Rate Of Severe Maternal Morbidity Research Articles

Substance Use Disorder and Severe Maternal Morbidity: Is there a Differential Impact?

BackgroundSubstance use disorder (SUD) is a disease characterized by behavior patterns of substance use leading to dysfunction in cognition, mood, and quality of life. The prevalence of perinatal substance use disorders in the United States continues to rise and have adverse effects on the maternal-infant dyad. Mirroring the rise in SUD is an increasing prevalence of severe maternal morbidity (SMM). However, this relationship needs further examination. Objective(s)The primary objective of this study was to evaluate the association between perinatal SUD and SMM. We hypothesized that SUD would predict a significantly increased risk for SMM events, both as a composite and individually, in adjusted multivariable regression analyses. Study DesignWe conducted a cross-sectional analysis of inpatient pregnancy hospitalizations from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) from 2016 to 2020. ICD-10 codes were used to identify patients with a SUD and/or a SMM event. SUD was defined as a composite. Our primary outcome was rate of SMM as defined by the CDC. Multivariable logistic regression analyses were performed to predict the likelihood of SMM among pregnancy hospitalizations with and without SUD as well as to predict the likelihood of SMM for each individual type of SUD in a subgroup of hospitalizations with SUD and SMM. ResultsOf the 3,672,932 inpatient pregnancy hospitalizations included in the analyses, 6.27% (230,110/ 3,672,932) had SUD diagnosis and 2.10% (77021/ 3,672,932) had an SMM diagnosis. The prevalence of SMM was significantly higher among patients with SUD (7,357/ 230,110 – 3.20%) vs. without SUD (69,664/3,442,822– 2.02%, p <.0001). Patients with SUD were 1.5 times more likely to have a SMM event as compared to those without SUD (aOR 1.52; 95% CI 1.48-1.56). In subgroup analyses based on SUD type - the likelihood of SMM was strongest for stimulants (aOR 3.86; 95% CI 3.61-4.13) and sedatives (aOR 3.82; 95% CI 3.08-4.75). In subgroup analyses based on SMM event, SUD was a strong positive predictor for acute MI (aOR 3.63; 95% CI 2.78-4.74) and aneurysm (aOR 6.28; 95% CI 2.77-14.21). Conclusion(s)Pregnant patients with SUD carry significantly increased risk of experiencing an SMM event. These events occur more readily in patients with certain patterns of SUD use – most notably sedatives and stimulants. Patients with SUD were most likely to experience a cardiovascular-related SMM event, thus informing care.

Prophylactic red cell transfusions for sickle cell disease pregnancy: increased use of therapy could transform outcomes.

Pregnancy for people with sickle cell disease (SCD) is high risk with persistently high rates of severe maternal and fetal mortality and morbidity. Transfusion therapy is the best-studied treatment for SCD in pregnancy; hydroxyurea is not usually used because of teratogenicity concerns. In high-resource settings, red cell transfusions are likely underutilized, while in low-resource settings, they may be altogether unavailable. A randomized controlled trial and meta-analysis, two of the strongest forms of clinical research, show transfusion significantly reduces maternal and fetal death, painful crisis, thrombosis, and acute respiratory failure. Downstream benefits of treatment are less well measured and may include improving maternal anemia, reducing opioid exposure, and avoiding hospitalization, which presents risk for additional complications. Alloimmunization is a particular transfusion risk in SCD. However, many strategies can mitigate this risk. Accordingly, the American Society of Hematology classifies chronic transfusion in pregnancy as low risk. Given the low risk classification, lack of alternative therapies, dismal, stagnant pregnancy outcomes and the potential for profound treatment benefit, wider use of chronic transfusion therapy for SCD pregnancy is likely indicated. This review discusses the benefits and potential risks of prophylactic transfusions for SCD pregnancy. Use of chronic transfusions during pregnancy is indicated to help urgently transform outcomes.

