Indicator Of Severe Maternal Morbidity Research Articles

Association of Pregnancy Characteristics and Maternal Mortality With Amniotic Fluid Embolism

Amniotic fluid embolism (AFE) is an uncommon pregnancy complication but is associated with high maternal mortality. Because of the rarity of AFE, associated risks factors and maternal outcomes have been relatively understudied. To examine the clinical, pregnancy, and delivery characteristics and the maternal outcomes related to AFE in a recent period in the US. This retrospective cohort study examined hospital deliveries from January 1, 2016, to December 31, 2019, from the Healthcare Cost and Utilization Project's National Inpatient Sample. The primary outcome was clinical, pregnancy, and delivery characteristics of AFE, assessed with a multivariable binary logistic regression model. The coprimary outcome was failure to rescue, defined as maternal mortality after AFE. Associations with other severe maternal morbidity indicators and failure to rescue per clinical and pregnancy characteristics were also assessed. A total of 14 684 135 deliveries were examined, with AFE diagnosed in 880 women, corresponding to an incidence rate of 6.0 per 100 000 deliveries. The cohort-level median patient age was 29 years (IQR, 25-33 years). In a multivariable analysis, (1) patient factors of older age, Asian and Black race, Western US region, pregestational hypertension, asthma, illicit substance use, and grand multiparity; (2) pregnancy factors of placental accreta spectrum (PAS), placental abruption, uterine rupture, polyhydramnios, chorioamnionitis, preeclampsia, fetal growth restriction, and fetal demise; and (3) delivery factors of early gestational age, cervical ripening, cesarean delivery, operative delivery, and manual removal were associated with AFE. Among these characteristics, PAS had the largest association with AFE (adjusted odds ratio [aOR], 10.01; 95% CI, 7.03-14.24). When stratified by the PAS subtypes, more severe forms of PAS had a greater association with AFE (aOR for increta and percreta, 17.35; 95% CI, 10.21-28.48; and aOR for accreta, 7.62; 95% CI, 4.83-12.01). Patients who had AFE were more likely to have coagulopathy (aOR, 24.68; 95% CI, 19.38-31.44), cardiac arrest (aOR, 24.56; 95% CI, 17.84-33.81), and adult respiratory distress syndrome (aOR, 10.72; 95% CI, 8.09-14.20). The failure-to-rescue rate after AFE was 17.0% overall. However, the failure-to-rescue rate exceeded 30% when AFE co-occurred with other severe maternal morbidity indicators: 45.8% for AFE, cardiac arrest, and coagulopathy; 43.2% for AFE, shock, and cardiac rhythm conversion; and 38.6% for AFE, cardiac arrest, coagulopathy, and shock. The failure-to-rescue rate after AFE also exceeded 30% when AFE occurred in the setting of placental pathology: 42.9% for AFE and PAS and 31.3% for AFE and placental abruption. This contemporaneous, national-level analysis validated previously known risk factors for AFE and confirmed the dismal outcomes of pregnancy complicated by AFE. The association between PAS and AFE, which was not previously reported, warrants further investigation.

Associations Between State-Level Changes in Reproductive Health Services and Indicators of Severe Maternal Morbidity

This cross-sectional study examines the legislative, state, economic, and racial factors in increased severe maternal morbidity risk in pregnant individuals.

Trends in Severe Maternal Morbidity in the US Across the Transition to ICD-10-CM/PCS From 2012-2019

