, while the Centers for Disease Controls (CDC) diagnosis criteria used 2.19% (95% CI: 1.89-2.50) I2 = 99.41% at P = 0.00. CONCLUSION The pooled prevalence of PLTC is high globally, predominantly in low-income countries. The large disparity of potentially life-threatening conditions among different areas needs targeted intervention, particularly for women residing in low-income countries. The WHO diagnosis criteria minimize the underreporting of severe maternal morbidity. TRIAL REGISTRATION CRD42023409229.
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Affiliation(s)
- Fitiwi Tinsae Baykemagn
- Department of Nursing, College of Medicine and Health Sciences, Adigrat University, Tigray, Ethiopia.
- School of Public Health, College of Health Sciences, Mekelle University, Tigray, Ethiopia.
| | | | - Yibrah Berhe Zelelow
- Department of Obstetrics and Gynecology, School of Medicine, Mekelle University, Tigray, Ethiopia
| | - Abadi Kidanemariam Berhe
- School of Public Health, College of Medicine and Health Sciences, Adigrat University, Tigray, Ethiopia
- Tigray Health Research Institute, Mekelle, Ethiopia
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Roese N, Lan CW, Tirumala K, Joshi S. Community-Level Factors are Predictors of Severe Maternal Morbidity Among American Indian and Alaska Native Pregnant People in the Pacific Northwest in a Multilevel Logistic Regression. Matern Child Health J 2024; 28:125-134. [PMID: 37955840 DOI: 10.1007/s10995-023-03811-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION American Indian/Alaska Native (AI/AN) pregnant people face barriers to health and healthcare that put them at risk of pregnancy complications. Rates of severe maternal morbidity (SMM) among Indigenous pregnant people are estimated to be twice that of non-Hispanic White (NHW) pregnant people. METHODS Race-corrected Oregon Hospital Discharge and Washington Comprehensive Hospital Abstract Reporting System data were combined to create a joint dataset of births between 2012 and 2016. The analytic sample was composed of 12,535 AI/AN records and 313,046 NHW records. A multilevel logistic regression was used to assess the relationship between community-level, individual and pregnancy risk factors on SMM for AI/AN pregnant people. RESULTS At the community level, AI/AN pregnant people were more likely than NHW to live in mostly or completely rural counties with low median household income and high uninsured rates. They were more likely to use Medicaid, be in a high-risk age category, and have diabetes or obesity. During pregnancy, AI/AN pregnant people were more likely to have insufficient prenatal care (PNC), gestational diabetes, and pre-eclampsia. In the multilevel model, county accounted for 6% of model variance. Hypertension pre-eclampsia, and county rurality were significant predictors of SMM among AI/AN pregnant people. High-risk age, insufficient PNC and a low county insured rate were near-significant at p < 0.10. DISCUSSION Community-level factors are significant contributors to SMM risk for AI/AN pregnant people in addition to hypertension and pre-eclampsia. These findings demonstrate the need for targeted support in pregnancy to AI/AN pregnant people, particularly those who live in rural and underserved communities.
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Affiliation(s)
- Natalie Roese
- Northwest Portland Area Indian Health Board, Portland, OR, USA.
| | - Chiao Wen Lan
- Northwest Portland Area Indian Health Board, Portland, OR, USA
| | - Karuna Tirumala
- Northwest Portland Area Indian Health Board, Portland, OR, USA
| | - Sujata Joshi
- Northwest Portland Area Indian Health Board, Portland, OR, USA
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Serruya SJ, de Mucio B, Sosa C, Colomar M, Duran P, Gomez Ponce de Leon R, Aleman A, Luz AG, Souza RT, Costa ML, Cecatti JG. Surveillance of severe maternal morbidity and maternal mortality in maternity hospitals of the Latin American and Caribbean network - Red CLAP: study protocol. Glob Health Action 2023; 16:2249771. [PMID: 37722922 PMCID: PMC10512792 DOI: 10.1080/16549716.2023.2249771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/14/2023] [Indexed: 09/20/2023] Open
Abstract
The sustained reduction in maternal mortality in America underlines the need to analyse women who survived a complication that could have been fatal if appropriate and timely care had not been taken. Analysis of maternal near-miss (MNM) cases, as well as potentially life-threatening conditions (PLTC), are considered indicators for monitoring the quality of maternal care. The specific objective of this study protocol is to develop a surveillance system for PLTC, MNM and maternal mortality, as primary outcomes, in Latin American and Caribbean maternal healthcare institutions. Secondarily, the study was designed to identify factors associated with these conditions and estimate how often key evidence-based interventions were used for managing severe maternal morbidity. This is a multicenter cross-sectional study with prospective data collection. The target population consists of all women admitted to health centres participating in the network during pregnancy, childbirth, or the postpartum period. Variables describing the sequence of events that may result in a PLTC, MNM or maternal death are recorded. Relevant quality control is carried out to ensure the quality of the database and confidentiality. Centres with approximately 2,500 annual deliveries will be included to achieve a sufficient number of cases for calculation of indicators. The frequency of outcome measures for PLTC, MNM and maternal mortality and their confidence intervals and differences between groups will be calculated using the most appropriate statistical tests. Similar procedures will be performed with variables describing the use of evidence-based practices. Networking creates additional possibilities for global information management and interaction between different research groups. Lessons can be learned and shared, generating scientific knowledge to address relevant health problems throughout the region with provision of efficient data management.
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Affiliation(s)
- Suzanne J. Serruya
- CLAP/WR - Latin American Center for Perinatology, Women’s and Reproductive Health of the Pan American Health Organization (PAHO), Montevideo, Uruguay
| | - Bremen de Mucio
- CLAP/WR - Latin American Center for Perinatology, Women’s and Reproductive Health of the Pan American Health Organization (PAHO), Montevideo, Uruguay
| | - Claudio Sosa
- CLAP/WR - Latin American Center for Perinatology, Women’s and Reproductive Health of the Pan American Health Organization (PAHO), Montevideo, Uruguay
| | - Mercedes Colomar
- CLAP/WR - Latin American Center for Perinatology, Women’s and Reproductive Health of the Pan American Health Organization (PAHO), Montevideo, Uruguay
| | - Pablo Duran
- CLAP/WR - Latin American Center for Perinatology, Women’s and Reproductive Health of the Pan American Health Organization (PAHO), Montevideo, Uruguay
| | - Rodolfo Gomez Ponce de Leon
- CLAP/WR - Latin American Center for Perinatology, Women’s and Reproductive Health of the Pan American Health Organization (PAHO), Montevideo, Uruguay
| | - Alicia Aleman
- Department of Preventive and Social Medicine, School of Medicine, Universidad de la Republica, Montevideo, Uruguay
| | - Adriana G. Luz
- Department of Obstetrics and Gynecology, University of Campinas Medical School, Campinas, Brazil
| | - Renato T. Souza
- Department of Obstetrics and Gynecology, University of Campinas Medical School, Campinas, Brazil
| | - Maria L. Costa
- Department of Obstetrics and Gynecology, University of Campinas Medical School, Campinas, Brazil
| | - José G. Cecatti
- Department of Obstetrics and Gynecology, University of Campinas Medical School, Campinas, Brazil
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Du R, Ali MM, Sung YS, Pandit AA, Payakachat N, Ounpraseuth ST, Magann EF, Eswaran H. Maternal comorbidity index and severe maternal morbidity among medicaid covered pregnant women in a US Southern rural state. J Matern Fetal Neonatal Med 2023; 36:2167073. [PMID: 36683016 DOI: 10.1080/14767058.2023.2167073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The rates of SMM have been steadily increasing in Arkansas, a southern rural state, which has the 5th highest maternal death rate among the US states. The aims of the study were to test the functionality of the Bateman index in association to SMM, in clustering the risks of pregnancies to SMM, and to study the predictability of SMM using the Bateman index. STUDY DESIGN From the ANGELS database, 72,183 pregnancies covered by Medicaid in Arkansas between 2013 and 2016 were included in this study. The expanded CDC ICD-9/ICD-10 criteria were used to identify SMM. The Bateman comorbidity index was applied in quantifying the comorbidity burden for a pregnancy. Multivariable logistic regressions, KMeans method, and five widely used predictive models were applied respectively for each of the study aims. RESULTS SMM prevalence remained persistently high among Arkansas women covered by Medicaid (195 per 10,000 deliveries) during the study period. Using the Bateman comorbidity index score, the study population was divided into four groups, with a monotonically increasing odds of SMM from a lower score group to a higher score group. The association between the index score and the occurrence of SMM is confirmed with statistical significance: relative to Bateman score falling in 0-1, adjusted Odds Ratios and 95% CIs are: 2.1 (1.78, 2.46) for score in 2-5; 5.08 (3.81, 6.79) for score in 6-9; and 8.53 (4.57, 15.92) for score ≥10. Noticeably, more than one-third of SMM cases were detected from the studied pregnancies that did not have any of the comorbid conditions identified. In the prediction analyses, we observed minimal predictability of SMM using the comorbidity index: the calculated c-statistics ranged between 62% and 67%; the Precision-Recall AUC values are <7% for internal validation and <9% for external validation procedures. CONCLUSIONS The comorbidity index can be used in quantifying the risk of SMM and can help cluster the study population into risk tiers of SMM, especially in rural states where there are disproportionately higher rates of SMM; however, the predictive value of the comorbidity index for SMM is inappreciable.
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Affiliation(s)
- Ruofei Du
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mir M Ali
- Institute for Digital Health & Innovation, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Yi-Shan Sung
- Institute for Digital Health & Innovation, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ambrish A Pandit
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nalin Payakachat
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Songthip T Ounpraseuth
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Everett F Magann
- Department of Obstetrics & Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hari Eswaran
- Institute for Digital Health & Innovation, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Phillips JM, Bodnar LM, Himes KP. Association between gestational age at delivery and indicator-specific severe maternal morbidity. J Matern Fetal Neonatal Med 2023; 36:2198633. [PMID: 37045599 DOI: 10.1080/14767058.2023.2198633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVE Individuals who deliver preterm are disproportionately affected by severe maternal morbidity. Limited data suggest that indicator-specific maternal morbidity varies by gestational age at delivery. We sought to evaluate the relationship between gestational age at delivery and the incidence of severe maternal morbidity and indicator-specific severe maternal morbidity. METHODS We used a hospital administrative delivery database to identify all singleton deliveries between 16 and 42 weeks gestation from 2002 to 2018. We defined severe maternal morbidity as the presence of any International Classification of Disease diagnosis or procedure codes outlined by the Centers for Disease Control and Prevention, intensive care unit admission, and/or prolonged postpartum hospital length of stay. Indicator-specific severe maternal morbidity was based on the diagnosis and procedure codes and was characterized across gestational age epochs. We categorized gestational age into three epochs to capture extremely preterm birth (less than 28 weeks gestation), preterm birth (28-36 weeks gestation) and term birth (37 weeks gestation and above). Multivariable binomial regression was used to assess the association between categories of gestational age at delivery and severe maternal morbidity adjusting for confounders including age, race, body mass index (BMI), insurance status, and preexisting hypertension or diabetes. RESULTS Severe maternal morbidity occurred in 2.5% of all deliveries. The unadjusted incidence of severe maternal morbidity by gestational age epoch was 12% at less than 28 weeks gestation, 8.4% at 28 to 36 weeks of gestation, and 1.7% at greater than or equal to 37 weeks gestation. After controlling for potential confounders the predicted probability of severe maternal morbidity was 16% (95% CI 14,17%) at 24 weeks compared to 2.2% (95% CI 2.1,2.3%) at 38 weeks. Sepsis, acute respiratory distress syndrome, mechanical ventilation, and shock were the most common diagnostic codes in deliveries less than 28 weeks gestation. Heart failure and cardiac arrhythmias were more common in patients with severe maternal morbidity delivering at term. CONCLUSION A high proportion of severe maternal morbidity occurred in preterm patients, with the highest rates occurring at less than 28 weeks gestation. Individuals with severe maternal morbidity who deliver preterm had distinct indicators of morbidity compared to those who deliver at term.