Association between iron deficiency anemia and severe maternal morbidity: A retrospective cohort study

PurposeWe examined the association between iron deficiency anemia (IDA) and severe maternal morbidity (SMM) during delivery and up to 1-year postpartum. MethodsIn a retrospective cohort study across 3 states, we computed adjusted relative risks (aRR) for SMM comparing individuals with IDA versus those without, using modified Poisson regression models. ResultsAmong 2459,106 individuals, 10.3 % (n = 252,240) had IDA. Individuals with IDA experienced higher rates of blood transfusion and non-transfusion SMM (329 and 122 per 10,000 deliveries, respectively) than those without IDA (33 and 46 per 10,000 deliveries, respectively). The risk of blood transfusion (aRR: 8.2; 95 % CI 7.9–8.5) and non-transfusion SMM (aRR: 1.9; 95 % CI: 1.8–2.0) were higher among individuals with IDA. The attributable risk per 10,000 deliveries due to IDA for blood transfusion and non-transfusion SMM during delivery were 29.5 (95 % CI: 28.9–30.0) and 5.7 (95 % CI: 5.3–6.2), respectively. Within 1-year postpartum, the relative risk of non-transfusion SMM (aRR:1.3; 95 % CI: 1.2–1.3) was 30 % higher among individuals with IDA. ConclusionIDA is associated with increased SMM risk. Addressing IDA in pregnant individuals may reduce SMM rates.

Hereditary Hemorrhagic Telangiectasia: Pregnancy and Delivery-Specific Considerations and Outcomes.

Prior studies have evaluated maternal outcomes in patients with hereditary hemorrhagic telangiectasia (HHT), yet pregnancy- and delivery-specific data remain limited. This study aims to evaluate pregnancy and delivery outcomes in patients with HHT. This retrospective cohort study used the Nationwide Readmissions Database to identify patients with HHT diagnosis on delivery between 2010 and 2021. The primary outcome was severe maternal morbidity (SMM). Secondary outcomes included nontransfusion SMM, preterm birth, stillbirth, prelabor rupture of membranes or preterm prelabor rupture of membranes, cesarean delivery, respiratory bleeding, cerebrovascular complications, patient disposition, and length of stay. Trends in the prevalence of HHT at delivery were assessed with logistic regression. Logistic regression analyses, adjusting for age, payer, zip code income, hospital size, and teaching status, were also used to produce adjusted relationships between HHT status and outcomes. The cohort of 21,698,861 delivered pregnancies corresponded to a national estimate of 44,325,599. Of those, 612 (national estimate: 1,265; 2.8 per 100,000) had a diagnosis of HHT. A steady rise in the HHT diagnosis rate during pregnancy from 2010 to 2021 (1.7 per 100,000 in 2010, 3.8 per 100,000 in 2021, p < 0.001 for trend) was seen. Patients with HHT were significantly more likely to experience SMM compared with patients without HHT (7.8 vs. 1.7%, adjusted relative risk [aRR]: 4.49 [95% confidence interval, CI: 3.06, 6.58]). Rates of preterm birth (14.2 vs. 8.5%, aRR: 1.57 [95% CI: 1.22, 2.03]), cesarean delivery (41.0 vs. 32.9%, aRR: 1.23 [95% CI: 1.07, 1.41]), respiratory bleeding (2.1 vs. <0.1%, aRR: 94.44 [56.64, 157.46]), and cerebrovascular complications (0.9 vs. <0.1%, aRR: 22.89 [9.89, 52.96]) were higher in patients with HHT than non-HHT patients. There was no difference in stillbirth rates between groups. Patients with HHT have higher rates of SMM and adverse delivery outcomes when compared with the baseline population. · There was a steady rise in the rates of HHT during pregnancy from 2010 to 2021.. · Patients with HHT are more likely to experience SMM.. · Patients with HHT are more likely to have a preterm delivery and cesarean delivery..

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.

Public Maternal Health Dashboards in the United States: Descriptive Assessment.