Surveillance of severe maternal morbidity (SMM) is critical for monitoring maternal health and evaluating clinical quality improvement efforts. To evaluate national and state trends in SMM rates from 2012 to 2019 and potential disruptions associated with the transition to International Classification of Diseases, 10th Revision, Clinical Modification and Procedure Coding System (ICD-10-CM/PCS) in October 2015. This repeated cross-sectional analysis examined delivery hospitalizations from 2012 through 2019 in the Healthcare Cost and Utilization Project's National Inpatient Sample and State Inpatient Databases, an all-payer compendium of hospital discharge records from community, nonrehabilitation hospitals. Trends were evaluated using segmented linear binomial regression models that allowed for discontinuities across the ICD-10-CM/PCS transition. Analyses were completed from April 2021 through March 2022. Time, ICD-10-CM/PCS coding system, and state. SMM rates, excluding blood transfusion, per 10 000 delivery hospitalizations, overall and by indicator. From 2012 to 2019, there were 5 964 315 delivery hospitalizations in the national sample representing a weighted total of 29.8 million deliveries with a mean (SD) maternal age of 28.6 (5.9) years. SMM rates increased from 69.5 per 10 000 in 2012 to 79.7 per 10 000 in 2019 (rate difference [RD], 10.2; 95% CI, 5.8 to 14.6) without a significant change across the ICD-10-CM/PCS transition (RD, -3.2; 95% CI, -6.9 to 0.6). Of 20 SMM indicators, rates for 10 indicators significantly increased while 3 significantly decreased; 5 of these changes were associated with ICD-10-CM/PCS transition. Acute kidney failure had the largest increase, from 6.4 to 15.3 per 10 000 delivery hospitalizations (RD, 8.9; 95% CI, 7.5 to 10.3) with no change associated with ICD transition (RD, -0.1; 95% CI, -1.2 to 1.1). Disseminated intravascular coagulation had the largest decrease from 31.3 to 21.2 per 10 000 (RD, 10.2; 95% CI, -12.8 to -7.5), with a significant drop associated with ICD transition (RD, -7.9; 95% CI, -10.2 to -5.6). State SMM rates significantly decreased for 1 state and significantly increased for 21 states from 2012 to 2019 and associations with ICD transition varied. In this cross-sectional study, overall US SMM rates increased from 2012 to 2019, which was not associated with the ICD-10-CM/PCS transition. However, data for certain indicators and states may not be comparable across coding systems; efforts are needed to understand SMM increases and state variation.

Ways Forward in Preventing Severe Maternal Morbidity and Maternal Health Inequities: Conceptual Frameworks, Definitions, and Data, from a Population Health Perspective.

Ways Forward in Preventing Severe Maternal Morbidity and Maternal Health Inequities: Conceptual Frameworks, Definitions, and Data, from a Population Health Perspective.

MHPAEA/ACA Policy Implementation and Severe Maternal Morbidity Among Commercially Insured Individuals, 2008–2019 [A192

INTRODUCTION: We aimed to identify rates and trends in severe maternal morbidity (SMM) in relationship to implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) and Affordable Care Act (ACA). METHODS: We conducted a serial, cross-sectional analysis among individuals with continuous commercial coverage in the year preceding and following an inpatient livebirth using data from Optum Cliniformatics Data Mart. We identified hospital deliveries and cases of SMM using standard methods. We excluded cases of SMM in which blood transfusion represented the only indicator of SMM. We evaluated rates and trends in SMM in both the implementation (2008–2014) and post-implementation (2015–2019) periods using an interrupted time-series model fit with generalized estimating equations for the overall population and compared those with and without perinatal mood and anxiety disorders (PMAD). The University of Michigan Institutional Review Board deemed this study exempt from review. RESULTS: The sample included 681,616 births. SMM decreased by 53.2% from 195.8 (95% CI, 188.1–203.3) to 91.6 (95% CI, 85.7–97.6) per 10,000 hospitalizations for birth between 2008 and 2019. We identified decreasing SMM rates in both periods, with a larger decrease in the post-implementation period (implementation marginal effects [ME], −0.0012; post-implementation ME, −0.0015; P<.001). We observed decreasing SMM rates in both periods for those with and without PMAD, with the steepest decline among those with PMAD in the post-implementation period. CONCLUSION: These data suggest that implementation of the MHPAEA and ACA may have had a role in decreasing rates of SMM among childbearing individuals with commercial insurance.

Severe maternal morbidity and other perinatal complications among women with physical, sensory, or intellectual and developmental disabilities.

Little is known about severe maternal morbidity (SMM) among women with disabilities. We assessed differences in SMM and other perinatal complications by presence and type of disability. We hypothesised that SMM and other complications would be more common in births to women with disabilities than to women without disabilities. We conducted a retrospective cohort study of California births from 2000 to 2012, using birth and death certificate data linked with hospital discharge data. We included singleton deliveries with gestational age of 23-42weeks. We classified women as having any disability or not and identified disability type (physical, hearing, vision, intellectual/developmental disabilities [IDD]). Our primary outcome was a composite indicator of SMM. Secondary outcomes included additional perinatal complications: gestational hypertension, preeclampsia, gestational diabetes, venous thromboembolism, chorioamnionitis, puerperal endometritis and mental health disorders complicating pregnancy, childbirth or the puerperium. We used modified Poisson regression to obtain covariate-adjusted relative risks (RR) and 95% confidence intervals (CI) for the association of disability status and type with SMM and secondary outcomes. Of 5,787,090 deliveries, 33,044 (0.6%) were to women with disabilities. Of these, 311 per 10,000 were complicated by SMM, compared with 84 per 10,000 deliveries to women without disabilities. In multivariable analyses, risk of SMM for births to women with disabilities was nearly three times that for women without disabilities (RR 2.84, 95% CI 2.67, 3.02). Proportion and risk of SMM were greatest for vision disability (793 per 10,000; RR 4.04, 95% CI 3.41, 4.78). Secondary outcomes were also more common among women with disabilities. In particular, more than a third of births to women with IDD (37.4%) were complicated by mental health disorders (versus 2.2% for women without disabilities). As hypothesised, SMM and other perinatal complications were more common among women with disabilities than among women without disabilities.

