Severe Maternal Morbidity 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.

Recurrence of Severe Maternal Morbidity and Transfusion During Delivery Hospitalisations: A Retrospective Cohort Study.

To determine risks for non-transfusion severe maternal morbidity and transfusion during a second delivery hospitalisation based on clinical risk factors and obstetric complications from an index, first delivery hospitalisation. Retrospective cohort. Delivery hospitalisations in the 2010-2017 New York State Inpatient Database. Patients with a first index delivery hospitalisation followed by a second delivery hospitalisation during the study period were included. Clinical risk factors and obstetric complications were obtained from the first index delivery hospitalisation. Adjusted logistic regression models for non-transfusion severe maternal morbidity during the second delivery were performed with adjusted (aORs) odds ratios as measures of effect. These analyses were then repeated for the outcome of transfusion. Of 624 500 paired delivery hospitalisations to 312 250 women, severe maternal morbidity occurred among 0.85% of second deliveries (n = 2672). When adjusted analysis was performed, several clinical factors were associated with severe maternal morbidity in a subsequent pregnancy, including severe maternal morbidity during the index pregnancy (aOR 8.4, 95% CI 7.0, 9.9), transfusion (aOR 2.0, 95% CI 1.6, 2.4) and pregestational diabetes (aOR 2.2, 95% 1.6, 2.9). When analyses were repeated for transfusion, several factors were associated with increased risk, including severe maternal morbidity (aOR 1.5, 95% CI 1.2, 1.8), index transfusion (aOR 6.3, 95% CI 5.6, 7.0), chronic heart disease (aOR 1.6, 95% 1.4, 1.9) and pregestational diabetes (aOR 1.7, 95% 1.3, 2.2). Many obstetric complications and chronic conditions identified during an index delivery hospitalisation are associated with severe morbidity during a second, subsequent delivery. Index severe maternal morbidity is associated with the highest odds. These findings may be of use in patient counselling and risk stratification.

Hypertensive Disorders and Cardiovascular Severe Maternal Morbidity in the US, 2015-2019

The incidence of severe maternal morbidity (SMM)-and particularly cardiovascular SMM (cvSMM), the first cause of pregnancy-related mortality-has been rising in North America. Although hypertensive disorders of pregnancy (HDP) are common, their association with cvSMM specifically remains unclear. To assess the association between individual subtypes of HDP and cvSMM, in addition to overall SMM, in a large, nationally representative sample. A population-based cohort study using the United States National Inpatient Sample was conducted. Individuals with obstetric deliveries between 2015 and 2019 were included. Data analysis was performed from October 2023 to February 2024. HDP subtypes included gestational hypertension, chronic hypertension, preeclampsia without severe features, severe preeclampsia, and HELLP (hemolysis, elevated liver enzymes, and low platelet) syndrome. The primary outcome was a composite of cvSMM (including conditions such as pulmonary edema, stroke, and acute myocardial infarction) and the secondary outcome was a composite of overall SMM (including cvSMM and other conditions such as respiratory failure, severe postpartum hemorrhage, and sepsis). Adjusted risk ratios (aRRs) for the association between HDP subtypes and the outcomes were estimated using modified Poisson regression models adjusted for demographic and clinical characteristics. Among 15 714 940 obstetric deliveries, 2 045 089 (13.02%) had HDP, 23 445 (0.15%) were affected by cvSMM, and 282 160 (1.80%) were affected by SMM. The mean (SD) age of the cohort was of 29 (6) years. The incidence of cvSMM was higher in participants with HDP than those without HDP (0.48% [9770 of 2 045 089] vs 0.10% [13 680 of 13 669 851]; P < .001). Participants with HELLP syndrome had the highest risk for cvSMM (aRR, 17.55 [95% CI, 14.67-21.01]), followed by severe preeclampsia (aRR, 9.11 [95% CI, 8.26-10.04]), and chronic hypertension (aRR, 3.57 [95% CI, 3.15-4.05]). Although HDP subtypes were also associated with overall SMM, the association with HELLP syndrome (aRR, 9.94 [95% CI, 9.44-10.45]), severe preeclampsia (aRR, 3.66 [95% CI, 3.55-3.78]), and chronic hypertension (aRR, 1.96 [95% CI, 1.88-2.03]) was attenuated compared with cvSMM. In this cohort study, a graded relationship by severity characterized the association between HDP and cvSMM. Although all HDP subtypes were associated with an increased risk of overall SMM, the risk was more pronounced for cvSMM.