Data dashboards have become more widely used for the public communication of health-related data, including in maternal health. We aimed to evaluate the content and features of existing publicly available maternal health dashboards in the United States. Through systematic searches, we identified 80 publicly available, interactive dashboards presenting US maternal health data. We abstracted and descriptively analyzed the technical features and content of identified dashboards across four areas: (1) scope and origins, (2) technical capabilities, (3) data sources and indicators, and (4) disaggregation capabilities. Where present, we abstracted and qualitatively analyzed dashboard text describing the purpose and intended audience. Most reviewed dashboards reported state-level data (58/80, 72%) and were hosted on a state health department website (48/80, 60%). Most dashboards reported data from only 1 (33/80, 41%) or 2 (23/80, 29%) data sources. Key indicators, such as the maternal mortality rate (10/80, 12%) and severe maternal morbidity rate (12/80, 15%), were absent from most dashboards. Included dashboards used a range of data visualizations, and most allowed some disaggregation by time (65/80, 81%), geography (65/80, 81%), and race or ethnicity (55/80, 69%). Among dashboards that identified their audience (30/80, 38%), legislators or policy makers and public health agencies or organizations were the most common audiences. While maternal health dashboards have proliferated, their designs and features are not standard. This assessment of maternal health dashboards in the United States found substantial variation among dashboards, including inconsistent data sources, health indicators, and disaggregation capabilities. Opportunities to strengthen dashboards include integrating a greater number of data sources, increasing disaggregation capabilities, and considering end-user needs in dashboard design.

Association of in vitro fertilization with severe maternal morbidity in low-risk patients without comorbidities

To determine whether an association exists between invitro fertilization (IVF) and severe maternal morbidity among low-risk pregnant patients. Retrospective cohort study. Academic healthcare system. Low-risk pregnant patients who delivered between January 2019 and December 2022. Low-risk was defined as having an obstetric comorbidity index score of 0. Invitro fertilization. The primary outcome (dependent variable) was any severe maternal morbidity. The secondary outcome was the need for a cesarean delivery. A modified Poisson regression with robust error variance was used to model the probability of severe maternal morbidity as a function of IVF. Risk ratios and their associated 95% confidence intervals (CIs) were computed. An α value of 0.05 was considered statistically significant. A total of 39,668 pregnancies were included for analysis, and 454 (1.1%) were conceived by IVF. The overall severe maternal morbidity rate was 2.4% (n = 949), with the most common indicator being blood transfusion. The overall cesarean delivery rate was 18.8% (n = 7,459). On modified Poisson regression, IVF-conceived pregnancies were associated with 2.56 times the risk of severe maternal morbidity (95% CI, 1.73-3.79) and 1.54 times the risk of having a cesarean delivery (95% CI, 1.37-1.74) compared with non-IVF pregnancies. Invitro fertilization is associated with higher rates of severe maternal morbidity, primarily the need for a blood transfusion, and cesarean delivery in low-risk pregnancies without major comorbidities. Recognizing this association allows healthcare providers to implement proactive measures for better monitoring and tailored postpartum care.

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.

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.

Risk of Perinatal and Maternal Morbidity and Mortality Among Pregnant Women With Epilepsy

Maternal epilepsy is associated with adverse pregnancy and neonatal outcomes. A better understanding of this condition and the associated risk of mortality and morbidity at the time of delivery could help reduce adverse outcomes. To determine the risk of severe maternal and perinatal morbidity and mortality among women with epilepsy. This prospective population-based register study in Denmark, Finland, Iceland, Norway, and Sweden took place between January 1, 1996, and December 31, 2017. Data analysis was performed from August 2022 to November 2023. Participants included all singleton births at 22 weeks' gestation or longer. Births with missing or invalid information on birth weight or gestational length were excluded. The study team identified 4 511 267 deliveries, of which 4 475 984 were to women without epilepsy and 35 283 to mothers with epilepsy. Maternal epilepsy diagnosis recorded before childbirth. Prenatal exposure to antiseizure medication (ASM), defined as any maternal prescription fills from conception to childbirth, was also examined. Composite severe maternal morbidity and mortality occurring in pregnancy or within 42 days postpartum and composite severe neonatal morbidity (eg, neonatal convulsions) and perinatal mortality (ie, stillbirths and deaths) during the first 28 days of life. Multivariable generalized estimating equations with logit-link were used to obtain adjusted odds ratios (aORs) and 95% CIs. The mean (SD) age at delivery for women in the epilepsy cohort was 29.9 (5.3) years. The rate of composite severe maternal morbidity and mortality was also higher in women with epilepsy compared with those without epilepsy (36.9 vs 25.4 per 1000 deliveries). Women with epilepsy also had a significantly higher risk of death (0.23 deaths per 1000 deliveries) compared with women without epilepsy (0.05 deaths per 1000 deliveries) with an aOR of 3.86 (95% CI, 1.48-8.10). In particular, maternal epilepsy was associated with increased odds of severe preeclampsia, embolism, disseminated intravascular coagulation or shock, cerebrovascular events, and severe mental health conditions. Fetuses and infants of women with epilepsy were at elevated odds of mortality (aOR, 1.20; 95% CI, 1.05-1.38) and severe neonatal morbidity (aOR, 1.48; 95% CI, 1.40-1.56). In analyses restricted to women with epilepsy, women exposed to ASM compared with those unexposed had higher odds of severe maternal morbidity (aOR ,1.24; 95% CI, 1.10-1.48) and their neonates had an increased odd of mortality and severe morbidity (aOR, 1.37; 95% CI, 1.23-1.52). This multinational study shows that women with epilepsy were at considerably higher risk of severe maternal and perinatal outcomes and increased risk of death during pregnancy and postpartum. Maternal epilepsy and maternal use of ASM were associated with increased maternal morbidity and perinatal mortality and morbidity.