Trends in Racial and Ethnic Disparities in Severe Maternal Morbidity

There are large racial/ethnic disparities in severe maternal morbidity (SMM)--defined as unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health. We aimed to determine how racial/ethnic disparities in SMM have changed over time. This was a cross-sectional study of linked birth files and maternal hospital discharge records for 2008-2018 from the state of New Jersey (NJ), which has the 4th highest maternal mortality rate and one of the highest SMM rates in the nation. The birth files contain all birth records for NJ, and the hospital discharge records contain information from all in-patient hospitalizations in NJ over the study period. Inclusion criteria was residence in NJ at the time of delivery and delivery in a NJ hospital. The primary outcome was SMM. Women with SMM were identified using diagnosis and procedure codes for indicators of SMM based on criteria developed by the Centers for Disease Control and Prevention. Generalized linear models were fit to estimate risk ratios comparing SMM rates by race/ethnicity and over time. 1,010,426 women met the inclusion criteria. The overall SMM rate during 2008-2018 was 1.5% (CI: 1.5%-1.6%) among white non-Hispanic women, 3.4% (CI: 3.3%-3.5%) among Black non-Hispanic women, 1.6% (CI: 1.5%-1.7%) among Asian non-Hispanic women, and 2.1% (CI: 2.1%-2.2%) among Hispanic women (Figure 1). There was no change in SMM rates among white non-Hispanic women and Hispanic women, whereas SMM rates increased among Black non-Hispanic women (50.1%, CI: 35.7%-64.4%) and Asian non-Hispanic women (75.8%, CI: 26.2%-125.3%) (Figure 2). In NJ, one of the most diverse states in the US., racial disparities in SMM have widened, while the Hispanic-white SMM disparity has remained stable over the past decade. Addressing racial disparities in maternal health outcomes needs to continue to be a public health priority.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Natural history of postpartum hematocrit recovery in an urban, safety-net population

Postpartum anemia is common after delivery, and postpartum blood transfusion is the leading indicator of severe maternal morbidity in the United States. Although hematologic changes during the antepartum period are well understood, little is known about postpartum hematologic changes. Therefore, we investigated the hematologic changes in the postpartum period in a large, contemporary cohort. This study aimed to characterize hematologic recovery in the postpartum period and evaluate the effect of demographics, medical conditions, and pregnancy characteristics on the recovery. In a contemporary cohort of deliveries in 2019 at a single institution, the hematocrit of postpartum women before hospital discharge was compared with the hematocrit of women at the postpartum follow-up. Our population was composed of a predominantly Hispanic population at an urban, safety-net hospital. All women received a complete blood count on postpartum day 1 and a spun hematocrit at their postpartum follow-up visit in our hospital system. All women were scheduled for a routine postpartum visit 2 to 3 weeks after delivery. All deliveries of a live-born infant with available postpartum hematocrit before hospital discharge and at postpartum follow-up were included. Demographics and pregnancy characteristics, along with medical conditions, were evaluated. To evaluate an uncomplicated cohort, those with multiple gestation, preeclampsia with severe features, chronic hypertension, and diabetes mellitus were excluded in the secondary analysis. Statistical analysis included chi-square, paired Student t test, Student t test for independent groups, and analysis of variance. Of 12,456 deliveries, 9003 met the inclusion criteria. The average number of days from discharge to follow-up was 21.73±10.39 days. The average hematocrit levels were 30.77±3.61 before discharge and 38.70±3.61 at postpartum follow-up. From discharge to postpartum follow-up, the hematocrit levels increased by an average of 7.93±3.24. In the cohort without complications, the average increase in hematocrit levels was 8.19±3.09. The rise in hematocrit levels was significantly lower for those with chronic hypertension (6.9±3.6), diabetes mellitus (7.3±3.3), and preeclampsia with severe features (6.9±3.7). The severity of anemia influenced the rise in hematocrit levels in the postpartum period. In women with postpartum anemia (hematocrit<30%), the rise in hematocrit levels was 9.49±2.97 in the uncomplicated cohort. Postpartum hemorrhage did not influence the rise in postpartum hematocrit levels; women receiving blood transfusion had a greater rise in hematocrit levels (9.01±3.29). Our study establishes the natural course of hematologic recovery in the postpartum period, and we found that women with asymptomatic postpartum anemia may have a hematocrit level of 37% to 39% at their postpartum follow-up approximately 3 weeks after hospital discharge. Women with preexisting and obstetrical complications experienced less hematologic recovery and adapted more slowly to postpartum physiological changes.