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Affiliation(s)
- Jaclyn M Phillips
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lisa M Bodnar
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh Pennsylvania
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine P Himes
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh Pennsylvania
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Rodriguez MI, Acevedo AM, Renfro S, Tasset J, Sosanya O, Caughey AB. Association of intrapartum severe maternal morbidity with receipt of postpartum contraception among Medicaid recipients. Contraception 2023; 127:110110. [PMID: 37414330 PMCID: PMC10592377 DOI: 10.1016/j.contraception.2023.110110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/24/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVES We sought to determine the association between intrapartum severe maternal morbidity and receipt of postpartum contraception within 60 days among Medicaid recipients in Oregon and South Carolina. STUDY DESIGN We conducted a historical cohort study of all Medicaid births in Oregon and South Carolina from 2011 to April 2018. Intrapartum severe maternal morbidity was measured using diagnosis and procedure codes according to the Center for Disease Control's classifications. Our primary outcome of interest was receipt of postpartum contraception within 60 days of birth. We captured permanent and reversible forms of contraception. We examined the association of intrapartum severe maternal morbidity with receipt of postpartum contraception, and whether this varied by type of Medicaid (Traditional vs Emergency). We used Poisson regression models with robust (sandwich) estimation of variance to calculate relative risk (RR) for each model. RESULTS Our analytic cohort included 347,032 births. We identified 3079 births with evidence of intrapartum severe maternal morbidity (0.9% of all births). When adjusted for maternal age, rural vs urban status, and state of residence, Medicaid beneficiaries with births complicated by intrapartum severe maternal morbidity are 7% less likely to receive any contraception (RR 0.93, 95% CI (0.91, 0.95)) by 60 days postpartum. Among births complicated by severe maternal morbidity we found that Emergency Medicaid recipients were 92% less likely than Traditional Medicaid recipients to receive any method of contraception (RR 0.08, 95% CI (0.08, 0.08)). CONCLUSIONS Medicaid recipients experiencing intrapartum severe maternal morbidity are less likely to receive contraception within 60 days than Medicaid beneficiaries with uncomplicated births. IMPLICATIONS Medicaid recipients with intrapartum severe maternal morbidity are less likely to receive postpartum contraception, than Medicaid beneficiaries without severe maternal morbidity.
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Affiliation(s)
- Maria I Rodriguez
- Center for Reproductive Health Equity, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States.
| | - Ann Martinez Acevedo
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States
| | - Stephanie Renfro
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States
| | - Julia Tasset
- Center for Reproductive Health Equity, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States
| | - Oluwadamilola Sosanya
- Center for Reproductive Health Equity, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States
| | - Aaron B Caughey
- Center for Reproductive Health Equity, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States
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12
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Hall SV, Zivin K, Dalton VK, Bell S, Kolenic GE, Admon LK. Association of the Mental Health Parity and Addiction Equity Act and the Affordable Care Act on severe maternal morbidity. Gen Hosp Psychiatry 2023; 85:126-132. [PMID: 37866105 PMCID: PMC10897524 DOI: 10.1016/j.genhosppsych.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/02/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVE This study aimed to characterize the association between Mental Health Parity and the Affordable Care Act and rates of severe maternal morbidity among a population of commercially insured individuals, including individuals with and without perinatal mood and anxiety disorders. METHODS We conducted a serial, cross-sectional analysis of individuals with an inpatient delivery in Optum's Clinformatics® Data Mart Database from 2008 to 2021. We applied an interrupted time series model with autoregressive integrated moving average to evaluate changes in quarterly severe maternal morbidity rates. RESULTS Adjusted severe maternal morbidity rates declined from 167.2 (95%CI: [152.6, 181.9]) per 10,000 deliveries in the first quarter of 2008 to 98.2 (95%CI: [83.5, 112.8]) per 10,000 deliveries in the last quarter of 2021. Severe maternal morbidity rates remained higher, but declined to a greater degree, among those with perinatal mood and anxiety disorders (435.6, 95%CI: [379.9, 491.3], to 165.0, 95%CI: [109.3, 220.8] per 10,000 deliveries) compared to those without (153.0, 95%CI: [140.7, 165.3] to 81.8, 95%CI: [69.6, 94.1] per 10,000 deliveries). CONCLUSION The observed association suggests implementation of Mental Health Parity and Affordable Care Act may have played a role in lowering rates of severe maternal morbidity, particularly among individuals with perinatal mood and anxiety disorders.
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Affiliation(s)
- Stephanie V Hall
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States of America; Program on Women's Healthcare Effectiveness Research, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, United States of America.
| | - Kara Zivin
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States of America; Program on Women's Healthcare Effectiveness Research, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, United States of America; Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, United States of America; Department of Health Policy and Management, University of Michigan School of Public Health, Ann Arbor, MI, United States of America; VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States of America
| | - Vanessa K Dalton
- Program on Women's Healthcare Effectiveness Research, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, United States of America; Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, United States of America; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States of America
| | - Sarah Bell
- Program on Women's Healthcare Effectiveness Research, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, United States of America; Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Giselle E Kolenic
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
| | - Lindsay K Admon
- Program on Women's Healthcare Effectiveness Research, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, United States of America; Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, United States of America; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States of America
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13
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Gao X, Thomas TA, Morello-Frosch R, Allen AM, Snowden JM, Carmichael SL, Mujahid MS. Neighborhood gentrification, displacement, and severe maternal morbidity in California. Soc Sci Med 2023; 334:116196. [PMID: 37678111 PMCID: PMC10959124 DOI: 10.1016/j.socscimed.2023.116196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/29/2023] [Accepted: 08/29/2023] [Indexed: 09/09/2023]
Abstract
Gentrification, a racialized and profit-driven process in which historically disinvested neighborhoods experience an influx of development that contributes to the improvement of physical amenities, increasing housing costs, and the dispossession and displacement of existing communities, may influence the risk of severe maternal morbidity (SMM). Leveraging a racially diverse population-based sample of all live hospital births in California between 2006 and 2017, we examined associations between neighborhood-level gentrification and SMM. SMM was defined as having one of 21 procedures and diagnoses, as described in the SMM index developed by Centers for Disease Control and Prevention. We compared three gentrification measures to determine which operationalization best captures aspects of gentrification most salient to SMM: Freeman, Landis 3-D, and Urban Displacement Project Gentrification and Displacement Typology. Descriptive analysis assessed bivariate associations between gentrification and birthing people's characteristics. Overall and race and ethnicity-stratified mixed-effects logistic models assessed associations between gentrification and SMM, adjusting for individual sociodemographic and pregnancy factors while accounting for clustering by census tract. The study sample included 5,256,905 births, with 72,718 cases of SMM (1.4%). The percentage of individuals living in a gentrifying neighborhood ranged from 5.7% to 11.7% across exposure assessment methods. Net of individual and pregnancy-related factors, neighborhood-level gentrification, as measured by the Freeman method, was protective against SMM (OR = 0.89, 95% CI: 0.86-0.93); in comparison, gentrification, as measured by the Gentrification and Displacement Typology, was associated with greater risk of SMM (OR = 1.18, 95% CI: 1.14-1.23). These associations were significant among non-Hispanic White, non-Hispanic Black, and Hispanic individuals. Findings demonstrate that gentrification plays a role in shaping the risk of SMM among birthing people in California. Differences in how gentrification is conceptualized and measured, such as an emphasis on housing affordability compared to a broader characterization of gentrification's multiple aspects, may explain the heterogeneity in the directions of observed associations.
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Affiliation(s)
- Xing Gao
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Timothy A Thomas
- Urban Displacement Project, Institute of Governmental Studies, University of California Berkeley, Berkeley, CA, USA
| | - Rachel Morello-Frosch
- Department of Environmental Science, Policy and Management, University of California Berkeley, Berkeley, CA, USA; Division of Environmental Health Sciences, School of Public Health, University of California Berkeley, Berkeley, CA, USA; Division of Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Amani M Allen
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA; Division of Community Health Sciences, School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Jonathan M Snowden
- School of Public Health, Oregon Health & Science University-Portland State University, OR, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Division of Neonatal & Developmental Medicine, Stanford University, Stanford, CA, USA; Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Stanford University, Stanford, CA, USA
| | - Mahasin S Mujahid
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA.
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14
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Terada S, Fujiwara T, Sugawara J, Maeda K, Satoh S, Mitsuda N. Association of severe maternal morbidity with bonding impairment and self-harm ideation: A multicenter prospective cohort study. J Affect Disord 2023; 338:561-568. [PMID: 37385386 DOI: 10.1016/j.jad.2023.06.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Evidence on the association between severe maternal morbidity (SMM) and mother-infant bonding and self-harm ideation is limited. We aimed to examine these associations and the mediating effect of Neonatal Intensive Care Unit (NICU) admission at one-month postpartum. METHODS This multicenter, prospective cohort study was conducted in Japan (n = 5398). SMM included preeclampsia, eclampsia, severe postpartum hemorrhage, placental abruption, and a ruptured uterus. Lack of affection (LA) and Anger and Rejection (AR) were assessed using the Mother-Infant Bonding Scale (MIBS), and self-harm ideation was assessed using the 10th item of the Edinburgh Postnatal Depression Scale (EPDS). Linear and logistic regression models were used to examine the association between SMM and MIBS score and self-harm ideation. A structural equation model (SEM) was employed to examine the mediating effect of NICU admission on the association between SMM and mother-infant bonding and postpartum depressive symptoms. RESULTS Women with SMM had a 0.21 (95 % confidence interval [CI]: 0.03-0.40) point higher MIBS score and a decreasing trend in the risk of self-harm ideation (odds ratio 0.28, 95 % CI: 0.07-1.14) compared to those without SMM. SEM analysis revealed that SMM was associated with MIBS partially through NICU admission. LIMITATIONS EPDS scores during pregnancy could be an unmeasured confounder. CONCLUSIONS Women with SMM had higher MIBS scores, particularly on the LA subscale, which was partially mediated by NICU admission. Psychotherapy to support parent-infant relationships is necessary for women with SMM.
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Affiliation(s)
- Shuhei Terada
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeo Fujiwara
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Junichi Sugawara
- Graduate School of Medicine, Tohoku University, Miyagi, Japan; Suzuki Memorial Hospital, Miyagi, Japan
| | - Kazuhisa Maeda
- Department of Obstetrics and Gynecology, National Hospital Organizations: Shikoku Medical Center for Children and Adults, Kagawa, Japan
| | - Shoji Satoh
- Maternal and Perinatal Care Center, Oita Prefectural Hospital, Oita, Japan
| | - Nobuaki Mitsuda
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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15
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Auger N, Ukah UV, Wei SQ, Healy-Profitós J, Lo E, Dayan N. Impact of Covid-19 on risk of severe maternal morbidity. Crit Care 2023; 27:344. [PMID: 37670329 PMCID: PMC10481463 DOI: 10.1186/s13054-023-04584-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/17/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND We examined the risk of severe life-threatening morbidity in pregnant patients with Covid-19 infection. METHODS We conducted a population-based study of 162,576 pregnancies between March 2020 and March 2022 in Quebec, Canada. The main exposure was Covid-19 infection, including the severity, period of infection (antepartum, peripartum), and circulating variant (wildtype, alpha, delta, omicron). The outcome was severe maternal morbidity during pregnancy up to 42 days postpartum. We estimated risk ratios (RR) and 95% confidence intervals (CI) for the association between Covid-19 infection and severe maternal morbidity using adjusted log-binomial regression models. RESULTS Covid-19 infection was associated with twice the risk of severe maternal morbidity compared with no infection (RR 2.02, 95% CI 1.76-2.31). Risks were elevated for acute renal failure (RR 3.01, 95% CI 1.79-5.06), embolism, shock, sepsis, and disseminated intravascular coagulation (RR 1.35, 95% CI 0.95-1.93), and severe hemorrhage (RR 1.49, 95% CI 1.09-2.04). Severe antepartum (RR 13.60, 95% CI 10.72-17.26) and peripartum infections (RR 20.93, 95% CI 17.11-25.60) were strongly associated with severe maternal morbidity. Mild antepartum infections also increased the risk, but to a lesser magnitude (RR 3.43, 95% CI 2.42-4.86). Risk of severe maternal morbidity was around 3 times greater during circulation of wildtype and the alpha and delta variants, but only 1.2 times greater during omicron. CONCLUSIONS Covid-19 infection during pregnancy increases risk of life-threatening maternal morbidity, including renal, embolic, and hemorrhagic complications. Severe Covid-19 infection with any variant in the antepartum or peripartum periods all increase the risk of severe maternal morbidity.
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Affiliation(s)
- Nathalie Auger
- University of Montreal Hospital Research Centre, Montreal, QC, Canada.
- Institut national de santé publique du Québec, Montreal, QC, Canada.
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.
- Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, QC, Canada.
| | - U Vivian Ukah
- Institut national de santé publique du Québec, Montreal, QC, Canada
- HealthPartners Institute, Pregnancy and Child Health Research Center, Bloomington, MN, USA
| | - Shu Qin Wei
- Institut national de santé publique du Québec, Montreal, QC, Canada
- Department of Obstetrics and Gynecology, University of Montreal, Montreal, QC, Canada
| | - Jessica Healy-Profitós
- University of Montreal Hospital Research Centre, Montreal, QC, Canada
- Institut national de santé publique du Québec, Montreal, QC, Canada
| | - Ernest Lo
- Institut national de santé publique du Québec, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Natalie Dayan
- Department of Medicine, McGill University, Montreal, QC, Canada
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Sosa C, de Mucio B, Colomar M, Mainero L, Costa ML, Guida JP, Souza RT, Luz AG, Cecatti JG, Sousa MH, Cruz CM, Chevez LM, Lopez R, Carrillo G, Rizo U, Saint Hillaire EE, Arriaga WE, Guadalupe RM, Ochoa C, Gonzalez F, Castro R, Stefan A, Moreno A, Serruya SJ. The impact of maternal morbidity on cesarean section rates: exploring a Latin American network of sentinel facilities using the Robson's Ten Group Classification System. BMC Pregnancy Childbirth 2023; 23:605. [PMID: 37620835 PMCID: PMC10464484 DOI: 10.1186/s12884-023-05937-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 08/18/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Latin America has the highest Cesarean Section Rates (CSR) in the world. Robson's Ten Group Classification System (RTGCS) was developed to enable understanding the CSR in different groups of women, classified according to obstetric characteristics into one of ten groups. The size of each CS group may provide helpful data on quality of care in a determined region or setting. Data can potentially be used to compare the impact of conditions such as maternal morbidity on CSR. The objective of this study is to understand the impact of Severe Maternal Morbidity (SMM) on CSR in ten different groups of RTGCS. METHODS Secondary analysis of childbirth information from 2018 to 2021, including 8 health facilities from 5 Latin American and Caribbean countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic), using a surveillance database (SIP-Perinatal Information System, in Spanish) implemented in different settings across Latin America. Women were classified into one of RTGCS. The frequency of each group and its respective CSR were described. Furthermore, the sample was divided into two groups, according to maternal outcomes: women without SMM and those who experienced SMM, considering Potentially Life-threatening Conditions, Maternal Near Miss and Maternal Death as the continuum of morbidity. RESULTS Available data were obtained from 92,688 deliveries using the Robson Classification. Overall CSR was around 38%. Group 5 was responsible for almost one-third of cesarean sections. SMM occurred in 6.7% of cases. Among these cases, the overall CSR was almost 70% in this group. Group 10 had a major role (preterm deliveries). Group 5 (previous Cesarean section) had a very high CSR within the group, regardless of the occurrence of maternal morbidity (over 80%). CONCLUSION Cesarean section rate was higher in women experiencing SMM than in those without SMM in Latin America. SMM was associated with higher Cesarean section rates, especially in groups 1 and 3. Nevertheless, group 5 was the major contributor to the overall CSR.
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Affiliation(s)
- Claudio Sosa
- Latin American Center of Perinatology, Women and Reproductive Health (CLAP/WR), Montevideo, Uruguay
| | - Bremen de Mucio
- Latin American Center of Perinatology, Women and Reproductive Health (CLAP/WR), Montevideo, Uruguay
| | - Mercedes Colomar
- Latin American Center of Perinatology, Women and Reproductive Health (CLAP/WR), Montevideo, Uruguay
| | - Luis Mainero
- Latin American Center of Perinatology, Women and Reproductive Health (CLAP/WR), Montevideo, Uruguay
| | - Maria L Costa
- Department of Obstetrics and Gynecology, University of Campinas, Campinas, SP, Brazil
| | - Jose P Guida
- Department of Obstetrics and Gynecology, University of Campinas, Campinas, SP, Brazil
| | - Renato T Souza
- Department of Obstetrics and Gynecology, University of Campinas, Campinas, SP, Brazil
| | - Adriana G Luz
- Department of Obstetrics and Gynecology, University of Campinas, Campinas, SP, Brazil
| | - José G Cecatti
- Department of Obstetrics and Gynecology, University of Campinas, Campinas, SP, Brazil.
| | - Maria H Sousa
- Jundiaí School of Medicine - HU/FMJ, Jundiaí, SP, Brazil
| | | | - Luz M Chevez
- Hospital Berta Calderon Roque, Managua, Nicaragua
| | - Rita Lopez
- Hospital Berta Calderon Roque, Managua, Nicaragua
| | | | | | | | | | | | | | | | | | - Allan Stefan
- Hospital Leonardo Martinez Valenzuela, San Pedro Sula, Honduras
| | | | - Suzanne J Serruya
- Latin American Center of Perinatology, Women and Reproductive Health (CLAP/WR), Montevideo, Uruguay
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17
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Khusid E, Lui B, Tangel VE, Jiang SY, Oxford C, Abramovitz SE, Weinstein ER, White RS. Patient- and Hospital- Level Disparities in Severe Maternal Morbidity: a Retrospective Multistate Analysis, 2015-2020. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01763-7. [PMID: 37610646 DOI: 10.1007/s40615-023-01763-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 08/24/2023]
Abstract
The rate of severe maternal morbidity (SMM) in the United States (US) rose roughly 9% among all insured racial/ethnic groups between 2018 and 2020, disproportionately affecting racial and ethnic minority populations. Limited research on hospital-level factors and SMM found that even after adjusting for patient-level factors, women of all races delivering in high Black-serving delivery units had higher odds of SMM. Our retrospective cohort study augments the current understanding of multi-level racial/ethnic disparities in SMM by analyzing patient- and hospital- level factors using multistate data from 2015 to 2020. Because rises in SMM have been driven in part by an increase in blood transfusions, multivariable logistic regression models were employed to estimate the impact of patient- and hospital-level factors on the adjusted odds of experiencing any SMM, with and without blood transfusions, as well as blood transfusions alone. Our cohort consisted of 3,497,233 deliveries: 56,885 (1.63%) with any SMM, 16,070 (0.46%) with SMM excluding blood transfusion, and 45,468 (1.30%) with blood transfusions alone. We found that Black race, Hispanic ethnicity, and delivering at Black-serving delivery-units, both independently and interactively, increase the odds of any SMM with or without blood transfusions. Our findings illustrate the persistence of structural- and individual- level racial and ethnic disparities in maternal outcomes over time and emphasize the need for multi-level public policies to address racial/ethnic disparities in maternal healthcare.
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Affiliation(s)
- Elizabeth Khusid
- Weill Cornell Medical College, Weill Cornell Medicine, NY, New York, USA
| | - Briana Lui
- Weill Cornell Medical College, Weill Cornell Medicine, NY, New York, USA
| | - Virginia E Tangel
- Department of Anesthesiology, New York Presbyterian/Weill Cornell Hospital, 525 East 68th Street, M324, New York, NY, 10065, USA
| | - Silis Y Jiang
- Department of Anesthesiology, New York Presbyterian/Weill Cornell Hospital, 525 East 68th Street, M324, New York, NY, 10065, USA
| | - Corrina Oxford
- Department of Maternal and Fetal Medicine, New York-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Sharon E Abramovitz
- Department of Anesthesiology, New York Presbyterian/Weill Cornell Hospital, 525 East 68th Street, M324, New York, NY, 10065, USA
| | - Eliana R Weinstein
- Department of Anesthesiology, New York Presbyterian/Weill Cornell Hospital, 525 East 68th Street, M324, New York, NY, 10065, USA
| | - Robert S White
- Department of Anesthesiology, New York Presbyterian/Weill Cornell Hospital, 525 East 68th Street, M324, New York, NY, 10065, USA.
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Docheva N, Heimberger S, Mueller A, Bisson C, Arenas G, Perdigao JL, Kordik A, Stewart K, Goodall P, Lengyel E, Rana S. A Comparison of Obstetric Interventions and Outcomes Between Black and White Patients at an Urban Tertiary Medical Center. Reprod Sci 2023; 30:2313-2323. [PMID: 36717463 DOI: 10.1007/s43032-023-01174-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/13/2023] [Indexed: 02/01/2023]
Abstract
The objective of the study is to evaluate whether rates of selected labor and delivery interventions and severe maternal morbidity (SMM) differ between Black and White pregnant patients. This retrospective observational cohort study included all Black or White pregnant patients who delivered at the University of Chicago Medical Center between January 2015 and December 2019. Data queried included demographic information, antepartum complications, preterm interventions, labor and delivery events, and neonatal outcomes. SMM was a composite outcome, including intensive care unit admission, blood transfusion, hysterectomy, eclampsia, cardiac arrest, or death. In total, 10,885 parturients (9001 Black and 1884 White) and 11,211 neonates (9254 born to Black and 1957 to White patients) were included in the study. Black patients were more likely to have preterm labor (3.51% vs. 1.86%, p = 0.0002) and no prenatal care (17.83% vs. 4.05%, p < 0.0001). There was no significant difference in the administration of magnesium sulfate for fetal neuroprotection (Black 44.78% vs. White 49.32%, p = 0.48) or antenatal corticosteroids (Black 67.83% vs. White 71.98%, p = 0.28) among those with preterm delivery. There was no significant difference in SMM (Black 2.24% vs. White 2.44%, p = 0.60), and SMM rates decreased over time (OR 0.79 per year, 95% CI: 0.72-0.87, p < 0.0001) for all patients. Black patients had more pregnancy complications, but their complications were addressed with similar rates of obstetrical interventions. In a high-resource setting, there was no difference in rates of SMM when compared to White patients.
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Affiliation(s)
- Nikolina Docheva
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Sarah Heimberger
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Ariel Mueller
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Courtney Bisson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Gabriel Arenas
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Joana Lopes Perdigao
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Abbe Kordik
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Karie Stewart
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Perpetua Goodall
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Ernst Lengyel
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Sarosh Rana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA.
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19
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Mari KE, Yang N, Boland MR, Meeker JR, Ledyard R, Howell EA, Burris HH. Assessing racial residential segregation as a risk factor for severe maternal morbidity. Ann Epidemiol 2023; 83:23-29. [PMID: 37146923 PMCID: PMC10330880 DOI: 10.1016/j.annepidem.2023.04.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/17/2023] [Accepted: 04/27/2023] [Indexed: 05/07/2023]
Abstract
PURPOSE To measure associations of area-level racial and economic residential segregation with severe maternal morbidity (SMM). METHODS We conducted a retrospective cohort study of births at two Philadelphia hospitals between 2018 and 2020 to analyze associations of segregation, quantified using the Index of Concentration at the Extremes (ICE), with SMM. We used stratified multivariable, multilevel, logistic regression models to determine whether associations of ICE with SMM varied by self-identified race or hospital catchment. RESULTS Of the 25,979 patients (44.1% Black, 35.8% White), 1381 (5.3%) had SMM (Black [6.1%], White [4.4%]). SMM was higher among patients residing outside (6.3%), than inside (5.0%) Philadelphia (P < .001). Overall, ICE was not associated with SMM. However, ICErace (higher proportion of White vs. Black households) was associated with lower odds of SMM among patients residing inside Philadelphia (aOR 0.87, 95% CI: 0.80-0.94) and higher odds outside Philadelphia (aOR 1.12, 95% CI: 0.95-1.31). Moran's I indicated spatial autocorrelation of SMM overall (P < .001); when stratified, autocorrelation was only evident outside Philadelphia. CONCLUSIONS Overall, ICE was not associated with SMM. However, higher ICErace was associated with lower odds of SMM among Philadelphia residents. Findings highlight the importance of hospital catchment area and referral patterns in spatial analyses of hospital datasets.
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Affiliation(s)
- Katey E Mari
- Department of Anthropology, University of Pennsylvania, Philadelphia, PA; Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA
| | - Nancy Yang
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Mary Regina Boland
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; The Center for Excellence in Environmental Toxicology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA; Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, PA
| | - Jessica R Meeker
- Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA; Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, PA
| | - Rachel Ledyard
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth A Howell
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Heather H Burris
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.
