Indicator Of Severe Maternal Morbidity Research Articles

Severe Maternal Morbidity and Infant Mortality in Canada.

Severe maternal morbidity (SMM) comprises an array of conditions and procedures denoting an acutely life-threatening pregnancy-related condition. SMM may further compromise fetal well-being. Empirical data are lacking about the relation between SMM and infant mortality. This population-based cohort study included 1 892 857 singleton births between 2002 and 2017 in Ontario, Canada, within a universal health care system. The exposure was SMM as an overall construct arising from 23 weeks' gestation up to 42 days after the index delivery. The primary outcome was infant mortality from birth to 365 days. Multivariable modified Poisson regression generated relative risks and 95% confidence intervals (CIs), adjusted for maternal age, income, rurality, world region of origin, diabetes mellitus, and chronic hypertension. Infant mortality occurred among 174 of 19 587 live births with SMM (8.9 per 1000) vs 5289 of 1 865 791 live births without SMM (2.8 per 1000) (an adjusted relative risk of 2.93 [95% CI 2.51-3.41]). Of 19 587 pregnancies with SMM, 4523 (23.1%) had sepsis. Relative to births without SMM, the adjusted odds ratio for infant death from sepsis was 1.95 (95% CI 1.10-3.45) if SMM occurred without maternal sepsis and 6.36 (95% CI 3.50-11.55) if SMM included sepsis. SMM confers a higher risk of infant death. There is also coupling tendency (concurrent event of interest) between SMM with sepsis and infant death from sepsis. Identification of preventable SMM indicators, as well as the development of strategies to limit their onset or progression, may reduce infant mortality.

Substance use disorders and risk of severe maternal morbidity in the United States

BackgroundThe contribution of substance use disorders to the burden of severe maternal morbidity in the United States is poorly understood. The objective was to estimate the independent association between substance use disorders during pregnancy and risk of severe maternal morbidity. MethodsRetrospective analysis of a weighted 53.4 million delivery hospitalizations from 2003 to 2016 among females aged>18 in the National Inpatient Sample. We constructed measures of substance use disorders using diagnostic codes for cannabis, opioids, and stimulants (amphetamines or cocaine) abuse or dependence during pregnancy. The outcome was the presence of any of the 21 CDC indicators of severe maternal morbidity. Using weighted multivariable logistic regression, we estimated the association between substance use disorders and adjusted risk of severe maternal morbidity. Because older age at delivery is predictive of severe maternal morbidity, we tested for effect modification between substance use and maternal age by age group (18−34 y vs >34 y). ResultsPregnant women with an opioid use disorder had an increased risk of severe maternal morbidity compared with women without an opioid use disorder (18−34 years: aOR: 1.51; 95 % CI: 1.41,1.61, >34 years: aOR: 1.17; 95 % CI: 1.00,1.38). Compared with their counterparts without stimulant use disorders, pregnant women with a simulant use disorder (amphetamines, cocaine) had an increased risk of severe maternal morbidity (18−34 years: aOR: 1.92; 95 % CI: 1.80,2.0, >34 years: aOR: 1.85; 95 % CI: 1.66,2.06). Cannabis use disorders were not associated with an increased risk of severe maternal morbidity. ConclusionSubstance use disorders during pregnancy, particularly opioids, amphetamines, and cocaine use disorders, may contribute to severe maternal morbidity in the United States.

An Expanded Obstetric Comorbidity Scoring System for Predicting Severe Maternal Morbidity.

