Alliance For Innovation Research Articles

Community-engaged implementation of a safety bundle for pregnancy-related severe hypertension in the outpatient setting: protocol for a type 3 hybrid study with a multiple baseline design

BackgroundHypertensive disorders of pregnancy are among the leading causes of maternal mortality and morbidity in the U.S., with rates highest among birthing people who are Black, rural residents, and/or have low-income. Severe hypertension, in particular, increases risk of stroke and other serious pregnancy complications. To promote early detection and treatment of severe hypertension, the Alliance for Innovation on Maternal Health developed the Severe Hypertension During Pregnancy and Postpartum Period Safety Bundle (HTN Bundle). Multiple studies have demonstrated the HTN Bundle’s effectiveness in the inpatient setting. With funding from the National Heart, Lung, and Blood Institute, we engaged community partners to adapt the HTN Bundle for the outpatient setting (i.e., O-HTN Bundle) and planned for its implementation. In this paper, we describe the protocol for a study evaluating O-HTN Bundle implementation in 20 outpatient clinics serving Black, rural, and/or low-income populations.MethodsThis study is a hybrid type 3 effectiveness-implementation trial with a multiple baseline design. We will implement the O-HTN Bundle in three successive cohorts of clinics using a multicomponent implementation strategy to engage community partners (coalition, patient workgroup) and support clinics (training, facilitation, education materials, and simulations of severe hypertension events). To test the strategy, we will compare clinic fidelity to evidence-based guidelines for (a) patient education on hypertension and (b) blood pressure measurement technique, with repeated measures occurring before and after strategy receipt. We will also observe strategy effects on community- and clinic-level intermediate outcomes (community engagement, organizational readiness), implementation outcomes (reach, adoption, fidelity, maintenance), and effectiveness outcomes (receipt of guideline concordant care). Analyses will address whether outcomes are equitable across Black, rural, and/or low-income subgroups. Guided by the Consolidated Framework for Implementation Research 2.0, we will use mixed methods to identify adaptations and other determinants of implementation success.DiscussionThis study integrates community engagement and implementation science to promote equitable and timely response to severe HTN in the outpatient setting during pregnancy and postpartum. This is one of the first studies to implement an outpatient HTN Bundle and to use simulation as a strategy to reinforce team-based delivery of guideline concordant care.Trial registrationThis study was registered with ClinicalTrials.gov as “Testing Implementation Strategies to Support Clinic Fidelity to an Outpatient Hypertension Bundle (AC3HIEVE).” Registration number NCT06002165, August 21, 2023: https://clinicaltrials.gov/study/NCT06002165.

Severe Hypertension in Pregnancy: Progress Made and Future Directions for Patient Safety, Quality Improvement, and Implementation of a Patient Safety Bundle.

Hypertensive disorders of pregnancy account for approximately 5% of pregnancy-related deaths in the United States and are one of the leading causes of maternal morbidity. Focus on improving patient outcomes in the setting of hypertensive disorders of pregnancy has increased in recent years, and quality improvement initiatives have been implemented across the United States. This paper discusses patient safety and quality initiatives for hypertensive disorders of pregnancy, with an emphasis on progress made and a patient safety tool: the Alliance for Innovation on Maternal Health's Severe Hypertension in Pregnancy patient safety bundle. Future patient safety and quality directions for the treatment of hypertensive disorders of pregnancy will be reviewed.

A Statewide Mobile Simulation Program For Improving Obstetric Skills in Rural Hospitals.