Association of Epilepsy and Severe Maternal Morbidity.

To evaluate severe maternal morbidity (SMM) among patients with epilepsy and patients without epilepsy. We retrospectively examined SMM using linked birth certificate and maternal hospital discharge records in California between 2007 and 2012. Epilepsy present at delivery admission was the exposure and was subtyped into generalized, focal and other less specified, or unspecified. The outcomes were SMM and nontransfusion SMM from delivery up to 42 days' postpartum, identified using Centers for Disease Control and Prevention indicators. Multivariable logistic regression models were used to adjust for confounders, which were selected a priori. We also estimated the association between epilepsy and SMM independent of comorbidities by using a validated obstetric comorbidity score. Severe maternal morbidity indicators were then compared using the same multivariable logistic regression models. Of 2,668,442 births, 8,145 (0.3%) were to patients with epilepsy; 637 (7.8%) had generalized, 6,250 (76.7%) had focal or other less specified, and 1,258 (15.4%) had unspecified subtypes. Compared with patients without epilepsy, patients with epilepsy had greater odds of SMM (4.3% vs 1.4%, adjusted odds ratio [aOR] 2.91, 95% CI 2.61-3.24) and nontransfusion SMM (2.9% vs 0.7%, aOR 4.16, 95% CI 3.65-4.75). Epilepsy remained significantly associated with increased SMM and nontransfusion SMM after additional adjustment for the obstetric comorbidity score, though the effects were attenuated. When grouped by organ system, all SMM indicators were significantly more common among patients with epilepsy-most notably those related to hemorrhage and transfusion. Severe maternal morbidity was significantly increased in patients with epilepsy, and SMM indicators across all organ systems contributed to this.

The impact of Severe Maternal Morbidity on probability of subsequent birth in a population-based study of women in California from 1997-2017

ImportanceComplications during pregnancy and birth can impact whether an individual has more children. Individuals experiencing SMM are at a higher risk of general and reproductive health issues after pregnancy, which could reduce the probability of a subsequent birth. ObjectiveTo examine whether experiencing SMM during an individual's first birth affects their probability of having an additional birth, and whether this effect varies by maternal factors. MethodsThis retrospective cohort study US linked vital records and maternal discharges from 1997 to 2017 to identify all California births. The exposure, Severe Maternal Morbidity (SMM) was identified using a Centers for Disease Control and Prevention index. Individuals whose first birth was a singleton live birth were followed until their second birth or December 31, 2017, whichever came first. Hazard ratios for having a subsequent birth were estimated using Cox proportional hazard regression models. This association was assessed overall and stratified by maternal factors of a priori interest: age, race/ethnicity, and payer. ResultsOf the 3,916,413 individuals in our study, 51,872 (1.3%) experienced SMM at first birth. Compared to those who do not experience SMM, individuals who had SMM had a lower hazard, or instantaneous rate, of subsequent birth (adjusted HR 0.83, 95% CI: 0.82, 0.84); this association was observed in all levels of stratification (for example, adjusted HR range for known race/ethnicity: 0.78, 95% CI: 0.76, 0.80 for non-Hispanic White to 0.90, 95% CI: 0.88, 0.92 for Hispanic) and all indicators of SMM (0.24, 95% CI: 0.17, 0.35 for cardiac arrest/ventricular fibrillation to 0.84, 95% CI: 0.80, 0.87 for eclampsia). Conclusion and RelevanceOur findings suggest that individuals who experience SMM at the time of their first birth are less likely to have a subsequent birth as compared to those who do not experience SMM at the time of their first birth. While the reasons for these findings are unclear, they could inform reproductive life planning discussions for individuals experiencing SMM. Future directions include studies exploring the reasons for not having a subsequent birth.