Quantifying the association between doula care and maternal and neonatal outcomes

BackgroundThe US suffers from an increasing rate of severe maternal morbidity, paired with a wide disparity in maternal health by race. Doulas are posited to be a useful resource to increase positive outcomes and decrease this disparity. ObjectiveEvaluate the association of doula care with a broad range of maternal and neonatal outcomes in various subpopulations. Study DesignRetrospective cohort of deliveries from 1/2021-12/2022 at a single institution receiving prenatal care. Exposure was receipt of doula care prenatally and at delivery. We evaluated both maternal (cesarean delivery, cesarean delivery of nulliparous, term, singleton, vertex infant, vaginal birth after cesarean (VBAC), gestational hypertension, preeclampsia, postpartum emergency department visit, readmission and attendance at postpartum office visit) and neonatal (neonatal intensive care unit admission, unexpected complications in term newborns, breastfeeding, preterm delivery, and intrauterine fetal growth restriction) outcomes. Because our institution previously employed targeted outreach, offering doula services to patients at highest risk, we utilized multiple methods to generate an appropriate comparison population. We conducted multivariate logistic regression and conditional regressions using propensity scores, modeling likelihood of doula care, to generate adjusted risk differences associated with doula care. Analyses were repeated in populations stratified by race (White/Black) then payor status (public/commercial). ResultsOur cohort included 17,831 deliveries; 486 with doula care and 17,345 without. Patients receiving doula care were more likely to self-report Black race, be publicly insured, and live in a more disadvantaged neighborhood. Regardless of analytic approach, for every 100 patients under doula care there were 15-34 more VBACs [adjRD 15.6 (95%CI: 3.8, 27.4); adjRD 34.2 (95%CI: 0.046, 68.0)] and 5-6 more patients attending a postpartum office visit [adjRD 5.4 (95%CI: 1.4, 9.5); adjRD 6.8 (95% CI:3.7, 9.9)] compared with those not receiving doula services.Infants born to these patients were 20% more like likely to be exclusively breastfed [adjRR 1.22 (95%CI: 1.07, 1.38)], and doula care was associated with 3-4 fewer preterm births [adjRD -3.8 (95%CI: -6.1, -1.5); -4.0 (95%CI: -6.2, -1.8)] for every 100 deliveries receiving doula care. Results were consistent regardless of race or insurance. Results were also consistent when doula care was redefined as having at least 3 prenatal encounters with a doula. ConclusionsDoula care was associated with more VBACs, attendance at postpartum office visit, breastfeeding, and fewer preterm deliveries. The effect of doula care was consistent across race and insurance status.

Racial and ethnic disparities in severe maternal morbidity from pregnancy through 1-year postpartum