Closure of rural obstetric (OB) units has led to maternal care deserts, causing mothers to travel long distances for maternity care. Emergency departments (EDs) in hospitals where OB units have closed require regular training for personnel to maintain OB skills, as do rural Level-1 OB units with low volumes of maternity cases. We used a federal grant to develop an OB mobile simulation program to bring simulation-based training to rural providers. Our goal was to improve OB skills and standardize care through the framework of the Alliance for Innovation in Maternal Health (AIM) Patient Safety Bundles. We conducted needs assessments and built a mobile simulation unit. We defined 2 groups of learners: those in Level-1 OB units and those in EDs without OB units. For Level-1 OB units, we created a train-the-trainer curriculum, to create a statewide cohort of simulation experts to implement simulations in their facilities between our visits. We gifted each Level-1 unit an OB task trainer, implemented virtual train-the-trainer simulation and task trainer workshops, and conducted post-workshop assessments. We then traveled to each Level-1 unit and helped the cohort implement in situ simulations for their staff using facility-specific resources. We conducted assessments for the cohort and the hospital staff after the simulations. For EDs, we delivered virtual didactics to improve basic OB knowledge, then traveled to ED units, implemented in situ simulations, and conducted post-simulation assessments. We chose a postpartum hemorrhage (PPH) scenario for our first round of simulations. After train-the-trainer simulation workshops, 98% of participants surveyed agreed that workshop goals and objectives were achieved. After the task trainer workshop, 95% surveyed agreed that their knowledge of using the simulator had improved. After implementing in situ simulations in Level-1 OB units, 98.8% of the train-the-trainer cohort found that their ability to implement simulations had improved. The hospital staff participating in the simulations identified a 30% increase in ability to manage PPH. For the ED staff, postdidactic evaluations identified that 95.4% of participants reported moderate improvement in basic OB knowledge and after participation in the simulations >95% reported better skills as an ED team member when caring for pregnant patients. These results demonstrate improved skills of hospital staff in simulated PPH in Level-1 OB units and simulated OB emergencies in EDs that no longer have OB units. Further studies are warranted to assess improvement in maternal outcomes.

Alliance for Innovation on Maternal Health: Evolution of a program to address maternal morbidity and mortality

The Alliance for Innovation on Maternal Health program is a national investment in promoting safe care for every birth in the United States and lowering rates of preventable maternal mortality and severe maternal morbidity. Through its work with state and jurisdiction-based teams on patient safety bundle implementation, the program supports data-driven quality improvement. This paper details key aspects of the Alliance for Innovation on Maternal Health including patient safety bundles, technical assistance, implementation resource development, data support, and partnerships while providing an overview of the program's evolution, reach, impact, and future opportunities.

Addressing Perinatal Substance Use: A Triad Approach Led by the Colorado Perinatal Care Quality Collaborative.

Unintentional overdose is a leading driver of maternal death in Colorado. The high volume of maternal deaths from preventable causes lends questions to failures in our clinical and community-based care for pregnant and postpartum people. The Colorado Maternal Mortality Review Committee identified 3 main contributors including stigma in the community and health care system, fragmentation of the health care system, and the need for more clinician training. The Colorado Perinatal Care Quality Collaborative led a 3-pronged intervention to address these challenges and improve perinatal care. The first intervention, the Colorado Alliance for Innovation on Maternal Health Substance Use Disorder quality improvement initiative, partnered with birthing hospitals statewide to institute universal screening and timely referral for individuals at risk of substance use disorder (SUD) and perinatal mood and anxiety disorders. The second intervention, the Improve Perinatal Access, Coordination, and Treatment for Behavioral Health initiative, established a perinatal support network within communities. This program assists individuals with SUD, perinatal mood and anxiety disorders, or social needs to navigate the perinatal period. The third intervention, the Colorado Maternal Overdose Matters Plus program, has enhanced in-hospital access to pharmacotherapy for pregnant and postpartum individuals with SUD through training and technical support. These collaborative initiatives aim to minimize barriers to care by integrating inpatient screening, treatment referrals, pharmacotherapy access, and community care support to mitigate maternal mortality in Colorado.

The Racial Disparities in Maternal Mortality and Impact of Structural Racism and Implicit Racial Bias on Pregnant Black Women: A Review of the Literature.