Severe maternal morbidity and mortality during delivery hospitalization of class I, II, III, and super obese women

Previous studies show that obesity predisposes patients to higher risks of adverse pregnancy outcomes. Data on the relationship between increasing degrees of obesity and risks of severe maternal morbidity, including mortality, are limited. We examined the association of increasing classes of obesity, especially super obesity, with the risk of severe maternal morbidity and mortality at the time of delivery hospitalization. Using New York City linked birth certificates and hospital discharge data, we conducted a retrospective cohort study. This study identified delivery hospitalizations for singleton, live births in 2008-2012. Women were classified as having obesity (class I, II, III, or super obesity), as opposed to normal weight or overweight, based on prepregnancy body mass index. Cases of severe maternal morbidity were identified based on International Classification of Diseases, Ninth Revision diagnosis and procedure codes according to Centers for Disease Control and Prevention criteria. Multivariable logistic regression was used to evaluate the association between obesity classes and severe maternal morbidity, adjusting for maternal sociodemographic characteristics. During 2008-2012, there were 570,997 live singleton births with available information on prepregnancy body mass index that met all inclusion criteria. After adjusting for maternal characteristics, women with class II (adjusted odds ratio, 1.14; 95% confidence interval, 1.05-1.23), class III (adjusted odds ratio, 1.34; 95% confidence interval, 1.21-1.49), and super obesity (adjusted odds ratio, 1.99; 95% confidence interval, 1.57-2.54) were all significantly more likely to have severe maternal morbidity than normal and overweight women. Super obesity was associated with specific severe maternal morbidity indicators, including renal failure, air and thrombotic embolism, blood transfusion, heart failure, and the need for mechanical ventilation. There is a significant dose-response relationship between increasing obesity class and the risk of severe maternal morbidity at delivery hospitalization. The risks of severe maternal morbidity are highest for women with super obesity. Given that this is a modifiable risk factor, women with prepregnancy obesity should be counseled on the specific risks associated with pregnancy before conception to optimize their pregnancy outcomes.

Incidence of Severe Maternal Morbidity During Delivery Hospitalization in U.S. Commercially Insured and Medicaid Populations.

Objective: To estimate the incidence rate and associated risk factors of severe maternal morbidity (SMM) in commercially and Medicaid-insured women. Materials and Methods: This was a retrospective cohort study of women with a live inpatient delivery recorded in 2016 in the MarketScan® databases for commercially insured and Medicaid populations. The incidence of SMM, defined by the Center for Disease Control and Prevention's algorithm of International Classification of Diseases, 10th edition diagnostic and procedural codes, was determined. Measurements also included the association of SMM in bivariate analyses with patient characteristics and the association of SMM with delivery type, gestation type, maternal age, and race in multivariate logistic regression analysis, adjusted for pre-existing conditions and pregnancy-related complications. Results: The incidence of SMM per 10,000 deliveries was 111.4 in the Commercial and 109.6 in the Medicaid population. The most frequent SMM indicators were eclampsia and blood transfusion in the Commercial population (35.0 and 25.7 per 10,000 deliveries, respectively) and eclampsia and adult respiratory distress syndrome in the Medicaid population (45.5 and 14.9 per 10,000 deliveries, respectively). A cesarean delivery was associated with SMM in both Commercial (odds ratio [OR] 3.37; 95% confidence interval [CI] 1.51-1.84) and Medicaid populations (OR 1.99; 95% CI 1.80-2.17). A multifetal gestation was also associated with SMM in both Commercial (OR 3.37; 95% CI 2.80-4.10) and Medicaid populations (OR 2.26; 95% CI 1.86-2.75). Conclusion: SMM occurred in 1.1% of live inpatient deliveries. A cesarean delivery, multifetal gestation, race, region, and several pre-existing comorbidities and obstetric complications were associated with SMM.

Severe maternal morbidity at delivery and postpartum readmission in the United States.

Little is known about the extent to which severe maternal morbidity (SMM) at delivery impacts early and late postpartum readmission. We examined readmission rates for women with and without SMM (and their 18 subtypes) at delivery and characterised the most common medical reasons for readmissions. We conducted a retrospective cohort study utilising the 2016-2017 Nationwide Readmissions Database among women giving births in the United States. Deliveries were classified according to the presence or absence of 18 SMM indicators defined by the Centers for Disease Control and Prevention using the International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) diagnosis and procedure codes. The primary outcome of this study was all-cause early (≤7day) and late (8 to 42day) postpartum readmission. Survey-weighted Poisson regression with robust error variance was used to generate adjusted risk ratios (RR) and 95% confidence intervals (CI) to investigate the association between SMM and early and late postpartum readmission. Additionally, we compared principal diagnoses codes during readmission hospitalisations among women with and without SMM at delivery. Of the 6193852 women examined, 4.9% (n=4928) with any SMM and 1.4% (n=83995) with no SMM were readmitted within 42days after delivery. After adjusting for obstetric co-morbidities and sociodemographic factors, women with any SMM were 57% (RR 1.57, 95% CI 1.47, 1.67) more likely to have an early readmission and 69% (RR 1.69, 95% CI 1.57, 1.82) more likely to have a late readmission compared to women with no SMM at delivery. However, the risk was attenuated when excluding women with blood transfusion only. Women with and without SMM were readmitted predominantly for obstetric complications and infections. Women with SMM at delivery were more likely to experience both early and late postpartum readmission, independent of their obstetrical co-morbidity burden and sociodemographic factors.

