Hospital Delivery Research Articles

Trends in severe maternal morbidity following an institutional team goal strategy for disparity reduction

BackgroundRacial disparities in maternal pregnancy outcomes, specifically in morbidity and mortality, are persistent in the U.S., and a multifaceted approach to mitigating these disparate outcomes is critical. In 2020, our health system committed to reducing severe maternal morbidity (SMM) in Black patients, employing multiple strategic interventions including implicit bias training, regular reporting of a composite SMM metric stratified by race and ethnicity, standardization of best practices, focused efforts for hemorrhage risk reduction, and system-wide team building. ObjectiveThe goal of this study is to investigate trends in SMM by race across this period of concentrated interventions to improve maternal outcomes overall, and specifically for Black patients. Study DesignThis is a retrospective cohort study evaluating all delivery admissions at an academic, urban, tertiary-care hospital in Philadelphia—one site of a health system encompassing five delivery hospitals—over a 3-year period from 2019 to 2021. Data including patient demographics, clinical features, and outcomes were extracted from the electronic medical record (EMR). Self-reported race was categorized as Black vs non-Black as documented in the EMR. SMM was defined according to established CDC indicators as well as additional codes identified by Vizient for common sources of SMM including hemorrhage, infection, and embolism. Data were analyzed by year with a multivariable logistic regression model including insurance type and obstetric comorbidity index (OB-CMI), a weighted scoring system accounting for numerous chronic medical conditions and antepartum pregnancy complications. ResultsIn total, 12,339 deliveries were included, 64.6% (N=8012) of which were to Black patients. Median OB-CMI score was higher for Black patients at 3 (interquartile range [IQR] 1–5) compared to 2 (IQR 1–4) for non-Black patients, P<.01. There was a significant decrease in SMM for the entire cohort over the study period (8.5% in 2019 to 6.5% in 2021, P=.001), driven by a decreased rate specifically among Black patients (8.9% in 2019 to 6.6% in 2021, P=.005) with a nonsignificant decrease for non-Black patients (7.8% in 2019 to 6.3% in 2021, P=.21). The adjusted model similarly demonstrated decreased risk of SMM over time for Black patients (2020 vs 2019 adjusted odds ratio [aOR] = 0.81, 95% confidence interval [CI] 0.69–0.96; 2021 vs 2019 aOR 0.73, 95% CI 0.62–0.86). ConclusionDedicated efforts to improve equity in maternal outcomes over a 2-year period (2020–2021) in this hospital serving a Black patient majority were associated with a significant decline in SMM, especially among Black patients. This finding demonstrates the success of a high-level, coordinated, and systematic approach in reducing SMM and associated disparities, and is highly consequential in light of the ongoing major epidemic of racial disparities in obstetric outcomes.

43 - Impact of manual perineal protection training on the percentage and degree of obstetric perineal injuries in vaginal deliveries in a regional hospital

43 - Impact of manual perineal protection training on the percentage and degree of obstetric perineal injuries in vaginal deliveries in a regional hospital

Investigating the relationship between personality types and resilience in pregnant women. A cross-sectional study

BackgroundChildbirth is considered a critical experience in a woman's life when she needs mental adaptation and reorganization of relationships. Factors such as personality and self-perception can help facing and solving crises. This study aimed to investigate the relationship between personality types and stress resilience among pregnant women. MethodsThis was a cross-sectional study on 210 multiparous and nulliparous pregnant women who were 32–37 weeks pregnant and referred to Shiraz medical hospitals for delivery selected via convenience sampling. Data collection tools were personal and midwifery information questionnaires and the Goldberg personality and visual pain assessment scale that were completed through interviews. Data analysis was performed by SPSS software using descriptive tests to describe the data and the Pearson correlation test to analyze the data. ResultsThe highest personality type was conscientiousness (48.1%) and the lowest was extraversion (2.4%). Maternal resilience had a significant positive relationship with extraversion (p=.001) and conscientiousness (p=.001). There was no significant relationship between the 2 variables of neuroticism and maternal resilience (p=.12). There was a significant positive relationship between the 2 variables of openness to experience and maternal resilience (p=.005). ConclusionWomen's healthcare providers can help to mitigate the negative effects of psychological distress, and psychologically empower this vulnerable group by considering the resilience and personality type of pregnant women during prenatal care.