BACKGROUNDPrevious studies examining racial and ethnic disparities in severe maternal morbidity (SMM) have mainly focused on intrapartum hospitalization. There is limited information regarding the racial and ethnic distribution of SMM occurring in the antepartum and postpartum periods, including SMM occurring beyond the traditional 6 weeks postpartum period. OBJECTIVETo examine the racial and ethnic distribution of SMM during antepartum, intrapartum, and postpartum hospitalizations through 1-year postpartum, overall and stratified by maternal sociodemographic factors, and to estimate the percent increase in SMM by race and ethnicity and maternal sociodemographic factors within each racial and ethnic group after accounting for both antepartum and postpartum SMM through 1-year postpartum rather than just SMM occurring during the intrapartum hospitalization. STUDY DESIGNWe 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 non-transfusion SMM and total SMM per 10,000 cases during antepartum, intrapartum, and postpartum hospitalizations through 365 days postpartum by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. We subsequently examined “SMM cases added” by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. The “SMM cases added” represent cases among unique individuals that are identified by considering the antepartum and postpartum periods but that would be missed if only the intrapartum hospitalization cases were included. RESULTSAmong 2,584,206 birthing individuals, a total of 37,112 (1.4%) individuals experienced non-transfusion SMM and 64,661 (2.5%) experienced any SMM during antepartum, intrapartum, and/or postpartum hospitalization. Black individuals had the highest rate of antepartum, intrapartum, and postpartum non-transfusion and total SMM followed by American Indian individuals. Asian individuals had the lowest rate of non-transfusion and total SMM during antepartum and postpartum hospitalizations while White individuals had the lowest rate of non-transfusion and total SMM during the intrapartum hospitalization. Black individuals were 1.9 times more likely to experience non-transfusion SMM during the intrapartum hospitalization than White individuals, which increased to 2.8 times during the antepartum period and to 2.5 times during the postpartum period. Asian and Hispanic individuals were less likely to experience SMM in the postpartum period than White individuals. Including antepartum and postpartum hospitalizations resulted in disproportionately more cases among Black and American Indian individuals than among White, Hispanic, and Asian individuals. The additional cases were also more likely to occur among individuals with lower educational levels and individuals on government insurance. CONCLUSIONRacial disparities in SMM are underreported in estimates that focus on the intrapartum hospitalization. Additionally, individuals with low socio-economic status bear the greatest burden of SMM occurring during the antepartum and postpartum periods. Approaches that focus on mitigating SMM during the intrapartum period only do not address the full spectrum of health disparities.El resumen está disponible en Español al final del artículo.

Severe maternal morbidity from pregnancy through 1 year postpartum

Few recent studies have examined the rate of severe maternal morbidity occurring during the antenatal and/or postpartum period to 42 days after delivery. However, little is known about the rate of severe maternal morbidity occurring beyond 42 days after delivery. This study aimed to examine the distribution of severe maternal morbidity and its indicators during antenatal, delivery, and postpartum hospitalizations to 365 days after delivery and to estimate the increase in severe maternal morbidity rate and its indicators after accounting for antenatal and postpartum severe maternal morbidity to 365 days after delivery. This was a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from Michigan, Oregon, and South Carolina from 2008 to 2020. This study examined the distribution of severe maternal morbidity, nontransfusion severe maternal morbidity, and severe maternal morbidity indicators during antenatal, delivery, and postpartum hospitalizations to 365 days after delivery. Subsequently, this study examined "severe maternal morbidity 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. A total of 64,661 (2.5%) individuals experienced severe maternal morbidity, whereas 37,112 (1.4%) individuals experienced nontransfusion severe maternal morbidity during antenatal, delivery, and/or postpartum hospitalization. A total of 31% of severe maternal morbidity cases were added after accounting for severe maternal morbidity occurring during the antenatal or postpartum hospitalization to 365 days after delivery, whereas 49% of nontransfusion severe maternal morbidity cases were added after accounting for nontransfusion severe maternal morbidity occurring during the antenatal or postpartum periods. Severe maternal morbidity occurring between 43 and 365 days after delivery contributed to 12% of all severe maternal morbidity cases, whereas nontransfusion severe maternal morbidity occurring between 43 and 365 days after delivery contributed to 19% of all nontransfusion severe maternal morbidity cases. Our study showed that a total of 31% of severe maternal morbidity and 49% of nontransfusion severe maternal morbidity cases were added after accounting for severe maternal morbidity occurring during the antenatal or postpartum hospitalization to 365 days after delivery. Our findings highlight the importance of expanding the severe maternal morbidity 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.

Centering Equity and Fostering Stakeholder Collaboration and Trust-Pillars of the Maternal Health Innovation Program in Maryland.