To develop and validate an expanded obstetric comorbidity score for predicting severe maternal morbidity that can be applied consistently across contemporary U.S. patient discharge data sets. Discharge data from birth hospitalizations in California during 2016-2017 were used to develop the score. The outcomes were severe maternal morbidity, defined using the Centers for Disease Control and Prevention index, and nontransfusion severe maternal morbidity (excluding cases where transfusion was the only indicator of severe maternal morbidity). We selected 27 potential patient-level risk factors for severe maternal morbidity, identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. We used a targeted causal inference approach integrated with machine learning to rank the risk factors based on adjusted risk ratios (aRRs). We used these results to assign scores to each comorbidity, which sum to a single numeric score. We validated the score in California and national data sets and compared the performance to that of a previously developed obstetric comorbidity index. Among 919,546 births, the rates of severe maternal morbidity and nontransfusion severe maternal morbidity were 168 and 74 per 10,000 births, respectively. The highest risk comorbidity was placenta accreta spectrum (aRR of 30.5 for severe maternal morbidity and 54.7 for nontransfusion severe maternal morbidity) and the lowest was gestational diabetes mellitus (aRR of 1.06 for severe maternal morbidity and 1.12 for nontransfusion severe maternal morbidity). Normalized scores based on the aRR were developed for each comorbidity, which ranged from 1 to 59 points for severe maternal morbidity and from 1 to 36 points for nontransfusion severe maternal morbidity. The overall performance of the expanded comorbidity scores was good (C-statistics were 0.78 for severe maternal morbidity and 0.84 for nontransfusion severe maternal morbidity in California data and 0.82 and 0.87, respectively, in national data) and improved on prior comorbidity indices developed for obstetric populations. Calibration plots showed good concordance between predicted and actual risks of the outcomes. We developed and validated an expanded obstetric comorbidity score to improve comparisons of severe maternal morbidity rates across patient populations with different comorbidity case mixes.

Racial/Ethnic Disparities in Costs, Length of Stay, and Severity of Severe Maternal Morbidity

Research ObjectiveSimilar to maternal mortality, the United States has experienced increases in the rates of severe maternal morbidity (SMM) and has pronounced racial/ethnic disparities in SMM, with non‐Hispanic Black (NHB) women having twice the rate as non‐Hispanic White (NHW) women. This study further examined these racial/ethnic disparities, looking for differences in costs, lengths of stay (LOS), and severity of SMM.Study DesignSecondary data analysis was performed using the CDC definition of SMM, including readmissions up to 42 days postpartumAUTHOR: Please confirm if the edits made in the sentence ‘Secondary data analysis…up to 42 days postpartum’ convey the intended meaning.. GLM models with a gamma distribution and a log link, with and without hospital fixed‐effects, were used to estimate the effect of SMM on costs and LOS, controlling for race/ethnicity, cesarean delivery, type of insurance, parity, maternal age and BMI, multiple births, and an obstetric severity index.Population StudiedCalifornia linked birth certificate‐patient discharge data for 2009‐2011. About 200 000 were excluded for missing charge data (almost all insured by Kaiser Permanente). Cost‐to‐charge ratios were used to estimate costs (including readmissions) after adjusting for inflation to December 2017 dollars. Mean DRG‐specific reimbursement was used to estimate physician payments. The final N = 1 262 862.Principal FindingsSMM was observed in 1.34% of NHW and 2.62% of NHB. Adjusting for delivery method, among those deliveries with SMM, NHB women also had 38% longer LOS (5.1 vs 3.7 days) and 23% higher average costs per case ($19 507 vs $15 879) compared to NHW women. There were small racial/ethnic differences in the rates for the specific groups of diagnoses in the CDC definition of SMM, but NHB women had higher costs and LOS per case within almost all of these groups. Adjusting for risk, NHB women with SMM had costs that were 22% higher without and 17% higher with hospital fixed‐effects. For LOS, these were 21% and 20%, respectively. These effects were slightly smaller (15% and 12% for costs and 14% and 13% for LOS, respectively) when the different indicators of SMM were controlled for, indicating that NHB women were somewhat more likely to have more serious types of SMM. Asian women experienced added costs that were similar to NHB women in models without hospital fixed‐effects, but these differences were much smaller in the fixed‐effects models.ConclusionsThere are racial/ethnic disparities in the per‐case costs and LOS among patients with SMM. The moderation of these effects for NHB women in the fixed‐effects models indicates that some of the elevated costs and LOS are due to disparate quality of care at hospitals more likely to treat NHB women. This effect is even more pronounced for Asian women.Implications for Policy or PracticeThese results indicate a key policy role for facility‐based improvements and interventions. Additionally, the moderation of overall effects when the type of SMM is controlled for indicates that some of the added costs and LOS for NHB and Asian women are due to a higher prevalence of more serious types of SMM. This individual risk could also be shaped by broader social determinants of health as well as policies. Initiatives to reduce racial disparities in SMM should account for both individual risk (clinical complexity) and structural risk (hospital‐ and system‐level factors).Primary Funding SourceNational Institutes of Health.

Accuracy of Blood Transfusion Records in a Population-based Perinatal Data Registry.