Cancer diagnosis during pregnancy is associated with severe maternal and neonatal morbidity

BackgroundData on maternal and fetal outcomes in patients diagnosed with cancer during pregnancy are limited. Given expected increase in patients diagnosed with cancer during pregnancy, there is a growing need to evaluate clinical outcomes. ObjectiveTo evaluate obstetric outcomes among women with early-stage gynecologic or breast cancer who were diagnosed during pregnancy compared to women without cancer in a population-based cohort. MethodsWe performed a population-based study of women aged 18-45 years with stage I gynecologic or stage I-III breast cancer reported to the California Cancer Registry for the years 2000-2012. Data were linked to the 2000-2012 California birth data to produce a database with cancer characteristics and obstetric outcomes. We included patients who had a delivery within the 10 months following cancer diagnosis. The primary outcome was severe maternal morbidity (SMM). Secondary outcomes included pre-term birth (PTB) and neonatal morbidity. Propensity scores were used to match similar controls to cases in a 2:1 ratio based on demographic attributes and medical comorbidities included in the Obstetric Comorbidity Index (OB-CMI). Logistic regressions were used to evaluate outcomes. ResultsThe cohort consisted of 503 women with cancer in pregnancy (319 breast, 125 ovarian, 59 cervical), and 1,006 matched controls. Cancer during pregnancy was associated with higher odds of SMM (6.8% vs <1.1%; odds ratio [OR] 8.03, 95% CI 3.82-16.88), PTB between 32-36 weeks (32.6% vs 8.3%, OR 5.38, 95% CI 4.02-7.20), and neonatal morbidity (12.5% vs 6.1%; OR 2.22, 95% CI 1.53-3.21) compared to matched controls. In sub-analysis of SMM indicators, hysterectomy and sepsis were significantly associated with cancer during pregnancy (4.8% vs <1.1%, P<.001; <2.2% vs 0.0%, P=.037, respectively). ConclusionCancer during pregnancy is associated with increased risk of maternal and neonatal morbidity. These findings highlight the need for careful management and consideration of obstetric outcomes in these patients.

Examining associations between social vulnerability and maternal morbidity among a multicentre cohort of pregnancies complicated by placenta accreta spectrum disorder in New York City

BackgroundPlacenta accreta spectrum (PAS) disorder is a source of severe obstetric morbidity and mortality worldwide. The objective of this paper was to evaluate the potential relationship between social vulnerability and...

HELLP syndrome and associated factors among pregnant women with preeclampsia/eclampsia at a referral hospital in southwestern Uganda: a cross-sectional study