Risk of short-term cardiovascular disease in relation to the mode of delivery in singleton pregnancies: a retrospective cohort study

Cardiovascular disease (CVD) is increasing in prevalence and affects up to 4% of pregnancies in otherwise healthy persons. The specific factors that drive the development of CVD in pregnant people are poorly characterised. This study aimed to determine whether the mode of delivery in singletons affects the risk of cardiovascular morbidity and mortality within one year in patients without prior CVD. We designed a retrospective cohort study utilising the Nationwide Readmissions Database (NRD) to identify singleton delivery hospitalisations in the United States from Jan 1, 2010 to Nov 30, 2018. International Classification of Disease (ICD) versions 9 and 10 codes were used to identify patients with readmission for CVD within the calendar year of index delivery. Patients aged 15-54 who underwent a singleton vaginal or caesarean delivery were included. Patients with pre-existing CVD hospitalisations before or during delivery, ectopic pregnancies, or abortive outcomes were excluded. Participant data was retrieved from the NRD database. The primary outcome was hospital readmission, defined by ICD 9 and 10 codes for fatal or non-fatal CVD in the same calendar year as delivery. Cox proportional hazard regression models were used to adjust for confounders. These included maternal age, hospital bed size, hospital type, hospital teaching status, income quartile, insurance, and year of delivery. Additional sub-analyses were performed adjusting for hypertensive disorders of pregnancy and diabetes mellitus. Of the 14,179,299 singleton deliveries, 32% (n=4,553,492) underwent a caesarean. CVD readmissions occurred in 255.2 per 100,000 (n=11,710) caesarean deliveries compared with 133.9 per 100,000 (n=12,507) vaginal deliveries (rate difference [RD], 121.4, 95% confidence interval [CI], 114.8-127.9; hazard ratio [HR] adjusted for all confounders including hypertensive disorders of pregnancy and diabetes mellitus was 1.42, 95% CI 1.35-1.50). This association was highest in the first 0-29 days following delivery (HR 1.68, 95% CI 1.59-1.78). The risk of readmission for CVD persisted for one year. These findings suggest that caesarean delivery of singletons is associated with a higher risk of cardiovascular morbidity in patients without pre-existing CVD. This risk was highest in the first month but remained elevated for one year after delivery. These findings add to the accumulating evidence that undergoing caesarean delivery may have long-standing health implications and support the extension of the post-partum surveillance period. Limitations of this study include the lack of adjustment for body mass index, race, and parity. We were also unable to determine the reason for the caesarean delivery. None.

Trends in Postpartum Hemorrhage Prevalence and Comorbidity Burden: Insights from the ENACT Network Aggregated Electronic Health Record Data.

The goal of this study was to assess trends in postpartum hemorrhage (PPH), its risk factors, and maternal comorbidity burden in the United States using aggregate data from the Evolve to Next-Gen Accrual to Clinical Trials (ENACT) network. This federated network employs interactive querying of electronic health record data repositories in academic medical centers nationwide. We conducted repeated annual cross-sectional analyses to evaluate PPH occurrence and comorbidities across various ethnoracial and sociodemographic groups, starting with a large cohort of 1,287,675 unique delivery hospitalizations collected from 22 ENACT sites between 2005 and 2022. During this time, there was a statistically significant increasing trend in the prevalence of PPH, rising from 5,634 to 10,504 PPH per 100,000 deliveries (P trend <0.001). Our findings revealed a continuous upward trend in PPH rates that remained consistent among women with ≥ 1 comorbid conditions (P trend <0.001) and those with ≥ 1 maternal risk factor (P trend <0.001). This result aligns with prior studies and extends beyond the time periods previously reported. Overall, Native Hawaiian or Other Pacific Islander women had the highest PPH prevalence (~ 13%), followed by Asian (9.8%), American Indian or Alaska Native (8.9%), multirace (8.6%), Black or African American (8.4%) and White (7.4%) women. The top PPH risk factor identified was placenta previa or accreta, while the top comorbidity was antepartum hemorrhage / placental abruption. The most common cause of PPH, namely uterine atony, was prevalent in ENACT data. Our analysis highlights significant ethnoracial disparities and underscores the need for targeted preventative interventions.