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Youssefzadeh AC, Klar M, Seifert GJ, Mandelbaum RS, Sangara RN, McCarthy LE, Cheng V, Matsushima K, Ouzounian JG, Matsuo K. Pregnancy characteristics and outcomes after bariatric surgery: national-level analysis in the United States. Surg Obes Relat Dis 2023; 19:364-373. [PMID: 36470811 DOI: 10.1016/j.soard.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/16/2022] [Accepted: 10/16/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Bariatric surgery is an effective surgical treatment for weight reduction in individuals with obesity. Pregnancy outcomes related to prior bariatric surgery are currently under active investigation. OBJECTIVE To assess national-level trends, characteristics, and outcomes of pregnancy after bariatric surgery in the United States. SETTING Retrospective cohort study queried the National Inpatient Sample. METHODS The study population was 14,648,135 patients who had vaginal or cesarean delivery from January 2016 to December 2019. Exposure allocation was based on the history of bariatric surgery. The main outcomes were (1) trends and characteristics related to bariatric surgery, assessed with multivariable binary logistic regression model; and (2) Centers for Disease Control and Prevention-defined severe maternal morbidity, assessed by propensity score matching and generalized estimating equation. RESULTS A total of 53,950 (.4%) patients had prior bariatric surgery. The number of patients with prior bariatric surgery increased from .3% to .5%, and this trend remained independent in multivariable analysis (P < .001). Patients who had bariatric surgery were also more likely to be older and have obesity, medical co-morbidities, fetal growth restriction, preterm birth, and cesarean delivery compared with those without bariatric surgery (all, P < .05). In a propensity score matched model, patients who had bariatric surgery were more likely to receive blood product transfusion (2.3% versus 1.6%; odds ratio = 1.45; 95% confidence interval, 1.19-1.77), but severe maternal morbidity other than blood product transfusion was comparable to those without (1.1% versus 1.4%; odds ratio = .80; 95% confidence interval, .63-1.02). CONCLUSION There is a gradual increase of pregnancy after bariatric surgery in recent years in the United States.
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Affiliation(s)
- Ariane C Youssefzadeh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Gabriel J Seifert
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California; Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Rauvynne N Sangara
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Lauren E McCarthy
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California; Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Vincent Cheng
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California.
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21
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Aa C, P P, C CD, C CH, F V, C LR, C DT. Peripartum severe acute maternal morbidity in low-risk women: A population-based study. Midwifery 2023; 119:103602. [PMID: 36738542 DOI: 10.1016/j.midw.2023.103602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 01/18/2023] [Accepted: 01/22/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND Knowledge of severe acute maternal morbidity (SAMM) and its risk factors is constantly growing, but studies have rarely focused on the specific population of low-risk women. AIM To estimate the prevalence and to identify subgroups at risk of peripartum SAMM in low-risk women METHODS: From a population-based cohort-nested case-control study conducted in six French regions, i.e., 182 309 women who gave birth at ≥22 weeks in 119 maternity units, we selected women considered at low risk up to the end of pregnancy before labour according to the NICE guidelines and compared those experiencing peripartum SAMM (during birth and up to 7 days postpartum; n = 489) to a 2% random sample of women without peripartum SAMM from the same units (n = 1800). Risk factors for peripartum SAMM were identified by multivariable logistic regression. FINDINGS amongst low-risk women, the estimated rate of SAMM was 0.548/100 deliveries (95%CI 0.501-0.599). Severe obstetric haemorrhage was the main cause (83.6% of SAMM cases). Main risk factors for peripartum SAMM were primiparity (aOR 2.4, 95%CI 1.9-3.0), IVF pregnancy (aOR 1.8, 1.0-3.4), third-trimester anaemia (aOR 1.7, 1.3-2.3), being born out of Europe or Africa (aOR 1.9, 1.2-3.0). CONCLUSION amongst women considered at low risk up to the end of pregnancy before labour, peripartum SAMM is rare but still exists. Knowledge of risk factors of SAMM in this population will inform the discussion on peripartum risks and the most appropriate place of birth for each woman.
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Affiliation(s)
- Chantry Aa
- Université Paris Cité, Center of Research in Epidemiology and StatisticS/CRESS/Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, INRA, F-75004 Paris, France; Midwifery School of Baudelocque, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, F-75006 Paris, France.
| | - Peretout P
- Université Paris Cité, Center of Research in Epidemiology and StatisticS/CRESS/Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, INRA, F-75004 Paris, France
| | - Chiesa-Dubruille C
- Université Paris Cité, Center of Research in Epidemiology and StatisticS/CRESS/Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, INRA, F-75004 Paris, France
| | - Crenn-Hébert C
- Perinat-ARS-IDF, Regional Health Agency of Ile-de-France (ARS-IDF), F-93200 Saint-Denis, France; Louis Mourier Maternity Unit, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, F-92025 Colombes, France
| | - Vendittelli F
- Auvergne Perinatal Health Network, CHU Clermont-Ferrand, F-63000 Clermont-Ferrand, France; Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, Institut Pascal, F-63000 Clermont-Ferrand, France
| | - Le Ray C
- Université Paris Cité, Center of Research in Epidemiology and StatisticS/CRESS/Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, INRA, F-75004 Paris, France; Port Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, F-75014 Paris, France
| | - Deneux-Tharaux C
- Université Paris Cité, Center of Research in Epidemiology and StatisticS/CRESS/Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, INRA, F-75004 Paris, France
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22
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Dakin A, Clinton S, Sloan J, Dicker P, Byrne BM. Severe maternal morbidity trends over 20 years in a tertiary referral stand-alone maternity unit. Eur J Obstet Gynecol Reprod Biol 2023; 283:136-140. [PMID: 36868005 DOI: 10.1016/j.ejogrb.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/08/2023] [Accepted: 02/12/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Severe maternal morbidity (SMM) is a better indicator of quality of care than maternal mortality, which is a rare event. Risk factors such as advanced maternal age, caesarean section (CS) and obesity are increasing. The aim of this study was to examine the rate and trends in SMM at our hospital over a 20-year period. STUDY DESIGN Retrospective review was performed of cases of SMM from January 1st 2000 to December 31st 2019. Yearly rates for SMM and Major Obstetric Haemorrhage (MOH) were calculated (per 1000 maternities) and linear regression analysis was used to model the trends over time. Average SMM and MOH rates were also calculated for the periods 2000-2009 and 2010-2019 and compared using a chi-square test. The patient demographics of the SMM group were compared to the background population delivered at our hospital using a chi-square test. RESULTS 702 women with SMM were identified out of 162,462 maternities over the study period yielding an incidence of 4.3 per 1000 maternities. When the two time periods (2000-2009 and 2010-2019) are compared, the rate of SMM increased 2.4 vs 6.2 (p < 0.001), largely due to an increase in MOH 1.72 vs 3.86 (p < 0.001) and pulmonary embolus (PE) also increased 0.2 vs 0.5 (p = 0.012). Intensive-care unit (ICU) transfer rates more than doubled 0.19 vs 0.44 (p = 0.006). Eclampsia rates decreased 0.3 vs 0.1 (p = 0.047) but the rate of peripartum hysterectomy 0.39 vs 0.38 (p = 0.495), uterine rupture 0.16 vs 0.14 (p = 0.867), cardiac arrest (0.04 vs 0.04) and cerebrovascular accidents (CVA) (0.04 vs 0.04) remained unchanged. Maternal age > 40 years 9.7% vs 5% (p = 0.005), previous CS 25.7% vs 14.4%; p < 0.001 and multiple pregnancy 8 vs 3.6% (p = 0.002) were more prevalent in the SMM cohort compared to the hospital population. CONCLUSIONS Overall, rates of SMM have increased threefold and transfer for ICU care has doubled over 20 years in our unit. The main driver is MOH. The rate of eclampsia has decreased and peripartum hysterectomy, uterine rupture, CVA and cardiac arrest remain unchanged. Advanced maternal age, previous caesarean delivery and multiple pregnancy were more prevalent in the SMM cohort compared to the background population.
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Affiliation(s)
- A Dakin
- RCSI Department of Obstetrics and Gynaecology, Ireland; Coombe Women and Infants University Hospital, Dublin 8, Ireland.
| | - S Clinton
- RCSI Department of Obstetrics and Gynaecology, Ireland
| | - J Sloan
- RCSI Department of Obstetrics and Gynaecology, Ireland; Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - P Dicker
- RCSI Department of Statistics, Ireland
| | - B M Byrne
- RCSI Department of Obstetrics and Gynaecology, Ireland; Coombe Women and Infants University Hospital, Dublin 8, Ireland
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23
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Ben-Ayoun D, Walfisch A, Wainstock T, Sheiner E, Imterat M. Trend and risk Factors for Severe Peripartum Maternal morbidity - a population-based Cohort Study. Matern Child Health J 2023; 27:719-727. [PMID: 36670306 DOI: 10.1007/s10995-022-03568-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/29/2022] [Accepted: 12/20/2022] [Indexed: 01/22/2023]
Abstract
OBJECTIVES While the rates of maternal mortality in developed countries have remained low in recent years, rates of severe maternal morbidity (SMM) are still increasing in high income countries. As a result, SMM is currently used as a measure of maternity care level. The aim of this study was to investigate the prevalence and risk factors of SMM surrounding childbirth. METHODS A nested case-control study was performed between the years 2013-2018. SMM was defined as peripartum hospitalization involving intensive care unit (ICU). A comparison was conducted between parturient with SMM to those without, randomly matched for delivery mode and date of birth in a 1:1 ratio. Multivariable logistic regression models were used to evaluate the independent association between SMM and different maternal and pregnancy characteristics. RESULTS During the study period, 96,017 live births took place, of which 144 (1.5 per 1,000 live births-0.15%) involved SMM with ICU admissions. Parturient with SMM were more likely to have a history of 2 or more pregnancy losses (18.2% vs. 8.3%, p = 0.004), deliver preterm (48.9% vs. 8.8%, p < 0.001), and suffer from placenta previa (11.9% vs. 1.5%, p < 0.001), and/or placenta accreta (9.7% vs. 1.5%, p = 0.003). Several significant and independent risk factors for SMM were noted in the multivariable regression models: preterm delivery, history of ≥ 2 pregnancy losses, grand-multiparity, Jewish ethnicity, and abnormal placentation (previa or accreta). CONCLUSIONS FOR PRACTICE SMM rates in our cohort were lower than reported in developed countries. An independent association exists between peripartum maternal ICU admissions and several demographic and clinical risk factors, including preterm birth and abnormal placentation.
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Affiliation(s)
- Danielle Ben-Ayoun
- Faculty of Health Sciences, Ben-Gurion University of the Negev, 151 Izak Rager Ave. Beer-Sheva, 84101, Beer-Sheva, Israel.
| | - Asnat Walfisch
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamar Wainstock
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Majdi Imterat
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany
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Burns A, DeAtley T, Short SE. The maternal health of American Indian and Alaska Native people: A scoping review. Soc Sci Med 2023; 317:115584. [PMID: 36521232 PMCID: PMC9875554 DOI: 10.1016/j.socscimed.2022.115584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 11/30/2022]
Abstract
Indigenous people in the United States experience disadvantage in multiple domains of health. Yet, their maternal health receives limited research attention. With a focus on empirical research findings, we conduct a scoping review to address two questions: 1) what does the literature tell us about the patterns and prevalence of maternal mortality and morbidity of American Indian and Alaska Native (AI/AN) people? and 2) how do existing studies explain these patterns? A search of CINAHL, Embase and Medline yielded 4757 English-language articles, with 66 eligible for close review. Of these, few focused specifically on AI/AN people's maternal health. AI/AN people experience higher levels of maternal mortality and morbidity than non-Hispanic White people, with estimates that vary substantially across samples and geography. Explanations for the maternal health of AI/AN people focused on individual factors such as poverty, cultural beliefs, and access to healthcare (e.g. lack of insurance). Studies rarely addressed the varied historical and structural contexts of AI/AN tribal nations, such as harms associated with colonization and economic marginalization. Research for and by Indigenous communities and nations is needed to redress the effective erasure of AI/AN people's maternal health experiences and to advance solutions that will promote their health and well-being.
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Affiliation(s)
- Ailish Burns
- Department of Sociology, Brown University, 108 George St Box 1916, Providence RI, 02912, USA; Population Studies and Training Center, Brown University, 68 Waterman St Box 1836, Providence RI, 02912, USA.
| | - Teresa DeAtley
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA
| | - Susan E Short
- Department of Sociology, Brown University, 108 George St Box 1916, Providence RI, 02912, USA; Population Studies and Training Center, Brown University, 68 Waterman St Box 1836, Providence RI, 02912, USA
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25
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Jeffers NK, Berger BO, Marea CX, Gemmill A. Investigating the impact of structural racism on black birthing people - associations between racialized economic segregation, incarceration inequality, and severe maternal morbidity. Soc Sci Med 2023; 317:115622. [PMID: 36542927 PMCID: PMC9910389 DOI: 10.1016/j.socscimed.2022.115622] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Noelene K Jeffers
- Johns Hopkins Bloomberg School of Public Health, Department of Population Family, And Reproductive Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States.
| | - Blair O Berger
- Johns Hopkins Bloomberg School of Public Health, Department of Population Family, And Reproductive Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States.
| | - Christina X Marea
- Georgetown University School of Nursing & Health Studies, Department of Advanced Nursing Practice, St. Mary's Hall 3700 Reservoir Road, N.W., Washington D.C, 20057-1107, United States.
| | - Alison Gemmill
- Johns Hopkins Bloomberg School of Public Health, Department of Population Family, And Reproductive Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States.