Blood transfusion is frequently used as an indicator of severe maternal morbidity during pregnancy. However, few studies have examined its validity in population perinatal databases. We linked a perinatal database from British Columbia, Canada, with the province's Central Transfusion Registry for 2004-2015 deliveries. Using the Central Transfusion Registry records for red blood cell transfusion as the gold standard, we calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the perinatal database variable for red blood cell transfusion, overall and by transfusion risk factor status. We used multivariable logistic regression to examine whether outcome misclassification altered the odds ratios for different transfusion risk factors. Among 473,688 deliveries, 4,033 (8.5 per 1,000) had a red blood cell transfusion according to the Central Transfusion Registry. The sensitivity of the perinatal database transfusion variable was 72.3 [95% confidence interval (CI) = 72.2, 72.4]. Sensitivity differed according to the presence of many transfusion risk factors (e.g., 84.9% vs. 72.2% in deliveries with versus without uterine rupture). Odds ratios associated with some transfusion risk factors were exaggerated when the perinatal database transfusion variable was used to define the outcome instead of the Central Transfusion Registry variable, but 95% confidence intervals for these estimates overlapped. Blood transfusion was documented with reasonable sensitivity in this large population perinatal database. However, validity varied according to risk factor status. Our findings enable researchers to better account for outcome misclassification in studies of obstetrical transfusion risk factors.

Increased risk of severe maternal morbidity among infertile women: analysis of US claims data

Severe maternal morbidity continues to be an issue of national and global concern and is increasing in incidence. The incidence of infertility is also on the rise, and infertile women experience a higher risk of incident chronic medical disease and cancer, suggesting that fertility may serve as a window to a woman's overall health. To investigate the risk of severe maternal morbidity by maternal fertility status. This was a retrospective cohort analysis using Optum's de-identifed Clinformatics Data Mart Database between 2003 and 2015. Infertile women stratified by infertility diagnosis, testing, or treatment were compared to fertile women seeking routine gynecologic care. In both groups, only women who underwent pregnancy and delivery of a singleton during the follow-up period were included. Main outcomes were severe maternal morbidity indicators, defined by the Centers for Disease Control and Prevention and identified by International Classification of Diseases 10th Revision and Common Procedural Technology codes within 6 weeks of each delivery. Results were adjusted for maternal age, race, education, nulliparity, smoking, obesity, delivery mode, preterm birth, number of prenatal visits, and year of delivery. A total of 19,658 women comprised the infertile group and 525,695 women comprised the fertile group. The overall incidence of any severe maternal morbidity indicator was 7.0% among women receiving fertility treatment, 6.4% among women receiving a fertility diagnosis, 5.5% among women receiving fertility testing, and 4.3% among fertile women. Overall, infertile women had a significantly higher risk of developing any severe maternal morbidity indicator (adjusted odds ratio, 1.22; confidence interval, 1.14-1.31, P < .01) as well as a significantly higher risk of disseminated intravascular coagulation (adjusted odds ratio, 1.48; confidence interval, 1.26-1.73, P < .01), eclampsia (adjusted odds ratio, 1.37; confidence interval, 1.05-1.79, P < .01), heart failure during procedure orsurgery (adjusted odds ratio, 1.54; confidence interval, 1.21-1.97, P<.01), internal injuries of the thorax, abdomen, or pelvis (adjusted odds ratio, 1.59; confidence interval, 1.12-2.26, P < .01), intracranial injuries (adjusted odds ratio, 1.77; confidence interval, 1.20-2.61, P < .01), pulmonary edema (adjusted odds ratio, 2.18; confidence interval, 1.54-3.10, P < .01), thrombotic embolism (adjusted odds ratio, 1.58; confidence interval, 1.14-2.17, P < .01), and blood transfusion (adjusted odds ratio, 1.50; confidence interval, 1.30-1.72, P < .01) compared to fertile women. Fertile women did not face a significantly higher risk of any maternal morbidity indicator compared to infertile women. In subgroup analysis by maternal race/ethnicity, the likelihood of severe morbidity was significantly higher among fertile black women compared to fertile white women. There was no difference between infertile black women and infertile white women after multivariable adjustment. Using an insurance claims database, we report that women diagnosed with infertility and women receiving fertility treatment experience a significantly higher risk of multiple indicators of severe maternal morbidity compared to fertile women. The increased risk of severe maternal morbidity noted among fertile black women compared to fertile white women is attenuated among infertile black women, who face risks similar to those of infertile white women.