Trends in under-five mortality rate in China, 1996–2020: a Joinpoint regression and correlation analysis

ObjectivesTo analyse annual trends of the under-five mortality rate (U5MR) and main cause-specific U5MR in China from 1996 to 2020 and to assess the potential correlation of the healthcare system...

Maternal morbidity in postpartum severe preeclampsia by obstetric delivery volume

BackgroundPre-eclampsia is a leading cause of maternal morbidity and mortality in the United States. Emerging data suggests that postpartum pre-eclampsia may be associated with a higher incidence of maternal morbidity compared to hypertensive disorders of pregnancy (HDP) diagnosed antenatally. Understanding postpartum maternal risk across facilities with a spectrum of obstetric services is critical with the rising rates of pre-eclampsia in all healthcare settings. ObjectiveWe investigated the relationship between facility delivery volume and rates of nontransfusion severe maternal morbidity (SMM) among patients readmitted postpartum for pre-eclampsia with severe features. Study DesignThis is a retrospective cohort study using the Nationwide Readmissions Database (2015–2019) of postpartum patients readmitted for pre-eclampsia with severe features. Our primary outcome was nontransfusion SMM during readmission, defined per U.S. Centers for Disease Control and Prevention criteria. We also evaluated SMM, cardiac SMM, and individual morbidities. The exposure variable was the number of annual deliveries at the readmitting facility. Restricted cubic splines with 4 knots were used to assess the functional form of the relationship between obstetric delivery volume and nontransfusion SMM; a linear relationship was identified as optimal. Logistic regression was used to estimate adjusted odds ratios (aOR) which controlled for maternal age, nontransfusion SMM at delivery, expanded obstetric comorbidity index, and HDP during delivery. ResultsThe cohort included 29,472 patients readmitted with postpartum pre-eclampsia with severe features. The primary payer was 55% private and 42% governmental. Median age was 31.4 years. Most patients did not have prior HDP (65%) or chronic hypertension (86%) diagnosis antenatally. The median interval from delivery hospitalization to readmission was 3.9 days (25th percentile–75th percentile: 2.2–6.5). Nontransfusion SMM occurred in 7% of patients readmitted to facilities with >2000 deliveries compared to 9% with 1 to 2000 deliveries, and 52% without any delivery hospitalizations. The most common SMM was pulmonary edema and heart failure, observed in 4% of readmissions. We observed that for every increase in 1000 deliveries, the odds of a nontransfusion SMM at readmission decreased by 3.5% (aOR: 0.965; 95% confidence interval: 0.94, 0.99). ConclusionNontransfusion SMM for postpartum readmissions with pre-eclampsia with severe features was inversely associated with readmitting hospital delivery volume. This information may guide risk-reducing initiatives for identifying strategies to optimize postpartum care at facilities with lower or no delivery volume.

Care seeking during pregnancy: testing the assumptions behind service delivery redesign for maternal and newborn health in rural Kenya.

A health systems reform known as Service Delivery Redesign (SDR) for maternal and newborn health seeks to make high-quality delivery care universal in Kakamega County, in western Kenya, by strengthening hospital-level care and making hospital deliveries the default option for pregnant women. Using a large prospective survey of new mothers in Kakamega County, we examine several key assumptions that underpin the SDR policy's theory of change. We analyse data on place of delivery, travel time and distance, out-of-pocket spending, and self-reported quality of care for 19 127 women prospectively enrolled during antenatal care (ANC) and surveyed two times after their delivery. We analyze changes in womens' delivery location preferences in recent years in Kakamega, and over the course of their most recent pregnancy. We also evaluate travel time, out-of-pocket expenditures and patient satisfaction for women who deliver in public hospitals vs primary health centres. We find substantial changes in delivery location at the population level over time and for individual women over the course of pregnancy. Facility delivery has increased from 50.4% in 2010 to 89.5% in 2019; 70% of respondents deliver at a different facility than their reported intention at ANC. Out-of-pocket delivery expenditures are on average 1351 Kenyan shillings (Ksh) in hospitals compared to 964 Ksh in PHC (primary health care)s (P < 0.01). Transport expenditures are 337 Ksh for PHC level deliveries vs 422 Ksh for hospitals (P < 0.01). Self-reported average travel time is 51 min (PHC delivery) vs 47 min (hospital delivery) (P = 0.78). The average distance to a delivery location is 15.1 km for PHC deliveries vs 15.2 km for hospitals (P = 0.99). There were no differences in overall patient-reported quality scores, while some subcomponents of quality favoured hospitals. These findings support several key assumptions of the SDR theory of change in Kakamega County, while also highlighting important challenges that should be addressed to increase the likelihood of successful implementation.