A nationwide analysis of maternal morbidity and acute postpartum readmissions in women with epilepsy

ObjectiveTo compare maternal delivery hospitalization characteristics and postpartum outcomes in women with epilepsy (WWE) versus women without common neurological comorbidities. MethodsWe performed a retrospective cohort analysis of index characterizations and short-term postpartum rehospitalizations after viable delivery within the 2015–2017 National Readmissions Database using International Classification of Diseases, Tenth Revision codes. Wald chi-squared testing compared baseline demographic, hospital and clinical characteristics and postpartum complications between WWE and controls. Multivariable logistic regression models examined odds of nonelective readmissions within 30 and 90 days for WWE compared to controls (alpha = 0.05). ResultsA total of 38,518 WWE and 8,136,335 controls had a qualifying index admission for delivery. Baseline differences were most pronounced in Medicare/Medicaid insurance (WWE: 58.2%, controls: 43%, p < 0.0001), alcohol/substance abuse (WWE: 8.3%, controls: 2.5%, p < 0.0001), psychotic disorders (WWE: 1.2%, controls 0.1%, p < 0.0001), and mood disorder (WWE: 15.5%, controls: 3.7%, p < 0.0001). At the time of delivery, WWE were more likely to have edema, proteinuria, and hypertensive disorders (WWE: 19%, controls: 12.9%, p < 0.0001); a history of recurrent pregnancy loss (WWE: 1%, controls: 0.4%, p < 0.0001); preterm labor (WWE: 7.3%, controls: 4.8%, p < 0.0001), or presence of any Center for Disease Control severe maternal morbidity indicator (WWE: 3.2%, controls: 0.6%, p < 0.0001; AOR 5.16, 95% CI 4.70–5.67, p < 0.0001). A higher proportion of WWE were readmitted within 30 days (WWE: 2.4%, controls: 1.1%) and 90 days (WWE: 3.7%, controls: 1.6%). After adjusting for covariates, the odds of postpartum nonelective readmissions within 30 days (AOR 1.86, 95% CI 1.66–2.08, p-value <0.0001) and 90 days (AOR 2.04, 95% CI 1.83–2.28, p-value <0.0001) were higher in WWE versus controls. InterpretationWomen with epilepsy experienced critical obstetric complications and a higher risk of severe maternal morbidity indicators at the time of delivery. Although relatively low, nonelective short-term readmissions after delivery were higher in WWE than women without epilepsy or other common neurological comorbidities. Further research is needed to address multidisciplinary care inconsistencies, improve maternal outcomes, and provide evidence-based guidelines.

Race matters: maternal morbidity in the Military Health System

In the United States, Black women are 3 to 4 times more likely to die from childbirth and have a 2-fold greater risk of maternal morbidity than their White counterparts. This disparity is theorized to be related to differences in access to healthcare or socioeconomic status. Military service members and their dependents are a diverse community and have equal access to healthcare and similar socioeconomic statuses. This study hypothesized that universal access to healthcare, as seen in the military healthcare system, leads to similar rates of maternal morbidity regardless of race or ethnic background. A retrospective cohort study included data from the inaugural National Perinatal Information Center special report comparing indicators of severe maternal morbidity by race. National Perinatal Information Center data from participating military treatment facilities in the Department of Defense performing more than 1000 deliveries annually from April 1, 2018, to March 31, 2019, were included. Using this convenience data set, Chi-square analyses comparing the percentages of cesarean deliveries, adult intensive care unit admissions, and severe maternal morbidity between Black and White patients were performed. Black women were more likely to deliver via cesarean delivery (31.68% vs 23.58%; P<.0001; odds ratio, 1.5; 95% confidence interval, 1.38-1.63), be admitted to an adult intensive care unit (0.49% vs 0.18%; P=.0026; odds ratio, 2.78; 95% confidence interval, 1.46-5.27), and experience overall severe maternal morbidity (2.66% vs 1.66%; P=.0001; odds ratio, 1.67; 95% confidence interval, 1.3-2.15) even when excluding blood transfusion (0.64% vs 0.32%; P=.0139; odds ratio, 1.99; 95% confidence interval, 1.17-3.36) than their White counterparts. There were no substantial differences between races in overall severe maternal morbidity associated with postpartum hemorrhage even when excluding blood transfusion in this subset. Equal access to healthcare and similar socioeconomic statuses in the military healthcare system do not explain the healthcare disparities seen regarding maternal morbidity encountered by Black women having children in the United States. This study identifies healthcare disparities in severe maternal morbidity among active duty service members and their families. Further studies to assess causes such as systemic racism (including implicit and explicit medical biases) and physiological factors are warranted.