The maternal mortality rate (MMR) in the United States (USA) continues to increase despite medical advances and is exacerbated by stark racial disparities. Black women are disproportionately affected and are three times more likely to experience a pregnancy-related death (PRD) compared to Non-Hispanic White (NHW) women. A literature review was conducted to examine the racial disparities in the United States' MMR, specifically among pregnant Black women. PubMed and key organizations (World Health Organization, Center for Disease Control and Prevention, American College of Obstetricians and Gynecologists, Alliance for Innovation on Maternal Health, Association of American Medical Colleges, U.S. Census Bureau, and U.S. Congress) were searched for publications after 2014. Forty-two articles were reviewed to identify the role of structural racism, implicit biases, lack of cultural competence, and disparity education on pregnant Black women. This review highlights that maternal health disparities for Black women are further impacted by both structural racism and racial implicit biases. Cultural competence and educational courses targeting racial disparities among maternal healthcare providers (MHCP) are essential for the reduction of PRDs and pregnancy-related complications (PRC) among this target population. Additionally, quality and proper continuity of care require an increased awareness surrounding the risk of cardiovascular diseases for pregnant Black women. The surging MMR for Black women is a public health crisis that requires a multi-tiered approach. Interventions should be implemented at the provider and healthcare institution level to dismantle implicit biases and structural racism. Improving patient-provider relationships through increased cultural competency and disparity education will increase patient engagement with the maternal healthcare (MHC) system.

Fathers' Perspectives on Fatherhood and Paternal Involvement During Pregnancy and Childbirth.

There is limited research that specifically explores paternal involvement during pregnancy and childbirth. To address this gap, we completed a series of focus groups with fathers to examine social, cultural, and environmental factors that influence behaviors among new fathers while also providing community perspectives on men's experiences seeking care pre- and postdelivery. We used a phenomenological thematic approach to analyze data from 10 focus groups from five of the six Alliance for Innovation on Maternal Health-Community Care Initiative pilot sites collected between November 2021 and April 2022. The average age of fathers was 33.9 years (range = 24-61 years). The majority (86.25%) of men were African American, and approximately one sixth of focus group participants (16.25%) were Hispanic or Latino. Four key themes emerged: the importance and meaning of fatherhood, accessibility during pregnancy and childbirth, engagement during pregnancy and childbirth, and responsibility of fathers during pregnancy and childbirth. These fathers not only understood and embraced the awesome responsibility they had for their unborn child, but they also recognized and were invested in being present, accessible, engaged, and responsible to the pregnant woman during the pregnancy. Practitioners and policy makers should work to engage fathers as early in the pregnancy as possible; monitor father's mental health and financial stress; provide resources to educate fathers on maternal health, pregnancy, and childbirth; and emphasize fathers' rights, roles, and responsibilities.

Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care.

Sepsis in obstetric care is one of the leading causes of maternal death in the United States, with Black, Asian/Pacific Islander, and American Indian/Alaska Native obstetric patients experiencing sepsis at disproportionately higher rates. State maternal mortality review committees have determined that deaths are preventable much of the time and are caused by delays in recognition, treatment, and escalation of care. The "Sepsis in Obstetric Care" patient safety bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people by preventing infection and recognizing and treating infection early to prevent progression to sepsis. This is one of several core patient safety bundles developed by AIM (the Alliance for Innovation on Maternal Health) to provide condition- or event-specific clinical practices that should be implemented in all appropriate care settings. As with other bundles developed by AIM, the "Sepsis in Obstetric Care" patient safety bundle is organized into five domains: Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, and Respectful, Equitable, and Supportive Care. The Respectful, Equitable, and Supportive Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into the elements of each domain.

Promoting Best Practice in Obstetrics: Findings From a State-Based Perinatal Quality Collaborative Implementing the Obstetric Hemorrhage Maternal Safety Bundle [ID: 1377611