Impact of patient safety bundle and team-based training on obstetric hypertensive emergencies.

Hypertensive disorders of pregnancy, defined as chronic (<20 weeks) or gestational (>20 weeks), are a leading cause of pregnancy related mortality in the United States1. Hypertensive disorders of pregnancy had increased prevalence from 13.3% to 15.9% among delivery hospitalizations between 2017 and 20191. The objective of this project was to increase the percentage of obstetric patients with hypertensive emergency who received evidence-based treatment within 60 minutes at a single academic center. Study Design Data was collected before and after the implementation of a hypertension patient safety bundle. Each occurrence of hypertensive emergency was assessed to determine if evidence-based intervention occurred within 60 minutes, and if the intervention steps were successfully followed. Bundle implementation included creation of a standardized order set and interdisciplinary team-based simulations. Baseline data compared 250 pre-implementation to 250 post-implementation interventions. The quality improvement interdisciplinary team reevaluated data monthly and incorporated process improvements through Plan Do Study Act (PDSA) cycles to achieve a goal of 80% of patients receiving evidence-based treatment within 60 minutes. Results A total of 1025 hypertensive emergencies were identified in 543 patients. Prior to the protocol on average 64% of patients received evidence-based, timely treatment. After implementation of this bundle and several PDSA cycles, we sustained >80% of patients receiving target treatment for the final six months of data collection. The leading deviations were "no medication given" and "incorrect medication". Improvements in order set accessibility and repeated team-based trainings led to improvement in these identified protocol deviations. Conclusion Implementation of a patient safety bundle led to a sustained 6 month improvement in the percentage of patients receiving appropriate treatment of obstetric hypertensive emergency within 60 minutes of the first severe hypertension measurement. Processes that may have helped achieve this outcome included standardized order sets, team awareness of institutional data and team-based simulations.

The Impact of Hospital Delivery Volumes of Newborns Born Very Preterm on Mortality and Morbidity

To examine if the annual patient volume of infants born very preterm (VPT, gestational age <32weeks) at a hospital is associated with neonatal mortality and morbidity. We performed an observational, secondary data analysis using a 20-year panel of birth certificates linked to hospital discharge abstracts, including transfers in California, Michigan, Missouri, Oregon, Pennsylvania, and South Carolina from 1996 through 2015. The study included all in-hospital VPT deliveries (n=208 261). Study outcomes were in-hospital mortality or serious morbidity (intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, or bronchopulmonary dysplasia), attributed to the hospital of birth. Poisson regression models estimated the risk-adjusted relative risk (RR) for mortality and serious morbidity across different patient volume categories within a given hospital using hospital fixed effects. The risk of mortality and serious morbidity for VPT infants increased as the number of infants born VPT at a hospital decreased. Compared with VPT delivery volumes >100 infants per year, the risk of mortality increased when a given hospital had VPT delivery volumes < 60 per year, ranging from a RR of 1.13 (95% C.I. 1.02-1.25) for volumes between 50 to 59 and 1.39 (1.19-1.62) for VPT volumes <10, and the risk of mortality or serious morbidity increased when a given hospital had VPT volumes <100, ranging from a RR of 1.05 (1.02-1.08) for volumes between 90 to 99 and 1.27 (1.19-1.36) for VPT volumes <10. These results suggest that, for VPT infants, the risk of both mortality and mortality or serious morbidity is increased as the VPT volume within a given hospital declines.