BackgroundHemolysis Elevated Liver Enzymes Low Platelets (HELLP) syndrome, a complication of preeclampsia/eclampsia, is associated with severe maternal morbidity and mortality. In resource-limited settings, such as Uganda, gaps in routine laboratory assessments may lead to underdetection of HELLP syndrome. This study determined the prevalence and factors associated with HELLP syndrome among pregnant women with preeclampsia/eclampsia at Mbarara Regional Referral Hospital (MRRH), southwestern Uganda.MethodsA cross-sectional study was conducted at the high-risk ward of the MRRH from December 2022 to June 2023. Pregnant women diagnosed with preeclampsia or eclampsia were enrolled consecutively. Participants’ sociodemographic and clinical data were collected using an interviewer-administered questionnaire. The diagnosis of complete HELLP syndrome was made based on the Tennessee classification: aspartate aminotransferase enzyme ≥ 70 IU/L, platelet counts < 100,000 cells/µL, and serum lactate dehydrogenase enzyme ≥ 600 IU/L. We used multivariable modified Poisson regression analysis to determine factors associated with HELLP syndrome.ResultsA total of 129 participants with a mean age of 28 ± 6.6 years were enrolled in the study. The prevalence of HELLP syndrome was 18.6% (n = 24; 95% CI: 12.7–26.3%). Independent factors associated with HELLP syndrome were maternal age (adjusted prevalence ratio [aPR]: 4.96; 95% CI: 1.57–15.65; for mothers aged < 20 years compared to those aged 20–34 years), the presence of epigastric pain (aPR: 5.89; 95% CI: 1.41–14.63), and referral from other health facilities (aPR: 3.14; 95% CI: 1.27–7.72).ConclusionApproximately 2 of the 10 women who presented with preeclampsia or eclampsia had HELLP syndrome. It is more common among teenage mothers, those with a history of epigastric pain and those referred from lower health facilities. Incorporating routine laboratory testing for HELLP syndrome in the diagnostic protocol for preeclampsia or eclampsia, especially among adolescent mothers, those experiencing epigastric pain, and those referred from lower health facilities, could enhance timely detection and management of mothers with preeclampsia whose pregnancies are complicated by HELLP syndrome.

Severe Maternal and Neonatal Morbidity Among Gestational Carriers : A Cohort Study.

Use of a gestational ("surrogate") carrier is increasingly common. Risk for maternal and neonatal adversity is largely unknown in this birthing population. To determine the risk for severe maternal morbidity (SMM) and severe neonatal morbidity (SNM) in gestational carriers. Population-based cohort study. All of Ontario, Canada. All singleton births at more than 20 weeks' gestation, from 2012 to 2021. Exposure was type of conception, namely, gestational carriage (main exposure), unassisted conception (comparison group 1), and in vitro fertilization (IVF) (comparison group 2). Main composite outcomes were SMM and SNM. Modified Poisson regression models generated weighted relative risks (wRRs) using propensity score-based overlap weighting. Secondary outcomes included hypertensive disorders of pregnancy, cesarean delivery, preterm birth, and postpartum hemorrhage. Of all eligible singleton births, 846 124 (97.6%) were by unassisted conception, 16 087 (1.8%) by IVF, and 806 (0.1%) by gestational carriage. Respective risks for SMM were 2.3%, 4.3%, and 7.8%. The wRRs were 3.30 (95% CI, 2.59 to 4.20) comparing gestational carriage with unassisted conception and 1.86 (CI, 1.36 to 2.55) comparing gestational carriage with IVF. Respective risks for SNM were 5.9%, 8.9%, and 6.6%, generating wRRs of 1.20 (CI, 0.92 to 1.55) for gestational carriage versus unassisted conception and 0.81 (CI, 0.61 to 1.08) for gestational carriage versus IVF. Hypertensive disorders, postpartum hemorrhage, and preterm birth at less than 37 weeks were also significantly higher contrasting gestational carriers to either comparison group. Absence of information about indications for choosing a gestational carrier, and oocyte or sperm donor source. Among singleton births of more than 20 weeks' gestation, a higher risk for SMM and adverse pregnancy outcomes was seen among gestational carriers compared with women who conceived with and without assistance. Although gestational carriage was associated with preterm birth, there was less clear evidence of severe neonatal morbidity. Potential mechanisms for higher maternal morbidity among gestational carriers require elucidation, alongside developing special care plans for gestational carriers. The Canadian Institutes of Health Research.

Maternal and Infant Morbidity and Mortality in relation to Delivery Mode in a large US Healthcare Claims Database in 2019 and 2020.