INTRODUCTION: The Perinatal Neonatal Quality Improvement Network (PNQIN) of Massachusetts engaged hospital teams in a statewide improvement initiative to address maternal morbidity from obstetric hemorrhage (OB HEM) through support of implementation and adherence to best practices in screening for and diagnosis of OB HEM. METHODS: The Alliance for Innovation on Maternal Health (AIM) OB HEM bundle was adapted and implemented across hospitals in Massachusetts from June to December 2021. Each month, participating hospital teams joined educational webinars, learned quality improvement strategies, received access to resources for the intervention, and submitted data on six structure and five process measures. Severe maternal morbidity rates were provided using state hospital discharge data. Reliability of implementation was monitored by structure and process measure submission. Aggregate data were shared statewide. RESULTS: Fifty-three percent of birthing hospitals in the state (21 of 40) voluntarily participated. Baseline risk screening for OB HEM was 93% and quantitative blood loss measurement (QBL) was 60% in aggregate for all teams. Six participating hospitals reported all 11 measures monthly across the 6-month period. Half of these sites had all six structure measures in place at baseline and 83% reported completion of structure measures by the end of the study period. Among these six sites, the cumulative proportion QBL utilization increased 178% from 28% to 78% and documented OB HEM risk assessment during labor admission increased 8.4% from 83% to 90%. CONCLUSION: Implementation of the OB HEM bundle was effective in increasing adherence to evidence-based care among participating birth hospitals through a collaborative, quality improvement approach.

Adapting Obstetric-Capacity Assessments to a Rural Context to Drive System Improvements [ID: 1375979

INTRODUCTION: As part of its Health Resources and Services Administration Maternal Health Innovation, Centers for Disease Control and Prevention (CDC) ERASE MM, and the American College of Obstetricians and Gynecologists Alliance for Innovation on Maternal Health (AIM) awards, Montana assessed capacity to provide risk-appropriate care in Montana's hospitals with labor and delivery (L&D) units as well as critical access hospitals (CAHs) without L&D units that serve remote communities in maternity care deserts. METHODS: Montana conducted the CDC LOCATe assessment in 96% (N=25) of hospitals with an L&D and adapted an assessment used internationally by the World Health Organization to assess emergency obstetric capacity in 94% of CAHs without an L&D. Surveys were conducted in REDCap, and the research team provided facilities with technical support in their completion of the assessments. RESULTS: While half of CAHs without L&D reported an emergency delivery in the last 2 years, just one reported capacity to perform all services necessary to safely manage emergency deliveries. Two-thirds of facilities without L&D units did not have a written transport protocol. In hospitals with L&D who conducted the LOCATe assessment, nearly half (48%) overestimated the level of maternal health care that they were able to provide. Ultrasound and maternal-fetal medicine were the most common capacity insufficiencies. CONCLUSION: The system assessments revealed specific interventions that can expand capacity for quality obstetric care in a rural state like Montana, such as simulation training, adoption of AIM safety bundles through the perinatal quality collaborative, and enhanced access to ultrasound and maternal-fetal medicine services through telemedicine. National assessments like LOCATe should be adapted for the rural context to facilitate targeted resource investments.

The Ohio Maternal Safety Quality Improvement Project: initial results of a statewide perinatal hypertension quality improvement initiative implemented during the COVID-19 pandemic