The effects of a quality improvement project to reduce caesarean sections in selected private hospitals in Brazil

BackgroundBrazil is one of the countries with the highest rates of caesarean sections (CS), reaching almost 90% of births in the private sector. A quality improvement project called “Adequate Childbirth Project (PPA)” was conceived to reduce CS in the private sector. This project consisted of four primary components: “Governance”, “Participation of Women”, “Reorganization of Care” and “Monitoring”. This paper aims to evaluate: (1) which specific activities of the PPA had the largest effect on the probability of a woman having a vaginal delivery; (2) which primary component of the PPA had the largest effect on the probability of vaginal delivery and (3) which scenarios combining the implementation of different activities planned in the PPA had a higher effect on the probability of vaginal delivery.MethodsA sample of 12 private hospitals participating in the PPA was evaluated. We used a Bayesian Network (BN) to capture both non-linearities and complex cause-effect relations. The BN integrated knowledge from experts and data from women to estimate 26 model parameters. The PPA was evaluated in 2473 women belonging to groups 1–4 of the Robson classification, who were divided into two groups: those participating or not participating in the PPA.ResultsThe probability of a woman having a vaginal delivery was 37.7% higher in women participating in the PPA. The most important component of the project that led to an increase in the probability of vaginal delivery was “Reorganization of Care”, leading to a 73% probability of vaginal delivery among women in labor. The activity that had the greatest effect on the type of delivery was access to best practices during labor, with a 72% probability of vaginal delivery. Considering the 12 scenarios combining the different activities of the PPA, the best scenarios included: a non-scheduled delivery, access to information about best practices, access to at least 4 best practices during labor and respect of the birth plan, with an 80% probability of vaginal delivery in the best combinations.ConclusionPPA has been shown to be an effective quality improvement program, increasing the likelihood of vaginal delivery in private Brazilian hospitals.

Delivery Hospitalization Cardiac and Respiratory Complications during SARS-CoV-2 Delta Variant Dominance.

In 2021, the SARS-CoV-2 Delta variant rapidly proliferated and became dominant. Some but not all research evidence supports that Delta was associated with increased maternal risk. The purpose of this study was to determine whether Delta was associated with risk for cardiac and respiratory complications in a national sample. Of an estimated 3,495,188 delivery hospitalizations in 2021, 1.8% of pre-Delta deliveries (n=29,580) (January-June) and 2.1% of Delta-period deliveries (n=37,545) (July-December) had a COVID-19 diagnosis. The Delta period was associated with increased adjusted odds of respiratory complications (aOR 1.54, 95% CI 1.41, 1.69) and cardiac SMM (aOR 1.54, 95% CI 1.40, 1.69). Among deliveries with a COVID diagnosis, the Delta period was associated with higher incidence of respiratory complications (8.4% versus 3.7%) and cardiac SMM (8.4% versus 3.5%) (p<0.01 for both). These findings corroborate prior clinical studies suggesting that the Delta strain was associated with an increased maternal population-level clinical burden.

Severe Maternal Morbidity by Disability Status and Type in the United States

OBJECTIVE: To estimate the risk of severe maternal morbidity (SMM) among women with disabilities compared with those without disabilities in a nationally representative sample of U.S. delivery hospitalizations. METHODS: We conducted a retrospective cohort analysis using the 2016–2021 Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. We identified delivery hospitalizations and disability status using International Classification of Diseases, Tenth Revision diagnosis codes. The primary outcome was SMM, which was determined using 21 indicators specified by the Centers for Disease Control and Prevention. We used Poisson regression to estimate unadjusted and adjusted relative risks (aRRs) and 95% CIs for the association between disability status and type with SMM outcomes. RESULTS: Among 4,331,457 delivery hospitalizations, 128,413 (3.0%) were to women with disabilities. Women with disabilities had significantly higher rates of SMM compared with those without disabilities (396/10,000 deliveries vs 177/10,000 deliveries). In fully adjusted models, women with disabilities had an aRR of 1.86 (95% CI, 1.80–1.91) for one or more SMM indicators. The risk of SMM varied by disability type, with the highest risks observed for women who had vision disabilities (aRR 3.02, 95% CI, 2.70–3.38) or had physical disabilities (aRR 2.44, 95% CI, 2.34–2.55). Women with disabilities had the highest risk for other medical complications (puerperal cerebrovascular disorders and sickle cell disease with crisis), followed by other obstetric complications, respiratory complications, cardiovascular complications, acute renal failure, sepsis, and bleeding complications compared with women without disabilities. CONCLUSION: Women with disabilities have a significantly higher risk of SMM during delivery compared with those without disabilities, with the magnitude of risk varying by disability type. Efforts to reduce SMM and maternal mortality in the United States must prioritize the unique needs of this population and ensure equitable, disability-competent care for all women.