Provide contemporary data on maternal and infant outcomes after delivery to better understand risks of Cesarean section (CS). Data for deliveries in 2019 and 2020 were obtained from a large US commercial healthcare claims database. Maternal morbidity measures included twenty Severe Maternal Morbidity (SMM) outcomes and seven additional obstetric and mental health outcomes. Infant morbidity measures included eight outcomes related to respiratory health, digestive health, atopic dermatitis, and birth trauma. Outcome prevalence was ascertained at 42 days (maternal only) and 360 days after delivery. Logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) for prevalence adjusted for risk factors for delivery mode and each outcome. Analyses were conducted for 2019 and 2020 to assess the influence of the COVID-19 pandemic. A total of 436,991 deliveries were identified (145,061 CS; 291,930 vaginal). The prevalence of SMM was 3.3% at 42 days and 4.1% at 360 days. The covariate-adjusted odds of SMM were higher among CS than vaginal deliveries at 42 days (OR: 2.0, 95% CI: 1.9, 2.1) and 360 days (OR: 1.7, 95% CI: 1.7, 1.8). There were 226,983 infants available for analysis of outcomes at 360 days. Most adverse infant outcomes were more prevalent at 360 days among CS than vaginal deliveries, and the covariate-adjusted odds of any adverse infant outcome at 360 days were higher among CS than vaginal deliveries (OR: 1.2; 95% CI: 1.1, 1.3). Respiratory morbidity was most affected by delivery mode. Maternal and infant mortality up to 360 days was rare. Similar trends were observed in the 2019 and 2020 cohorts. This observational study, performed using recent data obtained from a large US commercial claims database, provides contemporary evidence of risks to mothers and infants of CS relative to vaginal delivery.

Historical Redlining, Contemporary Gentrification, and Severe Maternal Morbidity in California, 2005-2018

Historically redlined neighborhoods may experience disinvestment, influencing their likelihood of gentrification, a process of neighborhood (re-)development that unequally distributes harms and benefits by race and class. Understanding the combined outcomes of redlining and gentrification informs how the mutually constitutive systems of structural racism and racial capitalism affect pregnancy outcomes. To examine if historical redlining and contemporary gentrification is associated with increased severe maternal morbidity (SMM) odds. This cross-sectional study used data from a statewide population-based sample of all live hospital births at 20 weeks' gestation or more between 2005 and 2018 in California. Analysis was conducted from March 2023 to January 2024. Redlining (as characterized by the federal Home Owners' Loan Corporation mortgage security maps) and displacement (using present-day sociodemographic and housing market information). Mixed-effects logistic regression models were used to assess the association of census tract-level exposure to historical redlining and contemporary gentrification with increased SMM odds, adjusting for sociodemographic and pregnancy related factors. Outcome classification was based on the Centers for Disease Control and Prevention SMM index, which defines SMM as having any of the 21 procedures and diagnoses based on the International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. The study sample included 1 554 837 births (median [SD] maternal age, 29.0 [6.4] years; 3464 American Indian or Alaskan Native [0.2%], 224 774 Asian [14.5%], 132 240 Black [8.5%], 880 104 Hispanic [56.6%], 312 490 White [20.1%]), with 22 993 cases of SMM (1.4%). Residents in historically redlined neighborhoods that were undergoing gentrification or displacement were more likely to be Black, Hispanic, and American Indian or Alaskan Native. Independent of individual-level characteristics, SMM odds were greater for individuals living in redlined neighborhoods that experienced displacement (OR, 1.21; 95% CI, 1.14-1.28) and in redlined neighborhoods undergoing gentrification (OR, 1.21; 95% CI, 1.13-1.29) compared with those in continuously advantaged neighborhoods. Findings from this cross-sectional study demonstrate that the legacies of redlining, intertwined with current dynamics of displacement and gentrification, affect SMM. Place-based sociopolitical mechanisms that inequitably distribute resources may be important intervention points to address structural drivers of adverse pregnancy outcomes and their racial inequities.

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.

Introduction of advanced maternal age based on mortality-specific severe morbidity.

SynopsisRe‐defining advanced maternal age based on the risk of severe maternal morbidity at delivery may be of value in obstetric medicine.

Neonatal and Maternal Outcomes in Nulliparous Individuals according to Prepregnancy Body Mass Index.