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Freeman C, Stanhope KK, Wichmann H, Jamieson DJ, Boulet SL. Neighborhood deprivation and severe maternal morbidity in a medicaid-Insured population in Georgia. J Matern Fetal Neonatal Med 2022; 35:10110-10115. [PMID: 36038962 DOI: 10.1080/14767058.2022.2118045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
BACKGROUND Despite growing acceptance of the role of context in shaping perinatal risk, data on how neighborhood factors may identify high-risk obstetric patients is limited. In this study, we evaluated the effect of neighborhood deprivation and neighborhood racial composition on severe maternal morbidity (SMM) among persons delivered in a large public health system in Atlanta, Georgia. METHODS We conducted a population cohort study using electronic medical record data on all deliveries at Grady Memorial Hospital during 2011-2020. Using residential zip codes, we calculated neighborhood deprivation index based on data from the US Census. We used log-binomial regression with generalized estimating equations to estimate crude and adjusted relative risks (aRR) and 95% confidence intervals (CI) for the association between tertile of neighborhood deprivation and SMM, adjusting for demographic, clinical, and neighborhood-level (racial composition, food desert, and transit access) covariates. RESULTS Among 25,257 deliveries, 6.2% (1566) experienced SMM. Approximately 24.0%, 32.0%, and 44.0% of women lived in the lowest, middle, and highest tertile of neighborhood deprivation, respectively and 64.9% lived in a neighborhood with majority non-Hispanic Black residents. After adjustment, there was no association between neighborhood deprivation and SMM (aRR: 1.0 (0.8, 1.1)) or residence in a majority Black neighborhood and SMM (aRR:1.0 (0.9, 1.2)). CONCLUSION In this safety-net hospital, residence in a high deprivation or majority Black neighborhood did not predict SMM at or following delivery. Individual-level social determinants may better explain variation in risk, particularly in high-burden populations.
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Affiliation(s)
- Christian Freeman
- Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Kaitlyn K Stanhope
- Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Hannah Wichmann
- Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Denise J Jamieson
- Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Sheree L Boulet
- Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
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Nam JY. Comparison of global indicators for severe maternal morbidity among South Korean women who delivered from 2003 to 2018: a population-based retrospective cohort study. Reprod Health 2022; 19:177. [PMID: 35964088 PMCID: PMC9375335 DOI: 10.1186/s12978-022-01482-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Even though several severe maternal morbidity (SMM) indicators exist globally, indicators that can serve as international standards are needed. Therefore, this study aimed to compare the SMM risk assessment using four international indicators and identify the factors underlying the differences among the risk assessments obtained by the various indicators. Methods This study used the National Health Insurance delivery cohort in South Korea from 2003 to 2018. SMM was estimated using four indicators: the United States Centers for Disease Control and Prevention (US-CDC) SMM algorithm, the American College of Obstetricians and Gynecologists (ACOG) gold standard guidelines, Zwart et al.’s indicators for the Netherlands, and the European Network on Severe Acute Maternal Morbidity (EURONET-SAMM) index. Generalized estimating equations models were used to identify the relationships between SMM indicators and risk factors. Results The SMM incidence rates in 6,421,091 deliveries, were 2.36%, 3.12%, 0.31%, and 1.36% using the US-CDC, ACOG, Zwart et al.’s, and EURONET SAMM indicators, respectively. In sub indicators, hemorrhage-related codes constituted the highest proportion of all SMM indicators. Advanced maternal age was related to high risk in all four SMM indicators (US-CDC: 40–44 years, RR 1.67, 95% CI 1.63–1.71; ACOG’s guidelines: 40–44 years, RR 1.52, 95% CI 1.49–1.56; Zwart’s indicators: RR 2.72, 95% CI 2.55–2.90; EURONET-SAMM: RR 2.04, 95% CI 1.97–2.11) compared to those aged 25–29 years. In residential area, women who lived in rural area had approximately 1.2- to 1.5-fold higher risk of SMM compared to those who lived in Seoul. Additionally, inadequate prenatal care was associated with a 1.1- to 1.4-fold higher risk of SMM compared to adequate prenatal care. Conclusions SMM was associated with maternal age, socioeconomic status, and adverse obstetric factors using various international SMM indicators. Further studies are needed to further determine risk and preventable factors for SMM and to identify more specific causes associated with the frequent sub-indicators of SMM. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-022-01482-y. There are several indicators of severe maternal morbidity (SMM) globally, but indicators that can serve as international standards are not exist yet. This study compared the SMM risk assessment using four international indicators such as US-CDC’s SMM, ACOG’s gold standard guidelines, Zwart et al.’s SMM, and EURONET-SAMM, and identify the factors underlying the differences among the risk assessments obtained by the various indicators. This study extracted women who were aged 15–49 years, those who had childbirth in the healthcare institute during 2003 to 2018 in South Korea using the National Health Insurance database. Of the 6,421,091 childbirth cases, the incidence of each SMM indicators were as follow: the US-CDC’s SMM: 2.4%; the ACOG’s gold standard guidelines: 3.1%; Zwart et al.’s SMM: 0.3%; the EURONET-SAMM: 1.4% indicators. In addition, the highest incidence of each sub-indicators was blood transfusion or obstetric hemorrhage which recorded more than 70% of total SMM cases. In particular, the risk factor on SMM were: advanced maternal age; living rural area; inadequate prenatal care. In conclusion, SMM was associated with maternal age, socioeconomic status, and adverse obstetric factors using various global SMM indicators. Therefore, further studies are needed to identify more specific causes associated with the frequent sub-indicators of SMM and to determine risk and preventable factors for SMM.
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Affiliation(s)
- Jin Young Nam
- Department of Healthcare Management, Eulji University, Sanseongdae-ro 553, Sujeong-gu, Seongnam, Gyeonggi-do, 13135, Republic of Korea.
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Nwabueze N, Docheva N, Arenas G, Mueller A, Lopes Perdigao J, Rana S. Prevalence and management of severe intrapartum hypertension in patients with preeclampsia at an urban tertiary care medical center. Pregnancy Hypertens 2022; 27:87-93. [PMID: 34973598 DOI: 10.1016/j.preghy.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Data on management of severe intrapartum hypertension is lacking. The aim of this study is to explore the proportion of timely interventions in severe, persistent intrapartum hypertension treatment by exploring the prevalence and management of intrapartum hypertension trends. STUDY DESIGN This was a retrospective case-control study of pregnant women who delivered at the University of Chicago between January 2015 and March 2017. Patients with severe preeclampsia who underwent labor (either induced or spontaneous) were stratified into two groups: severe intrapartum hypertension and no severe intrapartum hypertension. MAIN OUTCOME MEASURES Type of treatment and timing to treatment of severe hypertensive episodes were explored as well as prevalence of maternal adverse outcomes. RESULTS A total of 95 patients with severe preeclampsia in labor were identified. In patients with persistent severe intrapartum hypertension (n = 52), 15 (28.9%) received treatment. Patients experiencing greater than three episodes of blood pressure elevation were more likely to receive treatment as compared to those with fewer episodes. There was no significant difference in severe maternal morbidity (SMM) between those treated within 60 min compared to those untreated or treated after 60 min (16.7% vs 27.5%; p = 0.71). CONCLUSIONS Management protocols of intrapartum hypertensive episodes are variable or not universally implemented. Inadequately treated episodes of severe intrapartum hypertension trend towards higher rates of SMM.
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Gu N, Zheng Y, Dai Y. Severe maternal morbidity: admission shift from intensive care unit to obstetric high-dependency unit. BMC Pregnancy Childbirth 2022; 22:140. [PMID: 35189867 PMCID: PMC8862286 DOI: 10.1186/s12884-022-04480-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 02/15/2022] [Indexed: 11/18/2022] Open
Abstract
Background To study temporal trends of intensive care unit (ICU) admission in obstetric population after the introduction of obstetric high-dependency unit (HDU). Methods This is a retrospective study of consecutive obstetric patients admitted to the ICU/HDU in a provincial referral center in China from January 2014 to December 2019. The collected information included maternal demographic characteristics, indications for ICU and HDU admission, the length of ICU stay, the total length of in-hospital stay and APACHE II score. Chi-square and ANOVA tests were used to determine statistical significance. The temporal changes were assessed with chi-square test for linear trend. Results A total of 40,412 women delivered and 447 (1.11%) women were admitted to ICU in this 6-year period. The rate of ICU admission peaked at 1.59% in 2016 and then dropped to 0.67% in 2019 with the introduction of obstetric HDU. The average APACHE II score increased significantly from 6.8 to 12.3 (P < 0.001) and the average length of ICU stay increased from 1.7 to 7.1 days (P < 0.001). The main indications for maternal ICU admissions were hypertensive disorders in pregnancy (39.8%), cardiac diseases (24.8%), and other medical disorders (21.5%); while the most common reasons for referring to HDU were hypertensive disorders of pregnancy (46.5%) and obstetric hemorrhage (43.0%). The establishment of HDU led to 20% reduction in ICU admission, which was mainly related to obstetric indications. Conclusions The introduction of HDU helps to reduce ICU utilization in obstetric population.
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Affiliation(s)
- Ning Gu
- Department of Obstetrics and Gynecology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China
| | - Yaning Zheng
- Department of Obstetrics and Gynecology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China
| | - Yimin Dai
- Department of Obstetrics and Gynecology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China.
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Harden SR, Runkle JD, Sugg MM. An Exploratory Spatiotemporal Analysis of Socio-Environmental Patterns in Severe Maternal Morbidity. Matern Child Health J 2022. [PMID: 35060067 DOI: 10.1007/s10995-021-03330-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 10/19/2022]
Abstract
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.
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El Ayadi AM, Baer RJ, Gay C, Lee HC, Obedin-Maliver J, Jelliffe-Pawlowski L, Lyndon A. Risk Factors for Dual Burden of Severe Maternal Morbidity and Preterm Birth by Insurance Type in California. Matern Child Health J 2022. [PMID: 35041142 DOI: 10.1007/s10995-021-03313-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 11/06/2022]
Abstract
Objectives Among childbearing women, insurance coverage determines degree of access to preventive and emergency care for maternal and infant health. Maternal-infant dyads with dual burden of severe maternal morbidity and preterm birth experience high physical and psychological morbidity, and the risk of dual burden varies by insurance type. We examined whether sociodemographic and perinatal risk factors of dual burden differed by insurance type. Methods We estimated relative risks of dual burden by maternal sociodemographic and perinatal characteristics in the 2007–2012 California birth cohort dataset stratified by insurance type and compared effects across insurance types using Wald Z-statistics. Results Dual burden ranged from 0.36% of privately insured births to 0.41% of uninsured births. Obstetric comorbidities, multiple gestation, parity, and birth mode conferred the largest risks across all insurance types, but effect magnitude differed. The adjusted relative risk of dual burden associated with preeclampsia superimposed on preexisting hypertension ranged from 9.1 (95% CI 7.6–10.9) for privately insured to 15.9 (95% CI 9.1–27.6) among uninsured. The adjusted relative risk of dual burden associated with cesarean birth ranged from 3.1 (95% CI 2.7–3.5) for women with Medi-Cal to 5.4 (95% CI 3.5–8.2) for women with other insurance among primiparas, and 7.0 (95% CI 6.0–8.3) to 19.4 (95% CI 10.3–36.3), respectively, among multiparas. Conclusions Risk factors of dual burden differed by insurance type across sociodemographic and perinatal factors, suggesting that care quality may differ by insurance type. Attention to peripartum care access and care quality provided by insurance type is needed to improve maternal and neonatal health. Supplementary Information The online version contains supplementary material available at 10.1007/s10995-021-03313-1.
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Abstract
Maternal morbidity and mortality are rising due in part to the rising prevalence of chronic illness, socioeconomic and racial disparities, and advanced maternal age. Prevention of maternal adverse outcomes requires prompt escalation of care to facilities with appropriate capabilities including intensive care services. The development of obstetrical-specific risk assessment tools and protocolized care for the most common causes of maternal intensive care unit (ICU) admission has helped to reduce preventable complications. However, significant work remains to address barriers to the escalation of maternal care and minimize delays in appropriate management.