Maternal mortality due to obstetric hemorrhage by surgical injury during cesarean section: A nationwide study.

Obstetric hemorrhage remains a largely preventable cause of maternal mortality globally. The contribution of uterine atony to hemorrhage-related maternal mortality has decreased in France, while the contribution of other causes of obstetric hemorrhage such as surgical injury during cesarean has been reported to increase. However, little evidence exists regarding the risk factors and care processes of women who died from this cause of hemorrhage. Therefore, we aimed to describe the clinical profile, underlying mechanisms, and preventability factors among women who died from obstetric hemorrhage by surgical injury during cesarean section. Nationwide analysis of all hemorrhage-related maternal deaths by surgical injury during cesarean in France identified by the nationwide permanent enhanced maternal mortality surveillance system (ENCMM) between 2007 and 2018. We described the characteristics of the women, delivery hospitals, circumstances of hemorrhage, features of obstetric and resuscitation/transfusion care, and main preventability factors. Between 2007 and 2018, hemorrhage-related maternal mortality in France decreased from 1.6/100 000 live births (95% CI 1.1-2.2) (39/2 472 650) in 2007-2009 to 0.8/100 000 live births (95% CI 0.5-1.3) (19/2 311 783) in 2016-2018. Hemorrhage-related maternal mortality ratio due to surgical injury during cesarean increased from 0.08 (95% CI 0.01-0.3) (2/2 472 650) to 0.2 (95% CI 0.07-0.5) (5/2 311 783) per 100 000 live births. Among the 18 women who died from surgical injury during cesarean over the 12-year study period, we report a high prevalence of obesity (67%, 12/18), previous cesarean (72%, 13/18), and second-stage cesareans (56%, 10/18). In 22% (4/18), cesarean section was performed in a hospital providing <1000 births annually, with no blood bank (39%, 7/18) or no adult intensive care (44%, 8/18) on-site. Overall preventability of deaths was 94% (17/18). Main preventability factors were related to delay in hemorrhage diagnosis (77%, 14/18) due to late recognition of abnormal parameters (33%, 6/18) and late bedside ultrasound (56%, 10/18), and delay in management due to insufficient surgical skills (56%, 10/18). In France, surgical injury during cesarean section is an increasing, largely preventable contributor to hemorrhage-related maternal mortality, as other causes of fatal hemorrhage have become less frequent. The profile of these women showed a high prevalence of obesity, previous cesarean, second-stage cesarean, and delivery in hospitals with limited medical and surgical resources, which suggests explanatory mechanisms for the fatal outcome and opportunities for prevention.

A retrospective analysis of postpartum red blood cell transfusions at a tertiary care obstetric centre.