This study aimed to examine the effect of incremental changes in body mass index (BMI, kg/m2) on the association with adverse pregnancy outcomes. This was a retrospective cohort study of U.S. vital statistics Live Birth and Infant Death linked data from 2011 to 2020. We limited analyses to nulliparas with singleton pregnancies who delivered at 20 weeks or greater. Outcomes were compared according to the prepregnancy BMI category using 5 kg/m2 increments, with each of the other BMI categories sequentially as the referent. The composite neonatal outcome was defined as any neonatal death, neonatal intensive care unit (ICU), surfactant use, ventilation use, or seizure. Severe maternal morbidity was defined as any maternal ICU, transfusion, uterine rupture, and hysterectomy. Adjusted relative risks were calculated for each BMI category as a referent group, using modified Poisson regression and adjusting for confounders. A total of 11,174,890 nulliparous individuals were included. From 2011 to 2020, the proportions of individuals with BMI 40 or greater, BMI 50 or greater, and BMI 60 or greater increased significantly (from 3.1 to 4.9%, from 0.4 to 0.6%, from 0.03 to 0.06%, respectively; all trend p-values < 0.001). As BMI deviated from normal BMI, risks of neonatal and maternal adverse outcomes increased progressively. For example, as BMI deviated from normal BMI (18.5-24.9), the risk of composite neonatal outcome increased by 2% in individuals with BMI < 18.5 and up to 2.11-fold in individuals with BMI 65-69.9. When compared with BMI 40 to 44.9, BMI 35 to 39.9 was associated with an 8% decreased risk of composite neonatal outcome, whereas BMI 45 to 49.9 was associated with an 8% increased risk of composite neonatal outcome. Incremental increases in prepregnancy BMI are linked to higher risks of adverse pregnancy outcomes, highlighting the need for effective weight management before conception. · Incremental BMI increases raise pregnancy risks.. · Higher BMI linked to adverse neonatal outcomes.. · Elevated BMI heightens severe maternal morbidity..

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.

Severe adverse maternal and neonatal outcomes according to the planned birth setting being midwife-led birth centers or obstetric-led units.

The establishment of midwife-led birth centers (MLBCs) is still being debated. The study aimed to compare severe adverse outcomes and mode of birth in low-risk women according to their birth planned in MLBCs or in obstetric-led units (OUs) in France. We used nationwide databases to select low-risk women at the start of care in labor in MLBCs (n = 1294) and in OUs (n = 5985). Using multilevel logistic regression, we compared severe adverse maternal and neonatal morbidity as a composite outcome and as individual outcomes. These include severe postpartum hemorrhage (≥1000 mL of blood loss), obstetrical anal sphincter injury, maternal admission to an intensive care unit, maternal death, a 5-minute Apgar score <7, neonatal resuscitation at birth, neonatal admission to an intensive care unit, and stillbirth or neonatal death. We also studied the mode of birth and the role of prophylactic administration of oxytocin at birth in the association between birth settings and severe postpartum hemorrhage. Severe adverse maternal and neonatal outcome indicated a slightly higher rate in women in MLBCs compared to OUs according to unadjusted analyses (4.6% in MLBCs vs. 3.4% in OUs; cOR 1.36; 95%CI [1.01-1.83]), but the difference was not significant between birth settings after adjustment (aOR 1.37 [0.92-2.05]). Severe neonatal morbidity alone was not different (1.7% vs. 1.6%; aOR 1.17 [0.55-2.47]). However, severe maternal morbidity was significantly higher in MLBCs than in OUs (3.0% vs. 1.9%; aOR 1.61 [1.09-2.39]), mainly explained by higher risks of severe postpartum hemorrhage (2.4 vs. 1.1%; aOR 2.37 [1.29-4.36]), with 2 out of 5 in MLBCs partly explained by the low use of prophylactic oxytocin. Cesarean and operative vaginal births were significantly decreased in women with a birth planned in MLBCs. In France, 3 to 4% of low-risk women experienced a severe adverse maternal or neonatal outcome regardless of the planned birth setting. Results were favorable for MLBCs in terms of mode of birth but not for severe postpartum hemorrhage, which could be partly addressed by revising practices of prophylactic administration of oxytocin.