Association of Preexisting Disability With Severe Maternal Morbidity or Mortality in Ontario, Canada

Severe maternal morbidity and mortality are important indicators of maternal health. Pregnancy rates are increasing in women with disabilities, but their risk of severe maternal morbidity and mortality is unknown, despite their significant social and health disparities. To determine the risk of severe maternal morbidity or mortality among women with a physical, sensory, or intellectual/developmental disability compared with women without disabilities. This population-based cohort study used linked health administrative data in Ontario, Canada, from 2003 to 2018. The cohort included all singleton births to women with preexisting physical, sensory, and intellectual/developmental disabilities as well as with 2 disabilities or more compared with women without a disability. Data analysis was conducted from September 2019 to September 2020. Disabilities were identified with published algorithms applied to diagnoses in 2 physician visits or more or at least 1 emergency department visit or hospitalization. Severe maternal morbidity (a validated composite of 40 diagnostic and procedural indicators) or all-cause maternal mortality, arising between conception and 42 days post partum. Relative risks were adjusted for maternal age, parity, income quintile, rurality, chronic medical conditions, mental illness, and substance use disorders. The cohort comprised women with physical disabilities (144 972 women; mean [SD] age, 29.8 [5.6] years), sensory disabilities (45 259 women; mean [SD] age, 29.1 [6.0] years), intellectual/developmental disabilities (2227 women; mean [SD] age, 26.1 [6.4] years), and 2 or more disabilities (8883 women; mean [SD] age, 29.1 [6.1] years), and those without disabilities (1 601 363 women; mean [SD] age, 29.6 [5.4] years). The rate of severe maternal morbidity or death was 1.7% (27 242 women) in women without a disability. Compared with these women, the risk of severe maternal morbidity or death was higher in women with a physical disability (adjusted relative risk [aRR], 1.29; 95% CI, 1.25-1.34), a sensory disability (aRR, 1.14; 95% CI, 1.06-1.21), an intellectual/developmental disability (aRR, 1.57; 95% CI, 1.23-2.01), and 2 or more disabilities (aRR, 1.74; 95% CI, 1.55-1.95). Similar aRRs were observed for severe maternal morbidity or death arising in pregnancy, from birth to 42 days post partum, and from 43 to 365 days post partum. Women with disabilities were more likely than those without disabilities to experience multiple severe maternal morbidity indicators. The most prevalent indicators in all groups were intensive care unit admission, severe postpartum hemorrhage, puerperal sepsis, and severe preeclampsia. In this study, women with a preexisting disability were more likely to experience severe maternal morbidity or mortality. Preconception and perinatal care provisions should be considered among women with a disability to mitigate the risk of these rare but serious outcomes.

739 Maternal transfusion may overestimate severe maternal morbidity when used as an indicator

Although blood transfusion (TF) has been classified as an indicator of severe maternal morbidity (SMM), some patients receive blood without experiencing other morbid events possibly inflating rates of SMM. As many scientific bodies consider ≥ 4 units RBC to be significant for SMM, we sought to compare rates of SMM by this cutoff. This retrospective analysis included all women who delivered in a four-hospital system from January 2016 through January 2020. Demographic and clinical data were extracted using an automated query from the hospital system's electronic data warehouse, which aggregates data from the EHR, billing system, and other sources. Our primary analysis was to examine the rate of non-transfusion related SMM indicators (ntSMM) stratified by the number of units of RBCs (uRBC) transfused. ntSMM were identified using billing codes and receipt of blood TF was identified based on electronic orders. We then examined rates of specific ntSMM by units transfused. The cohort included 60,034 deliveries of which 1,452 (2%) received at least 1uRBC and of these 254 (17.5%) received ≥4uRBC. Patients who received ≥4uRBC tended to be older and have lower hematocrits prior to delivery with similar race, ethnicity and payer status. The average number of ntSMM increased when ≥ 4uRBC were transfused with 98% having at least one ntSMM (figure 1). Of those who received ≥ 4uRBC, the most prevalent ntSMM were hysterectomy (22.8%), disseminated intravascular coagulation (16.9%), sepsis (14.6%), shock (13.8%), acute kidney injury (11.8%) and acute respiratory distress syndrome (4.3%) (table 1). Among those who received <4uRBC, all individual ntSMM indicators were detected at rates ≤ 3%. An overwhelming majority of patients transfused ≥4uRBC have an associated ntSMM, making its use as a trigger for case review appropriate but use as a separate indicator of SMM unnecessary. Also, as a minority of patients with <4uRBC transfused have an associated ntSMM, the use of transfusion as an indicator may overestimate morbidity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1012 Acute kidney injury in pregnancies complicated by preeclampsia with severe features