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Affiliation(s)
- Elisa C Walsh
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA 02114, USA
| | - Emily E Naoum
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA 02114, USA.
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Murugappan G, Alvero RJ, Lyell DJ, Khandelwal A, Leonard SA. Development and validation of a risk prediction index for severe maternal morbidity based on preconception comorbidities among infertile patients. Fertil Steril 2021; 116:1372-1380. [PMID: 34266662 DOI: 10.1016/j.fertnstert.2021.06.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/10/2021] [Accepted: 06/10/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To develop and validate a preconception risk prediction index for severe maternal morbidity (SMM), defined by the Centers for Disease Control and Prevention as indicators of a life-threatening complication, among infertile patients. DESIGN Retrospective analysis of live births and stillbirths from 2007 to 2017 among infertile women. SETTING National commercial claims database. PATIENT(S) Infertile women identified on the basis of diagnosis, testing, or treatment codes. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The primary outcome was SMM, identified as any indicator from the Centers for Disease Control and Prevention Index except blood transfusion alone, which was found to overestimate cases. Twenty preconception comorbidities associated with a risk of SMM were selected from prior literature. Targeted ensemble learning methods were used to rank the importance of comorbidities as potential risk factors for SMM. The independent strength of the association between each comorbidity and SMM was then used to define each comorbidity's risk score. RESULT(S) Among 94,097 infertile women with a delivery, 2.3% (n = 2,181) experienced an SMM event. The highest risk of SMM was conferred by pulmonary hypertension, hematologic disorders, renal disease, and cardiac disease. Associated significant risks were lowest for substance abuse disorders, prior cesarean section, age ≥40 years, gastrointestinal disease, anemia, mental health disorders, and asthma. The receiver operating characteristic area under the curve for the developed comorbidity score was 0.66. Calibration plots showed good concordance between the predicted and actual risk of SMM. CONCLUSION(S) We developed and validated an index to predict the probability of SMM on the basis of preconception comorbidities in patients with infertility. This tool may inform preconception counseling of infertile women and support maternal health research initiatives.
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Affiliation(s)
- Gayathree Murugappan
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Stanford University, Sunnyvale, California.
| | - Ruben J Alvero
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Stanford University, Sunnyvale, California
| | - Deirdre J Lyell
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University, Stanford, California
| | - Abha Khandelwal
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California
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Abstract
Racism in America has deep roots that impact maternal health, particularly through pervasive inequities among Black women as compared with White, although other racial and ethnic groups also suffer. Health care providers caring for pregnant women are optimally positioned to maintain vigilance for these disparities in maternal care, and to intervene with their diverse skillsets and knowledge. By increasing awareness of how structural racism drives inequities in health, these providers can encourage hospitals and practices to develop and implement national bundles for patient safety, and use bias training and team-based training practices aimed at improving care for racially diverse mothers.
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Affiliation(s)
- Rebecca D Minehart
- Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, GRJ 440, Boston, MA 02114, USA.
| | - Allison S Bryant
- Department of Obstetrics and Gynecology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Founders 4, Boston, MA 02114, USA. https://twitter.com/asbryantmantha
| | - Jaleesa Jackson
- Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, GRJ 440, Boston, MA 02114, USA. https://twitter.com/jjacksonMD
| | - Jaime L Daly
- Department of Anesthesiology, University of Colorado School of Medicine, University of Colorado Hospital, 12605 East 16th Avenue, Aurora, CO 80045, USA
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Sushma R, Norhayati MN, Nik Hazlina NH. Prevalence of neonatal near miss and associated factors in Nepal: a cross-sectional study. BMC Pregnancy Childbirth 2021; 21:422. [PMID: 34107909 PMCID: PMC8190855 DOI: 10.1186/s12884-021-03894-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 05/24/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The rate of neonatal mortality has declined but lesser than the infant mortality rate and remains a major public health challenge in low- and middle-income countries. There is an urgent need to focus on newborn care, especially during the first 24 h after birth and the early neonatal period. Neonatal near miss (NNM) is an emerging concept similar to that of maternal near miss. NNM events occur three to eight times more often than neonatal deaths. The objective of this study was to establish the prevalence of NNM and identify its associated factors. METHODS A hospital-based cross-sectional study was conducted in Koshi Hospital, Morang district, Nepal. Neonates and their mothers of unspecified maternal age and gestational age were enrolled. Key inclusion criteria were pragmatic and management markers of NNM and admission of newborn infants to the neonatal intensive care unit (NICU) in Koshi Hospital. Non-Nepali citizens were excluded. Consecutive sampling was used until the required sample size of 1,000 newborn infants was reached. Simple and multiple logistic regression was performed using SPSS® version 24.0. RESULTS One thousand respondents were recruited. The prevalence of NNM was 79 per 1,000 live births. Severe maternal morbidity (adjusted odds ratio (aOR) 4.52; 95% confidence interval (CI) 2.07-9.84) and no formal education (aOR 2.16; 95% CI 1.12-4.14) had a positive association with NNM, while multiparity (aOR 0.52; 95% CI 0.32-0.86) and caesarean section (aOR 0.44; 95% CI 0.19-0.99) had negative associations with NNM. CONCLUSIONS Maternal characteristics and complications were associated with NNM. Healthcare providers should be aware of the impact of obstetric factors on newborn health and provide earlier interventions to pregnant women, thus increasing survival chances of newborns.
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Affiliation(s)
- Rajbanshi Sushma
- Women's Health Development Unit, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Mohd Noor Norhayati
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia.
| | - Nik Hussain Nik Hazlina
- Women's Health Development Unit, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia
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Easter SR, Gilmore KC, Schulkin J, Robinson JN. Provider Attitudes on Regionalization of Maternity Care: A National Survey. Matern Child Health J 2021; 25:1402-1409. [PMID: 34097190 DOI: 10.1007/s10995-021-03179-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To explore provider perspectives surrounding national guidelines proposing regionalization of maternal care. METHODS An 18-item survey focused on provider attitudes and practices surrounding regionalized maternity care was administered to a national sample of practicing obstetricians. We classified respondants reporting less than 500 annual deliveries at their hospital as low-volume providers and those practicing at hospitals performing 500 or more annual deliveries as high-volume providers. We compared responses according to hospital delivery volume using univariate analysis. RESULTS Of the 497 physicians surveyed, 278 people responded (56%) with 229 currently practicing obstetrics. The median annual delivery volume amongst respondents was 200 (interquartile range 100-1900) with 146 (63.7%) practicing in low-volume delivery centers. The need for medical or surgical expertise was the most commonly reported indication for maternal transfer (19.7%) and independent of practice setting. Ninety-six percent of providers agreed with the concept of regionalization, but respondents in high-volume centers reported higher familiarity with the levels of maternal care paradigm compared to their low-volume counterparts (81.9% v. 62.3%, p < 0.01). Financial factors (60.3%), geography (48.9%), and access to care (43.2%) were the most cited major barriers to regionalization. High-volume providers endorsed geography as a major barrier more often than low-volume providers (57.8% v. 43.8%, p = 0.04). CONCLUSIONS FOR PRACTICE Obstetricians may agree with the concept of regionalized maternity care but also identify significant barriers to its implementation. Early and frequent engagement of providers reflecting the diversity of delivery centers in a region is a simple but necessary step in any attempts to designate levels of maternal care.
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Affiliation(s)
- Sarah Rae Easter
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02215, USA.
| | - Kelly C Gilmore
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Jay Schulkin
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02215, USA
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Blanc J, Rességuier N, Loundou A, Boyer L, Auquier P, Tosello B, d'Ercole C. Severe maternal morbidity in preterm cesarean delivery: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2021; 261:116-123. [PMID: 33932682 DOI: 10.1016/j.ejogrb.2021.04.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/13/2021] [Accepted: 04/19/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE More than half of extremely preterm infants are delivered by cesarean section. Few data are available about severe maternal morbidity (SMM) of these extremely preterm cesarean. The objective was to determine whether gestational age under 26 weeks of gestation (weeks) was associated with an increased risk of SMM compared with gestational age between 26 and 34 weeks in women having a cesarean delivery. MATERIAL AND METHODS We searched MEDLINE, ISI Web of Science, the Cochrane Database, PROSPERO, and ClinicalTrials.gov on January 31, 2020. The search strategy clustered terms describing SMM and preterm cesarean delivery. No restrictions on language, publication status, and study design were applied. Abstracts were included if there was sufficient information to assess study quality. The authors of all identified studies were contacted to request for aggregated data. Relative risks (RR) were calculated using the inverse variance method. The primary outcome was SMM as defined in each study. We analyzed data on preterm cesarean deliveries between 22 and 34 weeks. The protocol was registered in PROSPERO (registration: CRD42019128644). RESULTS Six studies involving 45,572 women (3,440 delivering < 26 weeks; 42,132 delivering between 26 and 34 weeks) were included. SMM occurred in 607 women (17.6 %) < 26 weeks and 4,483 women (10.6 %) between 26 and 34 weeks. Gestational age < 26 weeks was associated with an increased risk of SMM (RR, 1.65; 95 % CI [Confidence Interval], 1.52-1.78; I2 = 40 %). Gestational age < 26 weeks remained associated with SMM in the subgroup analyses depending on the type of the study (prospective or retrospective), country of the study (European or non-European), and high quality of the study. A sensitivity analysis showed that gestational age < 25 weeks was also associated with SMM in preterm cesarean delivery (RR, 1.66; 95 % CI, 1.50-1.83; I2 = 3%). CONCLUSIONS Gestational age < 26 weeks was associated with an increased risk of SMM in women having a preterm cesarean delivery. Obstetricians and neonatologists should be aware of the increased risk of SMM in cesarean.
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Affiliation(s)
- Julie Blanc
- Department of Obstetrics and Gynecology, Nord Hospital, APHM, Chemin des Bourrely, 13015, Marseille, France; EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France.
| | - Noémie Rességuier
- EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France
| | - Anderson Loundou
- EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France
| | - Laurent Boyer
- EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France
| | - Pascal Auquier
- EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France
| | - Barthélémy Tosello
- Department of Neonatology, North Hospital, Assistance Publique des Hôpitaux de Marseille, France; Aix-Marseille Univ, CNRS, EFS, ADES, Marseille, France
| | - Claude d'Ercole
- Department of Obstetrics and Gynecology, Nord Hospital, APHM, Chemin des Bourrely, 13015, Marseille, France; EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France
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Abstract
OBJECTIVE Rates of severe maternal morbidity (SMM) are significantly higher among Black women and some data suggests further worsening of these rates among hospitals with the highest proportion of Black deliveries. In this study, we sought to examine whether Black women have higher SMM in Washington State and whether this varied by hospital. METHODS We conducted a retrospective cohort study using linked birth-hospital discharge data from Washington State. We compared Non-Hispanic Black women with Non-Hispanic white women and excluded observations with missing hospital information. SMM was defined using an already published algorithm. We ranked hospitals into low-, medium- and high Black-serving hospitals by using proportions of deliveries to Black women among all deliveries. Multivariable logistic regression models were used to examine the association of Black women with SMM adjusted for demographics, co-morbidities and clustering within hospital. RESULTS In the cohort of 407,808 women, 4556 (1.12%) had SMM. High Black-serving hospitals had the highest rate of SMM (1.94%) as compared to medium Black-serving hospitals (1.16%) and low Black-serving hospitals (1.06%) (p < .01). Odds of SMM was higher in Black women (OR = 1.58, 95% CI: 1.39-1.78) and remained elevated after adjusting for demographics and the level of Black-serving hospital (aOR= 1.29, 95% CI: 1.11-1.49). CONCLUSION We found that the risk of SMM was higher among Black women. Hospital level performance and health outcomes stratified by maternal race and ethnicity in hospitals and hospital systems should be addressed to further reduce disparities and optimize outcomes.
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Affiliation(s)
- Bharti Garg
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Alyssa Hersh
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Aaron B Caughey
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Rachel A Pilliod
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
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Abstract
Racism in the United States has deep roots that affect maternal health, particularly through pervasive inequalities among black women compared with white. Anesthesiologists are optimally positioned to maintain vigilance for these disparities in maternal care, and to intervene with their unique acute critical care skills and knowledge. As leaders in patient safety, anesthesiologists should drive hospitals and practices to develop and implement national bundles for patient safety, as well as using team-based training practices designed to improve hospitals that care for racially diverse mothers.