Maternal immigrant status and survival among children with congenital heart disease

ObjectiveTo examine associations between maternal immigrant status and survival of children with congenital heart disease (CHD). ApproachA retrospective population-based cohort study of hospital live births between April 2002 to September 2020 in Ontario, Canada was conducted at ICES. We identified children aged 0-17 years with a diagnosis of CHD from inpatient and health services datasets. The exposure was maternal immigrant status obtained from the IRCC permanent resident database. The outcome was time-to-death from after birth to &lt;18 years olds. Multilevel Cox hazard regression models generated hazard ratios (HR) for associations between maternal immigrant status and children’s deaths while accounting for hospitals as a cluster factor and adjusting for maternal age at birth, neighbourhood income and education quantiles, comorbidities, a composite of severe maternal morbidity, gestational age at birth, birth weight, and infant sex. ResultsRelative to children born to non-immigrant mothers, the adjusted HR for death was 1.17 (95% CI:1.06-1.30) in children whose mothers were immigrants, and 1.33 (95% CI:1.07-1.65) in those from refugees. Moreover, compared to children residing in neighbourhoods with the highest income and educational levels, the adjusted HR of death for children who lived in neighbourhoods with the lowest income and educational level was 1.52 (95% CI: 1.24-1.88) and 1.47 (95% CI: 1.18-1.83) respectively. ConclusionChildren with CHD born to immigrant and refugee mothers, and those living in low socioeconomic status neighbourhoods had worse mortality. Health policy decision makers should target children with CHD from immigrant/refugee families and disadvantaged neighbourhoods to improve their survival.

Septic Abortion at 17 Weeks Gestation after Radical Trachelectomy and Transabdominal Cerclage: A Case Report

Septic abortion can lead to severe maternal morbidity and mortality. The management of septic abortion can be complicated by a history of radical trachelectomy and transabdominal cerclage placement. A 33-year-old G1P0 at 17 weeks and 6 days gestation presented in severe septic shock after being diagnosed 6 days prior with previable rupture of membranes at an outside hospital and managed expectantly. History was notable for cervical adenocarcinoma status post radical trachelectomy and transabdominal cerclage placement. Due to uterine occlusion from the cerclage, the patient underwent emergent uterine evacuation via an abdominal approach. The risks and benefits of expectant management of pre-viable rupture of membranes in patients with abdominal cerclage should be weighed very cautiously. Among women with abdominal cerclage for whom uterine evacuation is indicated, a transabdominal approach may be necessary.

Severe Maternal Morbidity: The Impact of Race on Tricare Beneficiaries.

Maternal morbidity and mortality rates in the United States have increased in the last two decades with a disproportionate impact on women of color. While numerous factors contribute to the inequities in pregnancy-related mortality, access to health insurance is among the most significant. Military Tricare models universal health care access; however, in studies looking at births in military treatment facilities, disparities still exist for women of color. This study analyzed maternal delivery outcomes for all women with Tricare coverage, including deliveries in the civilian sector. We analyzed data from6.2 million births in the Centers for Disease Control (CDC) Wide-ranging Online Data for Epidemiology Research (WONDER) Linked Birth/Infant Death Records for 2017-2019. Data included all-cause morbidity (transfusions, perineal lacerations, uterine rupture, unplanned hysterectomy, and ICU admissions), severe maternal morbidity (SMM) excluding lacerations, and SMM excluding transfusion. Risk ratios were calculated by comparing overall maternal morbidity rates between Tricare, Medicaid, self-pay, and private insurance. In addition, risk ratios were calculated between insurance types stratified by race. In conclusion, there is an increased risk for women identifying as racial minorities for SMM and SMM excluding transfusion. While Tricare coverage seems to decrease the risk, the decrease is not significant and disparities in outcomes persist among women identifying as minorities. The risk of severe maternal morbidity remains elevated for women of color despite access to Tricare health insurance.

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.

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.