Postpartum anaemia is a prevalent health problem. We aimed to determine the compliance rate for red blood cell (RBC) transfusion indication among postpartum women in a single tertiary care centre in Quebec, Canada. Retrospective cohort study including all women ≥6 h postpartum who received ≥1 RBC transfusion during their delivery hospitalization between January 2005 and February 2022. We determined our centre's compliance rate by indication as compared to current society guidelines, all published after 2015 (Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis [NATA], Royal College of Obstetricians and Gynaecologists [RCOG], American College of Obstetricians and Gynecologists [ACOG]). We then explored predictors of guideline non-compliance and described transfusion practices in our centre. A total of 171 women were included. Our centre's compliance rate was 79.5% (95% confidence interval [CI] 72.7-84.8). Predictors of guideline non-compliance were maternal medical comorbidity or abnormal placentation, both limited by large CIs (odds ratio [OR] 2.26, CI 1.02-4.94, p = 0.04; OR 4.00, CI 1.31-12.06, p = 0.01, respectively). Postpartum haemorrhage was diagnosed among 68% of the cohort, mostly due to uterine atony (73.3%). Mean baseline and nadir haemoglobin were 111 g/L (±18) and 62 g/L (±7.7), respectively. Multiple unit initial transfusion was found in a majority of patients (63.7%). Iron therapy was administered to 51.5% of women in-hospital and 81.9% received an oral iron prescription at discharge. There were no differences in primary or secondary outcomes subsequent to relevant guideline publication. Our centre's compliance rate for RBC transfusion indication meets current practice guidelines. Areas for improvement include single-unit initial transfusion protocols and adjuvant iron treatment. Antenatal optimization of haemoglobin and ferritin stores may limit postpartum transfusions.

Maternal Risk Factors and Birth Outcomes of Pregnancies Complicated by Preeclampsia: A Case–control Study in a Tertiary Care Hospital of Central India

Background: Preeclampsia contributes substantially to maternal and perinatal mortality. Reduction of maternal and perinatal mortality is a global priority, particularly in low- and middle-income countries like India. Preeclampsia is often overlooked during pregnancy and emerges as a significant contributor to mortality if not addressed proactively. Hence, the present study planned to explore maternal risk factors and birth outcomes in women with preeclampsia admitted for delivery in a tertiary care hospital. Materials and Methods: The present case–control study, including 100 matched cases and a similar number of controls, was carried out. For cases, pregnant women admitted for delivery, diagnosed with preeclampsia, while controls included all pregnant women admitted for delivery without preeclampsia were interviewed. A structured interview questionnaire, patient documents, and maternal and child protection (MCP) cards were used for data collection. Results: Family history of hypertension (odds ratio [OR] = 2.90, 95% confidence interval [CI] = 1.65–5.31), history of chronic hypertension (OR = 6.00, 95% CI = 1.97–18.27), and primiparity (OR = 1.28, 95% CI = 0.72–2.26) were significantly associated with preeclampsia. Preterm birth occurred in 58.1% of cases and 41.8% of controls. No associations were found between preeclampsia and the mode of delivery, gender, and birth weight of the baby. Conclusion: Women with a family history of hypertension, primiparous women, and those with a chronic history of hypertension have more tendency to adverse consequences of pregnancy and its outcomes like preterm births. Recognizing high-risk cases promptly and implementing effective management strategies are essential for planning and executing women’s health programs ultimately enhancing nationwide maternal and child health-care delivery.

Obstetric outcomes among rural parturients across US urban and rural hospitals.

The objective of this study is to evaluate severe maternal morbidity (SMM) of rural parturients delivering at rural compared to urban hospitals in the US. We identified patients aged 18-40 years in a multi-institutional claims database who lived in a rural ZIP code and delivered at a rural or urban hospital between October-December of 2015 and October-December of 2022. The primary outcome was SMM, and the secondary outcome was SMM exclusive of blood transfusions. We combined exact ZIP code matching and propensity score matching to compare SMM risk among patients living in the same rural community and delivering in urban as compared to rural hospitals. A total of 214 296 patients from 571 ZIP codes were identified, including 47% delivering at rural facilities and 53% delivering at urban facilities. The SMM rate was 1.1% (0.3% excluding blood transfusions). After matching, urban versus rural delivery was associated with increased odds of SMM other than blood transfusion (odds ratio 2.44; 95% confidence interval 1.81-3.28), but was not associated with differences in risk of any SMM. There was no evidence of reduced SMM for rural patients delivering at an urban rather than a rural hospital. SMM exclusive of blood transfusions was increased for rural patients delivering at urban hospitals after matching on ZIP code and predictors of urban hospital delivery. Our findings undermine the assumption that delivery at a rural facility has inherently greater risks relative to delivery at an urban facility. As some health systems face challenges to maintain rural labor and delivery units, patient safety must be considered if confronted with the possibility of unit or hospital closures.