Hypertensive disorders of pregnancy are a leading cause of severe maternal morbidity and mortality, and studies have shown that more than 60% of cases are preventable. As part of a statewide quality Maternal Safety Quality Improvement Project, we adapted the Alliance for Innovation on Maternal Health Severe Hypertension in Pregnancy bundle in a consortium of maternity hospitals in Ohio to improve care processes and outcomes for patients with a severe hypertensive event during pregnancy or the postpartum period. This study aimed to report the first year of data from this Maternal Safety Quality Improvement Project, including an assessment of the process measures by hospital level of maternal care designation, and provide perspective on the unique challenges of implementing a large-scale Maternal Safety Quality Improvement Project during a global pandemic. This Maternal Safety Quality Improvement Project engaged Ohio level 1 to 4 maternity hospitals and provided multimodal quality improvement support. Participating hospitals submitted monthly patient-level data, which included all cases of new-onset sustained severe hypertension. The primary process measure was the proportion of birthing people in Ohio with sustained severe hypertension who received treatment with appropriate acute antihypertensive therapy within 60 minutes. The secondary process measures included receipt of a follow-up appointment after hospital discharge within 72 hours (if discharged on medication) or 10 days (if discharged without medication), a blood pressure cuff on hospital discharge, and education about urgent maternal warning signs. Data for primary and secondary process measures were plotted on a biweekly basis, and statistical process control methods were used to identify special cause variation over time. Data were stratified by various demographic variables, including race or ethnicity, insurance status, and maternal level of care. To assess the effect of the COVID-19 pandemic on this Maternal Safety Quality Improvement Project, process measure data were compared with COVID-19 case volume in Ohio across the study epoch. A total of 29 hospitals participated in the project from July 2020 to September 2021. Data were collected on 4948 hypertensive events representing 4678 unique patients. In aggregate, the primary process measure (timely and appropriate treatment) demonstrated a 19.3% increase (from a baseline of 56.5% to 67.4%; P<.001). The secondary process measures demonstrated significant increases ranging from 26.1% to 166.8% (all P<.001). Both non-Hispanic Black and White pregnant or postpartum people demonstrated shifts and sustained improvements in the treatment of severe hypertension, which did not differ by race across the study period. Process measure improvements were achieved and sustained across peaks in the COVID-19 pandemic. This Ohio Maternal Safety Quality Improvement Project demonstrated meaningful changes in project process measures in the identification and treatment of severe hypertension in pregnancy and the postpartum period. Process measures improvements were achieved across all hospital levels of maternal care, and differences were not observed by race or ethnicity. Our findings suggest that a robust and comprehensive quality improvement initiative with appropriate support and resources can achieve meaningful gains in the setting of a global pandemic.

Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas.

The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Alliance for Innovation on Maternal Health: Consensus Bundle on Cardiac Conditions in Obstetric Care.

Cardiac conditions are the leading cause of pregnancy-related deaths and disproportionately affect non-Hispanic Black people. Multidisciplinary maternal mortality review committees have found that most people who died from cardiac conditions during pregnancy or postpartum were not diagnosed with a cardiovascular disease before death and that more than 80% of all pregnancy-related deaths, regardless of cause, were preventable. In addition, other obstetric complications, such as preeclampsia and gestational diabetes, are associated with future cardiovascular disease risk. Those with cardiac risk factors and those with congenital and acquired heart disease require specialized care during pregnancy and postpartum to minimize risk of preventable morbidity and mortality. This bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people with cardiac conditions and to respond to cardio-obstetric emergencies. This bundle is one of several core patient safety bundles developed by the Alliance for Innovation on Maternal Health that provide condition- or event-specific clinical practices for implementation in appropriate care settings. The Cardiac Conditions in Obstetric Care bundle is organized into five domains: 1) Readiness , 2) Recognition and Prevention , 3) Response , 4) Reporting and Systems Learning , and 5) Respectful Care . This bundle is the first by the Alliance to be developed with the fifth domain of Respectful Care . The Respectful Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into elements in each domain.

Retracted] Parameter Optimization and Performance Analysis of Composite Substance That Can Prevent Burning Based on Machine Learning

In the past 30 years, a substance that can prevent burning has played an important role in reducing the loss of life and property caused by fire. At present, the total amount of antibaking agent is second only to plasticizer and various plastic additives in the world. With an average annual growth rate of 0.5% from 2019 to 2021. The fire protection industry is a regulatory industry and a globally competitive industry. Therefore, the entry into force and gradual improvement of relevant laws and regulations at home and abroad will affect the pattern of the whole fire protection industry. China’s “Twelfth Five‐Year Plan” will bring a substance that can prevent burning into key development industries and form a strategic alliance for technological innovation of green substance that can prevent burning industries. It provides a policy platform for the development of a substance that can prevent burning in industry. Firstly, we introduce several common a substance that can prevent burnings, then we use machine learning method to establish prediction model and to analyze the performance of composite combustibles. And draw the conclusion: composite material is better than the other two composites; among the six machine learning algorithms, the gradient boosting regression (GBR) model has the best prediction ability, followed by the extra tree regressor (ETR) model and the random forest regressor (RFR) model. Compared with the above three integrated algorithms, Ridge, Ada Boost regressor (ABR), and Lasso regression algorithms have relatively poor prediction results.