To describe two main pillars of the Maryland Maternal Health Innovation Program (MDMOM): (1) centering equity and (2) fostering broad stakeholder collaboration and trust. We summarized MDMOM's key activities and used severe maternal morbidity (SMM) surveillance and program monitoring data to quantify MDMOM's work on the two pillars. We developed measures of hospital engagement with MDMOM (participation in quality improvement [QI] activities, participation in check-in meetings, staff involvement) and with other partners (participation in QI activities, representation in state-level groups). We examined Bonferroni-adjusted correlations between these hospital engagement measures and with key hospital characteristics: level of maternity care, annual delivery volume, and SMM rate. Over 100 national and state organizations and individual stakeholders contributed to our building the MDMOM program and implementing key activities centering equity: hospital-based SMM surveillance in 20 of Maryland's 32 hospitals; almost 5,000 trainings offered to perinatal health care providers; two telemedicine/telehealth interventions; training of home visitors and community-based organization staff. Birthing hospitals represent MDMOM's main implementation partners. The strength of their participation in MDMOM QI activities is positively correlated to their participation in check-in meetings and with the degree of involvement by physicians in such activities. Higher engagement in MDMOM QI activities is also positively correlated to hospitals' participation in other state-level maternal health initiatives or groups. Our experience with the MDMOM program demonstrates that an equity focus and broad stakeholder collaboration building strong relationships and providing implementation support can lead to high levels of engagement in innovative maternal health interventions.

Identifying systems factors contributing to adverse events in maternal care using incident reports

The maternal mortality rate in the US increased significantly from 20.1 deaths per 100,000 live births in 2019 to 32.9 in 2021. Black women have a higher rate of mortality and also experience higher rates of severe maternal morbidity, which are life-threating maternal health complications. However, maternal mortality and SMM are preventable with timely and responsive care, suggesting opportunities to intervene at the point of care. To examine processes contributing to adverse maternal outcomes and racial/ethnic disparities in these outcomes, we analyzed 550 incident report (IRs) collected in the maternity units of a large academic hospital in 2019 and 2020. IRs were disaggregated by race/ethnicity and the IR narratives were coded using the systems factors from the SEIPS 2.0 model. Tasks (40%) and organization (30%) were most frequently reported SEIPS 2.0 categories. The majority of these incidents were the result of omissions (15%), staffing (9%), teamwork and coordination (7%), specimen labeling errors (7%), and hospital protocols (6%). These findings from this analysis can improve system safety and support the development of targeted efforts to improve health equity for women and birthing of people of color.

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

Non-Hispanic Black people (NHBP) have a three-fold higher rate of maternal mortality compared to other racial groups. Racial disparities in maternal morbidity are well-described; however, there are substantial differences in cultural, economic, and social determinants of health among racial groups. We thus sought to study the at-risk, non-Hispanic Black population as its own cohort to identify factors most associated with severe maternal morbidity (SMM). This is a population-based retrospective case-control study of all live births in the United States between 2017 and 2019 using birth records obtained from the National Center for Health Statistics. The primary outcome for this study was to determine demographic, social, medical, and obstetric factors associated with maternal morbidity among NHBP who did and did not experience an SMM event. Multivariable logistic regression was used to estimate the adjusted odds ratio between each individual factor and the outcome of SMM among NHBP. Of the 1,624,744 NHBP who delivered between 2017 and 2019, 1.1% experienced an SMM event defined as a composite of blood product transfusion, eclamptic seizure, intensive care unit admission, unplanned hysterectomy, and uterine rupture. The rates of these individual SMM events per 10,000 deliveries were 50, 40, 20, 5, and 4 among NHBP, respectively. Among NHBP, factors associated in multivariable regression analysis with SMM in order of strength of association included cesarean delivery, earlier gestational age at delivery, preeclampsia, induction of labor, chronic hypertension, prior preterm birth, lower educational attainment, multifetal gestation, advanced maternal age, pregestational diabetes, and cigarette smoking. The population attributable fraction for cesarean delivery, preterm birth, and pregnancy-induced hypertensive disease for the outcome of SMM were 0.46, 0.23, and 0.07, respectively. The three factors most associated with SMM among NHBP are potentially avoidable or modifiable by aggressive screening, prevention, and treatment of preeclampsia and preterm birth as well as reducing cesarean rates in this population. · The rate of SMM in NHBP may be modifiable.. · NHBP have a three-fold higher rate of maternal mortality.. · Preeclampsia, preterm birth, and cesarean sections are most associated with maternal morbidity..