Maternal admissions to Intensive Care Units in France: trends in rates, causes and severity

Abstract Introduction Maternal intensive care unit admission (ICU) is an indicator of severe maternal morbidity. This study aimed to estimate rates of maternal ICU admission during or following pregnancy in France, and to describe the characteristics of women admitted, the severity of their condition, associated diagnoses, regional disparities, and temporal trends between 2010 and 2014. Methods Women hospitalised in France in ICU during pregnancy or up to 42 days after pregnancy between 2010 and 2014 were identified using the national hospital discharge database (PMSI-MCO). The Simplified Acute Physiology Score (SAPS II) was used to estimate the severity. Trends in incidence rates were quantified using percentages of average annual variation based on a Poisson regression model. Results In total, 16,011 women were admitted to ICU, representing an overall rate of 3.97 ‰ deliveries. The average annual decrease in this rate between 2010 and 2014 was 1.7% (IC95%:-2, 00%; -1, 45%; p &amp;lt; 0.0001) on average per year. The SAPS II score increased significantly from 18.4 in 2010 to 21.5 in 2014. Obstetrical hemorrhage (39.8%) and hypertensive complications during pregnancy (24.8%) were the most common reasons for admission. Within mainland France, we found notable disparities in maternal ICU admission rates between regions, from lowest in Pays-de-la-Loire region (2.69‰) to highest in Ile-de-France (5.05‰). Conclusions The rate of maternal ICU admission decreased from 2010 to 2014 in France, with a concomitant increase in case severity. Additional studies are needed to understand the territorial disparities identified in our study. Key messages The decreasing incidence of maternal ICU admission could be due to organisational changes with increased admission to intermediate care units. These changes have to be understood to accurately use maternal CU admission for maternal health surveillance.

Rate and causes of severe maternal morbidity at readmission: California births in 2008-2012.

To determine the rate, maternal characteristics, timing, and indicators of severe maternal morbidity (SMM) that occurs at postpartum readmission. Women with a birth in California during 2008-2012 were included in the analysis. Readmissions up to 42 days after delivery were investigated. SMM was defined as presence of any of the 21 indicators defined by ICD-9 codes. Among 2,413,943 women with a birth, SMM at readmission occurred in 4229 women. Of all SMM, 12.1% occurred at readmission. Over half (53.5%) of the readmissions with SMM occurred within the first week after delivery hospitalization. The most common indicators of SMM were blood transfusion, sepsis, and pulmonary edema/acute heart failure. Twelve percent of SMM was identified at readmission with the majority occurring within 1 week after discharge from delivery hospitalization. Because early readmission may reflect lack of discharge readiness, there may be opportunities to improve care.

Learning to Identify Severe Maternal Morbidity from Electronic Health Records.

Severe maternal morbidity (SMM) is broadly defined as significant complications in pregnancy that have an adverse effect on women’s health. Identifying women who experience SMM and reviewing their obstetric care can assist healthcare organizations in recognizing risk factors and best practices for management. Various definitions of SMM have been posited, but there is no consensus. Existing definitions are further limited in that they 1) are often rooted in existing clinical knowledge (which is problematic as many risk factors remain unknown), leading to poor positive predictive performance (PPV), and 2) have limited scalability as they often require substantial chart review. Thus, in this paper, a machine learning framework was introduced to automatically identify SMM and relevant risk factors from electronic health records (EHRs). We evaluated this framework with EHR data from 45,858 deliveries at a large academic medical center. The framework outperformed a state-of-the-art model from the U.S. Centers for Disease Control and Prevention (AUC of 0.94 vs. 0.80). Specially, it improved upon PPV by 59% (CDC: 0.22 vs. our model: 0.35). In the process, we revealed several novel SMM indicators, including disorders of fluid or electrolytes, systemic inflammatory response syndrome, and acidosis.

Skin Color and Severe Maternal Outcomes: Evidence from the Brazilian Network for Surveillance of Severe Maternal Morbidity.