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Affiliation(s)
- Rebecca D Minehart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRJ 440, Boston, MA 02114, USA.
| | - Jaleesa Jackson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRJ 440, Boston, MA 02114, USA
| | - Jaime Daly
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRJ 440, Boston, MA 02114, USA
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Korst LM, Gregory KD, Nicholas LA, Saeb S, Reynen DJ, Troyan JL, Greene N, Fridman M. A scoping review of severe maternal morbidity: describing risk factors and methodological approaches to inform population-based surveillance. Matern Health Neonatol Perinatol 2021; 7:3. [PMID: 33407937 PMCID: PMC7789633 DOI: 10.1186/s40748-020-00123-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/09/2020] [Indexed: 11/10/2022] Open
Abstract
Background Current interest in using severe maternal morbidity (SMM) as a quality indicator for maternal healthcare will require the development of a standardized method for estimating hospital or regional SMM rates that includes adjustment and/or stratification for risk factors. Objective To perform a scoping review to identify methodological considerations and potential covariates for risk adjustment for delivery-associated SMM. Search methods Following the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews, systematic searches were conducted with the entire PubMed and EMBASE electronic databases to identify publications using the key term “severe maternal morbidity.” Selection criteria Included studies required population-based cohort data and testing or adjustment of risk factors for SMM occurring during the delivery admission. Descriptive studies and those using surveillance-based data collection methods were excluded. Data collection and analysis Information was extracted into a pre-defined database. Study design and eligibility, overall quality and results, SMM definitions, and patient-, hospital-, and community-level risk factors and their definitions were assessed. Main results Eligibility criteria were met by 81 studies. Methodological approaches were heterogeneous and study results could not be combined quantitatively because of wide variability in data sources, study designs, eligibility criteria, definitions of SMM, and risk-factor selection and definitions. Of the 180 potential risk factors identified, 41 were categorized as pre-existing conditions (e.g., chronic hypertension), 22 as obstetrical conditions (e.g., multiple gestation), 22 as intrapartum conditions (e.g., delivery route), 15 as non-clinical variables (e.g., insurance type), 58 as hospital-level variables (e.g., delivery volume), and 22 as community-level variables (e.g., neighborhood poverty). Conclusions The development of a risk adjustment strategy that will allow for SMM comparisons across hospitals or regions will require harmonization regarding: a) the standardization of the SMM definition; b) the data sources and population used; and c) the selection and definition of risk factors of interest. Supplementary Information The online version contains supplementary material available at 10.1186/s40748-020-00123-1.
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Affiliation(s)
- Lisa M Korst
- Childbirth Research Associates, LLC, North Hollywood, CA, USA.
| | - Kimberly D Gregory
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen Research Institute, Los Angeles, CA, USA.,Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Community Health Sciences, Fielding School of Public Health at UCLA, Los Angeles, CA, USA
| | - Lisa A Nicholas
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Samia Saeb
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen Research Institute, Los Angeles, CA, USA
| | - David J Reynen
- Maternal, Child and Adolescent Health Division, California Department of Public Health, Sacramento, CA, USA
| | - Jennifer L Troyan
- Maternal, Child and Adolescent Health Division, California Department of Public Health, Sacramento, CA, USA
| | - Naomi Greene
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen Research Institute, Los Angeles, CA, USA
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Friedman A. Clinical Implications of Maternal Disparities Administrative Data Research. Clin Perinatol 2020; 47:759-767. [PMID: 33153660 DOI: 10.1016/j.clp.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Administrative data research on maternal racial disparities supports 2 broad clinical inferences. First, failure to rescue in terms of both death and severe maternal morbidity likely accounts for a significant proportion of maternal disparities. Second, risk for adverse outcomes by race is generally differential with risk for cardiovascular complications particularly high for non-Hispanic black women. These differentials suggest that underlying health conditions may represent an important contributor to overall disparities, and optimal longitudinal care utilization with nonobstetric specialists is required to mitigate risk.
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Affiliation(s)
- Alexander Friedman
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, 622 West 168th Street, PH 16-66, New York, NY 10032, USA.
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Liu C, Wall-Wieler E, Urquia M, Carmichael SL, Stephansson O. Severe maternal morbidity among migrants with insecure residency status in Sweden 2000-2014: a population-based cohort study. J Migr Health 2020; 1-2:100006. [PMID: 34405161 PMCID: PMC8352011 DOI: 10.1016/j.jmh.2020.100006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Migrants with insecure residency status (i.e., undocumented migrants and asylum-seekers, who are denied or waiting for authorized residency) often experience social and psychosocial adversities and limited access to health care. Nonetheless, they have not been profiled on the risk of severe maternal morbidity (SMM), a sentinel measure of maternal health and maternity care. METHODS A cohort study on all births recorded in the Swedish Medical Birth Register from 2000-2014 (N = 1,570,472). Lacking a maternal personal identification number was used as an indicator for insecure residency status (1.3% of all births). We used Poisson regression models to estimate risk ratios of SMM in migrant women with insecure residency status compared to the Swedish-born or migrant women with long-term residency, adjusting for the calendar year of birth, maternal age, and parity. RESULTS Overall SMM rate among migrant women with insecure residency status was 21.5/1000 and 14.7/1000 among Swedish-born women. Compared to Swedish-born, migrants with insecure residency status had 50% higher risk of overall SMM (adjusted risk ratio (aRR)=1.54 [1.37-1.74]) and over 80% higher risk of SMM excluding transfusion-only cases (aRR=1.88 [1.37-2.57]). When compared to migrant women with long-term residency, migrant women with insecure residency also had a higher risk of SMM (overall SMM aRR=1.42 [1.26,1.61]; SMM excluding transfusion only cases aRR=1.43 [1.04,1.97]), suggesting that insecure residency conferred additional risks of SMM beyond migration. CONCLUSION Migrant women with insecure residency status had increased risk of severe maternal morbidity.
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Affiliation(s)
- Can Liu
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth Wall-Wieler
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Marcelo Urquia
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Suzan L. Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
- Division of Maternal- Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
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Zanardi DM, Santos JP, Pacagnella RC, Parpinelli MA, Silveira C, Andreucci CB, Ferreira EC, Angelini CR, Souza RT, Costa ML, Cecatti JG. Long-Term Consequences of Severe Maternal Morbidity on Infant Growth and Development. Matern Child Health J 2020; 25:487-496. [PMID: 33196923 DOI: 10.1007/s10995-020-03070-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Severe maternal morbidity (SMM) is already known to be associated with adverse neonatal outcomes, however, its association with long-term deficits of weight and height, and impairment in neurodevelopment among children was not yet fully assessed. We aim to evaluate whether SMM has repercussions on the weight and height-for-age and neurodevelopmental status of the child. METHODS A retrospective cohort analysis with women who had SMM events in a tertiary referral center in Brazil. They were compared to a control group of women who had not experienced any SMM. Childbirth and perinatal characteristics, weight and height-for-age deficits and neurodevelopmental impairment suspicion by Denver II Test were comparatively assessed in both groups using RR and 95% CI. Multiple regression analysis was used addressing deficit of weight-for-age, height-for-age and an altered Denver Test, estimating their independent adjusted RR and 95% CI. RESULTS 634 women with perinatal outcomes available (311 with SMM and 323 without) and 571 children were assessed. Among women with SMM, increased rates in perinatal deaths, Apgar lower than 7 at five minutes, shorter breastfeeding period, preterm birth (49.0% × 11.1%), low birthweight (45.8% × 11.5%), deficits of weight-for-age [RR 3.11 (1.60-6.04)] and height-for-age [RR 1.52 (1.06-2.19)] and altered Denver Test [RR 1.5 (1.02-2.36)] were more frequently found than in the control group. SMM was not identified as independently associated with any of the main outcomes. CONCLUSION SMM showed to be associated with a negative impact on growth and neurodevelopment aspects of perinatal and infant health. These findings suggest that effective health policies directed towards appropriate care of pregnancy may have an impact on the reduction of maternal, neonatal and infant morbidity and mortality.
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Affiliation(s)
- Dulce M Zanardi
- Department of Obstetrics and Gynecology, School of Medical Sciences, CAISM, University of Campinas, Campinas, Brazil
| | - Juliana P Santos
- Department of Obstetrics and Gynecology, School of Medical Sciences, CAISM, University of Campinas, Campinas, Brazil
| | - Rodolfo C Pacagnella
- Department of Obstetrics and Gynecology, School of Medical Sciences, CAISM, University of Campinas, Campinas, Brazil
| | - Mary A Parpinelli
- Department of Obstetrics and Gynecology, School of Medical Sciences, CAISM, University of Campinas, Campinas, Brazil
| | - Carla Silveira
- Department of Obstetrics and Gynecology, School of Medical Sciences, CAISM, University of Campinas, Campinas, Brazil
| | - Carla B Andreucci
- Department of Obstetrics and Gynecology, School of Medical Sciences, CAISM, University of Campinas, Campinas, Brazil
- Department of Medicine, School of Medicine, Federal University of Sao Carlos, São Carlos, Brazil
| | - Elton C Ferreira
- Department of Obstetrics and Gynecology, School of Medical Sciences, CAISM, University of Campinas, Campinas, Brazil
| | - Carina R Angelini
- Department of Obstetrics and Gynecology, School of Medical Sciences, CAISM, University of Campinas, Campinas, Brazil
| | - Renato T Souza
- Department of Obstetrics and Gynecology, School of Medical Sciences, CAISM, University of Campinas, Campinas, Brazil
| | - Maria L Costa
- Department of Obstetrics and Gynecology, School of Medical Sciences, CAISM, University of Campinas, Campinas, Brazil
| | - Jose G Cecatti
- Department of Obstetrics and Gynecology, School of Medical Sciences, CAISM, University of Campinas, Campinas, Brazil.
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de Morais LR, Patz BC, Campanharo FF, Dualib PM, Sun SY, Mattar R. Maternal near miss and potentially life-threatening condition determinants in patients with type 1 diabetes mellitus at a university hospital in São Paulo, Brazil: a retrospective study. BMC Pregnancy Childbirth 2020; 20:679. [PMID: 33172430 PMCID: PMC7653718 DOI: 10.1186/s12884-020-03392-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/30/2020] [Indexed: 11/10/2022] Open
Abstract
Background To date, the rates of potentially life-threatening condition (PTLC), maternal near miss (MNM) and maternal deaths in pregnant patients with type 1 diabetes mellitus (T1DM) and variables associated to it have not been studied. Methods This study was as a cross-sectional retrospective study conducted at São Paulo Hospital of Universidade Federal de São Paulo, a tertiary hospital that provides public medical care through the Brazilian unified health system to high-risk pregnancies. Inclusion criteria were T1DM pregnant women who delivered from January 2005 to December 2015. Three groups were established by the World Heath Organization criteria and associations were assessed using the chi-square test in between MNM and no morbidity or PLTC and no morbidity. A P value < 0.05 was considered statistically significant. Results The final sample included 137 patients, 8 MNM cases (5.84%), 51 PLTC (37.23%), no cases of maternal deaths and 78 patients (56.93%) did not present any complication. Moreover, there were 122 live births, resulting in a near miss rate of 65.5 per 1.000 live births in patients with T1DM. Two of the MNM cases were for clinical criteria (uncontrollable fit in both) and laboratory criteria for the other six: one patient with severe acute azotemia (creatinine > 300 μmol/ml), one patient with severe hypoperfusion (lactate > 5 mmol/L) and four of them with loss of consciousness and the presence of glucose and ketoacids in urine. PLTC criteria were studied in MNM and PLTC cases. Prolonged hospital stay was the most prevalent PLTC criteria in both groups (100% of MNM cases and 96% of PLTC), followed by renal failure in 50% of MNM cases and severe preeclampsia in 22% of PLTC cases. This study could not find any association between prenatal factors or sociodemographic characteristics with maternal morbidity. Conclusions MNM rate in T1DM was extremely high, and determined by complications of the primary disease or hypertensive disorders. No sociodemographic variables studied were related to maternal morbidity; therefore, we could not predict what increases MNM and PLTC in this specific population.