Executive summary: Workshop on social determinants of health and obstetrical outcomes, February 1–2, 2022, cosponsored by the Society for Maternal-Fetal Medicine, the Commonwealth Foundation, and the Alliance for Innovation on Maternal Health, with support from the Society for Women’s Health Research

Executive summary: Workshop on social determinants of health and obstetrical outcomes, February 1–2, 2022, cosponsored by the Society for Maternal-Fetal Medicine, the Commonwealth Foundation, and the Alliance for Innovation on Maternal Health, with support from the Society for Women’s Health Research

Service Level Agreement (SLA) Chains Supported by Cloud in a Complex Port Ecosystem with Competing Stakeholder Goals: Editorial

The European Union Digital Library (EUDL) is the central repository for all content published by the different branches of the European Alliance for Innovation (EAI). EUDL also hosts or indexes content from selected partner or member organizations and affiliates.

How to Improve Care of Obstetric Patients With Severe Hypertension in the Emergency Department

Despite implementing the Alliance for Innovation on Maternal Health (AIM) patient-safety bundle for severe hypertension in pregnancy, hospitals continue to struggle to engage the emergency department in appreciating the care bundle strategies. There appears to be a lack of knowledge and, thus, a failure to recognize severe hypertension in obstetric patients and the implications of severe morbidity and mortality this failure can cause.

Innovating to Rapidly Treat Postpartum Hemorrhage

Obstetric postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality and morbidity worldwide. In 2014 the Alliance for Innovation on Maternal Health (AIM) developed the obstetric hemorrhage bundle. OhioHealth began implementation of the bundle in 2018 with a strong effort to develop and provide consistency in obstetric care across the health care system. The work was rolled out through the OhioHealth Women and Infant Clinical Guidance Council to all obstetrician-gynecologist providers, medical students, and nurses.

Are Malware Detection Classifiers Adversarially Vulnerable to Actor-Critic based Evasion Attacks?

The European Union Digital Library (EUDL) is the central repository for all content published by the different branches of the European Alliance for Innovation (EAI). EUDL also hosts or indexes content from selected partner or member organizations and affiliates.

Using Longitudinally Linked Data to Measure Severe Maternal Morbidity.

To assess whether application of a standard algorithm to hospitalizations in the prenatal and postpartum (42 days) periods increases identification of severe maternal morbidity (SMM) beyond analysis of only the delivery event. We performed a retrospective cohort study using data from the PELL (Pregnancy to Early Life Longitudinal) database, a Massachusetts population-based data system that links records from birth certificates to delivery hospital discharge records and nonbirth hospital records for all birthing individuals. We included deliveries from January 1, 2009, to December 31, 2018, distinguishing between International Classification of Diseases Ninth (ICD-9) and Tenth Revision (ICD-10) coding. We applied the modified Centers for Disease Control and Prevention algorithm for SMM used by the Alliance for Innovation on Maternal Health to hospitalizations across the antenatal period through 42 days postpartum. Morbidity was examined both with and without blood transfusion. Overall, 594,056 deliveries were included in the analysis, and 3,947 deliveries met criteria for SMM at delivery without transfusion and 9,593 with transfusion for aggregate rates of 150.1 (95% CI 146.7-153.5) using ICD-9 codes and 196.6 (95% CI 189.5-203.7) using ICD-10 codes per 10,000 deliveries. Severe maternal morbidity at birth increased steadily across both ICD-9 and ICD-10 from 129.4 in 2009 (95% CI 126.2-132.6) using ICD-9 to 214.3 per 10,000 (95% CI 206.9-221.8) in 2018 using ICD-10. Adding prenatal and postpartum hospitalizations increased cases by 21.9% under both ICD-9 and ICD-10, resulting in a 2018 rate of 258.7 per 10,000 (95% CI 250.5-266.9). The largest increase in detected morbidity in the prenatal or postpartum time period was attributed to sepsis cases. Inclusion of prenatal and postpartum hospitalizations in the identification of SMM resulted in increased ascertainment of morbid events. These results suggest a need to ensure surveillance of care quality activities beyond the birth event.