Acute kidney injury (AKI) complicating pregnancy is used as a marker of severe maternal morbidity (SMM) and frequently associated with hypertensive disorders. Our aim was to examine AKI in pregnancies complicated by preeclampsia with severe features (SPE) using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. This was a retrospective cohort study of women with care established before 20 weeks with diagnosis of SPE and delivery > or = 34 weeks at an academic public hospital. To mitigate confounding of underlying renal dysfunction, women with chronic hypertension were excluded. KDIGO criteria for diagnosis of AKI were applied to stratify stages of renal disease at admission and during the delivery episode. Demographics and perinatal outcomes were compared using chi square with P<0.05 considered significant. From January 2015 through December 2019, 4028 women with SPE were delivered meeting inclusion criteria and 1096 (27%) of these met KDIGO criteria for AKI during their delivery episode. Of those with AKI, 690 (63%) had AKI at the time of admission and the remaining 406 (37%) developed AKI after admission. Of women with AKI, 1080 (98%) had stage I; 9 (0.82%) stage II; and 7 (0.63%) stage III renal disease stratified by KDIGO criteria. Demographic differences between those with and without AKI include younger age, race or ethnicity, and nulliparity (Table). Women with AKI had significantly higher rates of cesarean delivery, postpartum hemorrhage, and longer lengths of stay. More than a fourth of women with SPE delivered at > or = 34 weeks were found to have AKI by KDIGO criteria. The vast majority of AKI was stage I disease, and more than 60% were present on admission. AKI at time of delivery is associated with adverse outcomes. Future efforts defining SMM indicators could consider whether AKI is already present at the time of admission or develops intrapartum.

271 Impact of von willebrand disease on maternal morbidity at time of delivery

The impact of von Willebrand disease (VWD) on pregnancy has been narrowly characterized beyond an association with increased hemorrhage risk and need for transfusion. We sought to evaluate the relationship between VWD and severe maternal morbidity (SMM) at time of delivery. Using National Inpatient Sample data from 2007-2013, we identified delivery admissions for women with and without a diagnosis of VWD (ICD-9-CM 286.4). We examined the rates of SMM as defined by the Centers for Disease Control and Prevention for these two groups, both including then excluding blood product transfusion. Poisson regression evaluated the association between VWD and SMM controlling for maternal comorbidities using a validated index (low: 0, moderate: 1-2, high: >2) and mode of delivery. Data analysis was weighted to provide national estimates. We identified 5.7 million delivery admissions during this study period, of which 2,357 (0.04%) carried a diagnosis of VWD. The rate of SMM was significantly higher in women with VWD compared to women without VWD (6.6% vs 1.5%), and this persisted after excluding transfusion (1.31% vs 0.6%, both p<0.001). The incidence rate ratio after adjusting for maternal comorbidities and mode of delivery for overall SMM was 4.08 (95% CI 3.80-4.38) and with transfusion excluded was 1.97 (95% CI 1.68-2.31, both p<0.001). Several individual SMM indicators were associated with VWD including anesthesia complications, transfusion, air and thrombotic embolism, disseminated intravascular coagulation, acute respiratory distress syndrome and hysterectomy (Figure 1). Women with VWD experience four-fold the incidence of SMM at delivery compared with unaffected women. Even with blood product transfusion excluded, VWD doubles the incidence rate of SMM. Our study likely underestimates the complete impact of VWD on maternal morbidity as we focused only on the delivery admission. Further studies on the association of VWD with non-transfusion related SMM are needed to better inform delivery planning and postpartum care for women with VWD.

Socioethnic disparities in severe maternal morbidity in Western Australia: a statewide retrospective cohort study

ObjectivesTo assess the scale of ethnic inequalities in severe maternal morbidity (SMM) rates and quantify the contribution of maternal characteristics to these disparities.DesignRetrospective cohort study.SettingWhole-of-population linked administrative data from 2002...