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Affiliation(s)
- Luiza Russo de Morais
- Obstetrics Department, Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina, São Paulo, 04021-001, Brazil
| | - Beatriz Costa Patz
- Obstetrics Department, Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina, São Paulo, 04021-001, Brazil
| | - Felipe Favorette Campanharo
- Obstetrics Department, Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina, São Paulo, 04021-001, Brazil
| | - Patricia Médici Dualib
- Endocrinology Department, Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina, São Paulo, 04021-001, Brazil
| | - Sue Yazaki Sun
- Obstetrics Department, Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina, São Paulo, 04021-001, Brazil.
| | - Rosiane Mattar
- Obstetrics Department, Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina, São Paulo, 04021-001, Brazil
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Jarlenski M, Krans EE, Chen Q, Rothenberger SD, Cartus A, Zivin K, Bodnar LM. Substance use disorders and risk of severe maternal morbidity in the United States. Drug Alcohol Depend 2020; 216:108236. [PMID: 32846369 PMCID: PMC7606664 DOI: 10.1016/j.drugalcdep.2020.108236] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/08/2020] [Accepted: 08/11/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The contribution of substance use disorders to the burden of severe maternal morbidity in the United States is poorly understood. The objective was to estimate the independent association between substance use disorders during pregnancy and risk of severe maternal morbidity. METHODS Retrospective analysis of a weighted 53.4 million delivery hospitalizations from 2003 to 2016 among females aged>18 in the National Inpatient Sample. We constructed measures of substance use disorders using diagnostic codes for cannabis, opioids, and stimulants (amphetamines or cocaine) abuse or dependence during pregnancy. The outcome was the presence of any of the 21 CDC indicators of severe maternal morbidity. Using weighted multivariable logistic regression, we estimated the association between substance use disorders and adjusted risk of severe maternal morbidity. Because older age at delivery is predictive of severe maternal morbidity, we tested for effect modification between substance use and maternal age by age group (18-34 y vs >34 y). RESULTS Pregnant women with an opioid use disorder had an increased risk of severe maternal morbidity compared with women without an opioid use disorder (18-34 years: aOR: 1.51; 95 % CI: 1.41,1.61, >34 years: aOR: 1.17; 95 % CI: 1.00,1.38). Compared with their counterparts without stimulant use disorders, pregnant women with a simulant use disorder (amphetamines, cocaine) had an increased risk of severe maternal morbidity (18-34 years: aOR: 1.92; 95 % CI: 1.80,2.0, >34 years: aOR: 1.85; 95 % CI: 1.66,2.06). Cannabis use disorders were not associated with an increased risk of severe maternal morbidity. CONCLUSION Substance use disorders during pregnancy, particularly opioids, amphetamines, and cocaine use disorders, may contribute to severe maternal morbidity in the United States.
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Affiliation(s)
- Marian Jarlenski
- Dept of Health Policy and Management, University of Pittsburgh, 130 DeSoto Street Pittsburgh, PA 15261, USA.
| | - Elizabeth E Krans
- Magee-Womens Research Institute and Dept of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, 3380 Boulevard of the Allies, Pittsburgh, PA 15213, USA
| | - Qingwen Chen
- Dept of Health Policy and Management, University of Pittsburgh, 130 DeSoto Street Pittsburgh, PA 15261, USA
| | - Scott D Rothenberger
- Dept of General Internal Medicine, University of Pittsburgh, 200 Meyran Ave, Suite 300, Pittsburgh, PA 15213, USA
| | - Abigail Cartus
- Dept of Epidemiology, University of Pittsburgh, 130 DeSoto Street, Pittsburgh, PA 15261 USA
| | - Kara Zivin
- Dept of Psychiatry, University of Michigan, 2800 Plymouth Road, Building 16, Room 228W, Ann Arbor, MI 48109, USA
| | - Lisa M Bodnar
- Magee-Womens Research Institute and Dept of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, 3380 Boulevard of the Allies, Pittsburgh, PA 15213, USA,Dept of Epidemiology, University of Pittsburgh, 130 DeSoto Street, Pittsburgh, PA 15261 USA
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Charles CM, Amoah EM, Kourouma KR, Bahamondes LG, Cecatti JG, Osman NB, Govule P, Diallo AK, Sacarlal J, Pacagnella RDC. The SARS-CoV-2 pandemic scenario in Africa: What should be done to address the needs of pregnant women? Int J Gynaecol Obstet 2020; 151:468-470. [PMID: 33020902 PMCID: PMC9087788 DOI: 10.1002/ijgo.13403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/28/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Charles M'poca Charles
- Provincial Health Administration, DPS Manica, Chimoio, Manica Province, Mozambique.,Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, São Paulo, Brazil
| | - Emefa Modey Amoah
- Department of Population Family and Reproductive Health, University of Ghana, Accra, Ghana
| | | | - Luis Guilhermo Bahamondes
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, São Paulo, Brazil
| | - José Guilherme Cecatti
- Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, São Paulo, Brazil
| | - Nafissa Bique Osman
- Department of Obstetrics and Gynecology, Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique.,Department of Obstetrics and Gynecology, Maputo Central Hospital, Maputo, Mozambique
| | - Philip Govule
- Department of Epidemiology and Disease control, School of Public Health, University of Ghana, Accra, Ghana
| | - Abdou Karim Diallo
- Clinique Gynécologique et Obstétricale de l'Hôpital Aristide Le Dantec, Dakar, Senegal
| | - Jahit Sacarlal
- Department of Microbiology, Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
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Wall-Wieler E, Bane S, Lee HC, Carmichael SL. Severe maternal morbidity among U.S.- and foreign-born Asian and Pacific Islander women in California. Ann Epidemiol 2020; 52:60-63.e2. [PMID: 32795600 DOI: 10.1016/j.annepidem.2020.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/20/2020] [Accepted: 07/28/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of the study was to examine the risk of severe maternal morbidity (SMM)-a composite of serious, potentially life-threatening conditions related to childbirth-among subgroups of nulliparous women with Asian and Pacific Islander race/ethnicity. METHODS This study used linked hospital discharge and vital record data California to identify nulliparous Asian and Pacific Islander women from 1997 to 2012 (n = 453,525). We examined the risk of SMM for 15 Asian and Pacific Islander subgroups and compared the risk between U.S.- and foreign-born women. RESULTS The risk of SMM was higher among Pacific Islander women than that among Asian women (148 and 127 cases per 10,000 births, respectively). Among Asian women, the risk of SMM ranged from 94 (Korean) to 165 (Filipina) cases per 10,000 births, and among Pacific Islander women, the risk ranged from 125 (Hawaiian) to 162 (Other). With the exception of Korean and Filipina women, relative risks of SMM for U.S.- versus foreign-born Asian and Pacific Islander women were similar. CONCLUSIONS Differences in the risk of SMM exist between subgroups of the Asian and Pacific Islander community. These differences should be considered when conducting research on racial and ethnic differences of SMM and when counseling Asian and Pacific Islander women regarding their risk of SMM.
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Affiliation(s)
| | - Shalmali Bane
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA
| | - Henry C Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA; Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
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48
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Kestler E, Ambrosio G, Hemming K, Hughes JP, Matute J, Moreno M, Madriz S, Walker D. An integrated approach to improve maternal and perinatal outcomes in rural Guatemala: A stepped-wedge cluster randomized trial. Int J Gynaecol Obstet 2020; 151:109-116. [PMID: 32524605 DOI: 10.1002/ijgo.13262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 04/24/2020] [Accepted: 06/03/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To evaluate the impact of an intervention package on maternal and newborn health indicators. METHODS A randomized stepped-wedge non-blind trial was conducted across six subdistricts within two districts in Guatemala from January 2014 to January 2017. Data on outcomes were collected on all deliveries in all 33 health centers. The intervention package included distribution of promotional materials encouraging health center delivery; education for traditional birth attendants about the importance of health center delivery; and provider capacity building using simulation training. Main outcomes were number of health center deliveries, maternal morbidity, and perinatal morbidity and mortality. RESULTS Overall, there were 24 412 deliveries. Health center deliveries per 1000 live births showed an overall increase, although after adjustment for secular trends and clustering, the relative risk for the treatment effect was not statistically significant (aRR, 1.04; 95% confidence interval [CI], 0.97-1.11, P=0.242). Although not statistically significant, maternal morbidity (aRR, 0.78; 95% CI, 0.60-1.02; P=0.068) and perinatal morbidity (aRR, 0.84; 95% CI, 0.68-1.05; P=0.133) showed a tendency toward a decrease. CONCLUSION The present study represents one of the few randomized evaluations of an integrated approach to improve birth outcomes in a low-income setting. ClinicalTrials.gov: NCT0315107.
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Affiliation(s)
- Edgar Kestler
- Epidemiological Research Center in Sexual and Reproductive Health, Guatemala City, Guatemala
| | - Guillermo Ambrosio
- Epidemiological Research Center in Sexual and Reproductive Health, Guatemala City, Guatemala
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Jorge Matute
- Centro de Investigaciones en Nutrición y Salud, Guatemala City, Guatemala
| | - Mario Moreno
- USAID, Guatemala Monitoring and Evaluation Program, Guatemala City, Guatemala
| | | | - Dilys Walker
- University of California, San Francisco, CA, USA
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49
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Freese KE, Himes KP, Hutcheon JA, Parisi SM, Brooks MM, McTigue K, Bodnar LM. Excessive gestational weight gain is associated with severe maternal morbidity. Ann Epidemiol 2020; 50:52-56.e1. [PMID: 32703663 DOI: 10.1016/j.annepidem.2020.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/15/2020] [Accepted: 06/21/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE We determined the association between gestational weight gain and severe maternal morbidity. METHODS We used data on 84,241 delivery hospitalizations at Magee-Womens Hospital, Pittsburgh, PA (2003-2012). Total gestational weight gain (kilogram) was converted to gestational age-standardized z-scores. We defined severe maternal morbidity as having ≥1 of the 21 Centers for Disease Control diagnosis or procedure codes for severe maternal morbidity identification, intensive care unit admission, or extended postpartum stay. We used multivariable logistic regression to determine the association between weight gain and severe maternal morbidity after confounder adjustment. RESULTS High gestational weight gain z-scores were associated with an increased risk of severe maternal morbidity. Compared with z-score 0 SD (equivalent to 16 kg at 40 weeks in a normal-weight woman), risk differences (95% confidence intervals) for z-scores -2 SD (7 kg), -1 SD (11 kg), +1 SD (23 kg), and +2 SD (31 kg) were 1.5 (-0.71, 3.7), 0.056 (-0.81, 0.93), 3.4 (1.7, 5.0), and 8.6 (4.0, 13) per 1000 deliveries. The results did not vary by gestational age at delivery or prepregnancy body mass index. CONCLUSIONS The increased risk of severe maternal morbidity with high pregnancy weight gain may allow scientists to understand and prevent this serious condition.
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Affiliation(s)
- Kyle E Freese
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Katherine P Himes
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA; Magee-Womens Research Institute, Pittsburgh, PA
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Sara M Parisi
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Maria M Brooks
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Kathleen McTigue
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lisa M Bodnar
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA; Magee-Womens Research Institute, Pittsburgh, PA.
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50
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Costa ML, Pacagnella RC, Guida JP, Souza RT, Charles CM, Lajos GJ, Haddad SM, Fernandes KG, Nobrega GM, Griggio TB, Pabon SL, Serruya SJ, Ribeiro‐do‐Valle CC, Cecatti JG. Call to action for a South American network to fight COVID-19 in pregnancy. Int J Gynaecol Obstet 2020; 150:260-261. [PMID: 32412120 PMCID: PMC9087527 DOI: 10.1002/ijgo.13225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/13/2020] [Indexed: 11/29/2022]
Abstract
A call to action for joint efforts by South American centers to tackle COVID‐19 in pregnancy.
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Affiliation(s)
- Maria L. Costa
- Department of Obstetrics and GynecologyUniversity of CampinasCampinasSão PauloBrazil
| | - Rodolfo C. Pacagnella
- Department of Obstetrics and GynecologyUniversity of CampinasCampinasSão PauloBrazil
| | - Jose P. Guida
- Department of Obstetrics and GynecologyUniversity of CampinasCampinasSão PauloBrazil
| | - Renato T. Souza
- Department of Obstetrics and GynecologyUniversity of CampinasCampinasSão PauloBrazil
| | - Charles M. Charles
- Department of Obstetrics and GynecologyUniversity of CampinasCampinasSão PauloBrazil
| | - Giuliane J. Lajos
- Department of Obstetrics and GynecologyUniversity of CampinasCampinasSão PauloBrazil
| | | | | | - Guilherme M. Nobrega
- Department of Obstetrics and GynecologyUniversity of CampinasCampinasSão PauloBrazil
| | - Thayna B. Griggio
- Department of Obstetrics and GynecologyUniversity of CampinasCampinasSão PauloBrazil
| | - Stephanie L. Pabon
- Department of Obstetrics and GynecologyUniversity of CampinasCampinasSão PauloBrazil
| | - Suzanne J. Serruya
- Latin American Centre of Perinatology (CLAP‐WR/FGL‐PAHO)MontevideoUruguay
| | | | - Jose G. Cecatti
- Department of Obstetrics and GynecologyUniversity of CampinasCampinasSão PauloBrazil
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