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.

Program evaluation and early outcomes of a severe preeclampsia and eclampsia maternal safety bundle in a single institution in the Philippines

BACKGROUND: To reduce maternal morbidity and mortality associated with hypertension, standards for maternal safety and efforts to implement a structured team approach have been undertaken. Following the formulation of a policy document, a maternal safety bundle was developed. The implementation of bundle components including eclampsia kits, clinical pathways, and educational module occurred in phases due to pandemic restrictions. An eclampsia kit and clinical pathways were implemented in 2020. An online lecture was launched in 2021 followed by in-person eclampsia simulation workshop beginning 2022. OBJECTIVES: This paper aims to report the early outcomes of a severe preeclampsia and eclampsia maternal safety bundle implementation in a private hospital between 2020 to 2023. MATERIALS AND METHODS: Demographic information, posttest knowledge assessment and pre- and post- eclampsia workshop confidence scores were recorded. Structure, process, and outcome measures were determined. Descriptive statistics were used for participant demographics and score percentages. Paired t-Test with a significance level of P&lt;0.05 was used to compare the pre- and post-simulation confidence scores. Summary data for outcome and process metrics were manually calculated. Summary categorical data was used for structure metrics. RESULTS: Two hundred eighty-eight (288) participants completed the online didactic lecture. Average posttest knowledge assessment score was 88.1%, 88.88%, and 82.6% from 2020 to 2023. Ninety-nine participants completed the eclampsia simulation workshops. Mean post-simulation confidence scores were greater than mean pre-simulation confidence scores (42.3 vs. 39, p=0.0259 in 2022 and 41.975 vs 36.65, P=0.0035 in 2023). There is 100% compliance with timely management of severe hypertension and eclampsia prevention and a decreasing trend in hypertension related severe maternal morbidity rates. CONCLUSION: A severe preeclampsia and eclampsia maternal safety bundle is a feasible quality improvement initiative that promotes peer learning, strengthens clinical competencies, and improves access to emergency resuscitation supplies. The results of this program evaluation may serve as a framework for implementing quality improvement initiatives on maternal safety.

Delivery at an inadequate level of maternal care is associated with severe maternal morbidity

BackgroundImplementing levels of maternal care is one strategy proposed to reduce maternal morbidity and mortality. The levels of maternal care framework outline individual medical and obstetric 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 all birthing people get appropriate resources and personnel during delivery to reduce maternal morbidity. ObjectivesThis 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 designThe 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) obstetric care. We then used the Levels of Care Assessment Tool assessed levels to determine whether delivery occurred at a hospital that had the resources to meet an individual’s needs (i.e., if a patient received risk-inappropriate care).We conducted our analyses in two stages. First, multivariable logistic regression models predicted whether an individual delivered in a hospital that did not have the resources for their risk condition. The main explanatory variable of interest was whether the hospital self-assessed their level of maternal care to be higher than their Levels of Care Assessment Tool -assessment. We then used logistic regression to examine the association between delivery at an inappropriate level and the presence of severe maternal morbidity at delivery. ResultsAmong 64,441 deliveries in Massachusetts from January 1 to December 31, 2019, 33.2% (21,415/64,441) had one or more of the 16 high-risk conditions suggesting delivery should occur at a center designated as a level I or higher. Of the 21,415 individuals with a high-risk condition, 13% (2,793/21,415) or 4% (2,793/64,441) of the entire sample delivered at an inappropriate level of maternal care. Birthing individuals with high-risk conditions delivering at a hospital with an inappropriate level had elevated odds (aOR: 3.34, 95% CI: 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. ConclusionsBirthing people who delivered in a hospital with risk-inappropriate resources were significantly more likely to experience severe maternal morbidity. Delivery in a hospital with a discrepancy in their self-assessment and Levels of Care Assessment Tool assessment significantly 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.

Racial Disparity in Severe Maternal Morbidity Associated with Hypertensive Disorders in Washington State: A Retrospective Cohort Study.

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. 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. 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. In Washington, HTN disorders are associated with SMM in a dose-dependent fashion with the greatest impact among Black individuals.