Background Taking into account the probable role that race/skin color may have for determining outcomes in maternal health, the objective of this study was to assess whether maternal race/skin color is a predictor of severe maternal morbidity. Methods This is a secondary analysis of the Brazilian Network for Surveillance of Severe Maternal Morbidity, a national multicenter cross-sectional study of 27 Brazilian referral maternity hospitals. A prospective surveillance was performed to identify cases of maternal death (MD), maternal near miss (MNM) events, and potentially life-threatening conditions (PLTC), according to standard WHO definition and criteria. Among 9,555 women with severe maternal morbidity, data on race/skin color was available for 7,139 women, who were further divided into two groups: 4,108 nonwhite women (2,253 black and 1,855 from other races/skin color) and 3,031 white women. Indicators of severe maternal morbidity according to WHO definition are shown by skin color group. Adjusted Prevalence Ratios (PRadj - 95%CI) for Severe Maternal Outcome (SMO=MNM+MD) were estimated according to sociodemographic/obstetric characteristics, pregnancy outcomes, and perinatal results considering race. Results Among 7,139 women with severe maternal morbidity evaluated, 90.5% were classified as PLTC, 8.5% as MNM, and 1.6% as MD. There was a significantly higher prevalence of MNM and MD among white women. MNMR (maternal near miss ratio) was 9.37 per thousand live births (LB). SMOR (severe maternal outcome ratio) was 11.08 per 1000 LB, and MMR (maternal mortality ratio) was 170.4 per 100,000 LB. Maternal mortality to maternal near miss ratio was 1 to 5.2, irrespective of maternal skin color. Hypertension, the main cause of maternal complications, affected mostly nonwhite women. Hemorrhage, the second more common cause of maternal complication, predominated among white women. Nonwhite skin color was associated with a reduced risk of SMO in multivariate analysis. Conclusion Nonwhite skin color was associated with a lower risk for severe maternal outcomes. This result could be due to confounding factors linked to a high rate of Brazilian miscegenation.

Infertility treatment and risk of severe maternal morbidity: a propensity score-matched cohort study.

The extent to which infertility treatment predicts severe maternal morbidity is not well known. We examined the association between infertility treatment and severe maternal morbidity in pregnancy and the postpartum period. We conducted a cohort study using population-based registries from Ontario between 2006 and 2012. Pregnancies achieved using infertility treatment (ovulation induction, intrauterine insemination or in vitro fertilization with or without intracytoplasmic sperm injection) were compared with unassisted pregnancies using propensity score matching, based on demographic, reproductive and obstetric factors. The primary outcome was a validated composite of severe maternal morbidity or maternal death from 20 weeks' gestation to 42 days postpartum. We also calculated the odds ratio of a woman having 1, 2, or 3 or more severe maternal morbidity indicators in relation to invasive (e.g., in vitro fertilization) or noninvasive (e.g., intrauterine insemination) infertility treatment. We matched 11 546 infertility treatment pregnancies with 47 553 untreated pregnancies. Severe maternal morbidity or maternal death occurred in 356 infertility-treated pregnancies (30.8 per 1000 deliveries) versus 1054 untreated pregnancies (22.2 per 1000 deliveries); relative risk 1.39 (95% confidence interval [CI] 1.23-1.56). The likelihood of a woman having 3 or more severe maternal morbidity indicators was increased in women who received invasive infertility treatment (odds ratio [OR] 2.28, 95% CI 1.56-3.33) but not in those who received noninvasive infertility treatment (OR 0.99, 95% CI 0.57-1.72). Women who undergo infertility treatment, particularly in vitro fertilization, are at somewhat higher risk of severe maternal morbidity or death. Efforts are needed to identify patient- and treatment-specific predictors of severe maternal morbidity that may influence the type of treatment a woman is offered.

Abstract TP152: Maternal Morbidity Outcomes in Moyamoya Syndrome in New York State