Experiences of Care, Racism, and Communication of Postpartum Black Women Readmitted After Delivery

OBJECTIVE: To explore the contribution of psychosocial factors, perceived barriers to care, structural racism, and experiences of care to disparities in postpartum outcomes for Black patients, as measured by emergency department (ED) visits and postpartum readmissions. METHODS: We conducted semi-structured interviews with women of color who were readmitted or had an ED visit related to perinatal outcomes within 30 days of delivery hospitalization. We created an interview guide based on patient, community, and health system factors, asking questions about care and lived experience through delivery, discharge, coming home, and ED visits or readmission during the postpartum period. Patients were identified through the electronic medical record system. Interviews ranged from 30 to 60 minutes and were transcribed, and medical charts were reviewed for delivery and postpartum outcomes. We coded interviews through deductive engagement with the interview guide, which was validated through double-comparative coding between researchers, and used content analysis to delineate themes surrounding barriers to and lack of quality postpartum care for birthing people of color. RESULTS: Principal themes that emerged from the interviews with participants were: perceived lack of communication about the complications they experienced; structural racism described through examples of not being listened to or believed; a perceived lack of respect for Black women's bodies by doctors and nurses, which became embedded in inappropriate verbal and nonverbal communication practices by clinicians and staff; and mismatches in care for participants were noted from the care provided and chart documentation compared with what patients understood to be happening with their health. CONCLUSION: To counter the increasing rates of morbidity and mortality among postpartum Black patients, stronger efforts are required to address the needs of Black patients during the postpartum period through documenting and acknowledging patients' lived experiences, addressing communication needs, and understanding the consequences of structural racism.

Readmission Rates After Expedited Postpartum Discharge.

To characterize national trends in expedited postpartum discharge and, secondarily, to identify predictors of expedited postpartum discharge and assess whether expedited postpartum discharge was associated with postpartum readmissions within 60 days of delivery hospitalization discharge. Birth hospitalizations and subsequent 60-day postpartum readmissions were extracted from the 2016-2020 Nationwide Readmissions Database for this retrospective cohort study. Postpartum discharge was categorized as expedited (less than 2 days after vaginal birth or less than 3 days after cesarean birth), routine (2 days after vaginal birth or 3 days after cesarean birth), or prolonged (more than 2 days after vaginal birth or more than 3 days after cesarean birth). Trends in expedited discharge were assessed over the study period with joinpoint regression. Unadjusted and adjusted logistic regression models were performed to assess clinical, hospital, and demographic predictors of expedited postpartum discharge. Sixty-day postpartum readmission risk was calculated, and adjusted regression models were performed to evaluate the association between expedited postpartum discharge and readmission. Of 17.9 million birth hospitalizations, 32.9% had expedited postpartum discharge. The overall 60-day postpartum readmission rate after delivery hospitalization discharge was 1.7% for all patients, 1.4% for expedited postpartum discharge, 1.6% for routine discharge, and 3.3% for prolonged discharge. Rates of expedited postpartum increased from 29.1% in 2016 to 31.4% in 2019 and to 43.8% in 2020. This trend was not significant (average annual percent change: 9.9%, 95% CI, -1.6% to 23.7%), although rates of expedited discharge were significantly higher in 2020 than in 2016-2019 ( P <.01). Younger and older age, chronic comorbid conditions, mental health conditions, and obstetric complications (eg, transfusion, chorioamnionitis or endometritis) were associated with lower likelihood of expedited postpartum discharge. Expedited postpartum discharge was associated with 14% lower adjusted odds of 60-day postpartum readmission compared with routine discharge (adjusted odds ratio 0.86, 95% CI, 0.85-0.88). Rates of expedited postpartum discharge increased significantly in 2020 compared with 2016-2019 and were not associated with 60-day postpartum readmission. These findings suggest that broader use of expedited postpartum discharge has not resulted in increased risk of postpartum readmissions.

Administration of the Postpartum Glucose Tolerance Test During the Delivery Hospitalization Compared With 4–12 Weeks Postpartum

Administration of the Postpartum Glucose Tolerance Test During the Delivery Hospitalization Compared With 4–12 Weeks Postpartum