Background: Pregnancy is associated with increased stroke risk in young women. Idiopathic moyamoya syndrome (IMMS) is a rare condition characterized by progressive narrowing of large cerebral arteries resulting in flimsy collaterals prone to rupture or thrombosis. Data are limited on pregnancy outcomes in women with IMMS. We hypothesized that IMMS would be associated with increased pregnancy morbidity, including stroke. Methods: Using the New York State Department of Health Statewide Planning and Research Cooperative System data from 2000-2014 we identified all women aged 18 and older with diagnoses of IMMS (ICD-9 437.5) who had hospitalizations for delivery at any time either prior, concomitant or subsequent to IMMS diagnosis. We considered a pregnancy to be IMMS-exposed if it occurred ≤ 3 years prior to, or any time after, IMMS diagnosis. We defined pregnancy morbidity as admission within 1 year of delivery for any of the Center for Disease Control and Prevention’s severe maternal morbidity indicators, including stroke. We compared the morbidity of IMMS-exposed pregnancies to unexposed pregnancies occurring in the same cohort &gt;3 years prior to IMMS diagnosis. We used conditional logistic regression to calculate odds ratio (OR) and 95% confidence intervals (95%CI), adjusting for women with both exposed and unexposed pregnancies. Results: We identified 134 patients with IMMS, with 117 exposed pregnancies and 147 unexposed pregnancies. Severe maternal morbidity was higher for exposed pregnancies (33.3% vs 19.0%, OR: 2.1, 95%CI: 1.2-3.7). After adjusting for maternal morbidity, exposed pregnancies had more caesarean sections (44.4% vs 23.0%, OR: 4.2, 95%CI: 2.3-7.6). Complications occurring during and after exposed pregnancies included stroke, acute myocardial infarction, cardiac arrest, cardiac arrhythmia requiring conversion, eclampsia, pulmonary edema, and adult respiratory distress syndrome. Conclusion: Pregnancies within 3 years prior or any time after IMMS diagnosis had increased maternal morbidity within 1 year of delivery. Prospective studies are needed to better characterize increased maternal risks for women with moyamoya syndrome and develop preventive strategies.

Maternal admissions to intensive care units in France: Trends in rates, causes and severity from 2010 to 2014

IntroductionMaternal intensive care unit admission is an indicator of severe maternal morbidity. The objective of this study was to estimate rates of maternal intensive care unit admission during or following pregnancy in France, and to describe the characteristics of women concerned, the severity of their condition, associated diagnoses, regional disparities, and temporal trends between 2010 and 2014. MethodsWomen hospitalised in France in intensive care units during pregnancy or up to 42 days after pregnancy between January 2010 and December 2014 were identified using the national hospital discharge database (PMSI-MCO). Trends in incidence rates were quantified using percentages of average annual variation based on a Poisson regression model. ResultsIn total, 16,011 women were admitted to intensive care units, representing an overall incidence of 3.97‰ deliveries. This number decreased significantly by 1.7% on average per year. For women who gave birth (60.5% by C-section), 62.5% of admissions occurred during their hospitalisation for delivery. The SAPS II score, an indicator of severity, significantly increased from 18.4 in 2010 to 21.5 in 2014. Obstetrical haemorrhage (39.8%) and hypertensive complications during pregnancy (24.8%) were the most common reasons for admission. In mainland France, the Ile-de-France (i.e., greater Paris) region had the highest rates of intensive care units admission (5.05‰) while the Pays-de-la-Loire region had the lowest (2.69‰). ConclusionThe rate of maternal intensive care unit admission decreased from 2010 to 2014 in France, with a concomitant increase in case severity. In-depth studies are needed to understand the territorial disparities identified.

Insights from outside BJOG

Insights from outside BJOG

Prevalence of Severe Maternal Morbidity and Factors Associated With Maternal Mortality in Ontario, Canada

Severe maternal morbidity is defined by potentially life-threatening conditions. The association between the number of severe maternal morbidity (SMM) indicators and maternal death is not known. To quantify the association between the number of SMM indicators and maternal mortality. This population-based cohort study used provincial databases for data on all live birth and stillbirth hospital deliveries among women in Ontario, Canada, from April 1, 2002, to February 18, 2017. Excluded from this cohort were those with invalid identification number, non-Ontario residency, maternal age younger than 10 years or older than 55 years or unknown, or gestational age fewer than 20 weeks or unknown as well as any out-of-hospital births, ectopic pregnancies, or spontaneous or induced abortions. Number of SMM indicators identified between 20 weeks' gestation and 42 days after the index delivery. Maternal death occurring from delivery to 42 days after the index delivery. Of the 1 953 943 total births among 1 211 396 women, 181 maternal deaths occurred within 42 days after birth, a rate of 9.3 per 100 000 births. Of the 181 women who died, 123 (68.0%) had at least 1 SMM indicator compared with 1.7% (33 152) of women who survived. Standardized differences suggested that women who died, compared with the women who lived, were older (mean [SD] age, 31.0 [6.2] years vs 30.1 [5.5] years; standardized difference, 0.15) and more likely to reside in a lower-income area (99 [54.7%] vs 832 231 [42.6%]; standardized difference, 0.24), be nulliparous (93 [51.4%] vs 880 386 [45.1%]; standardized difference, 0.13), and be of Afro-Caribbean origin (12 [6.6%] vs 64 948 [3.3%]; standardized difference, 0.15). The most frequent SMM indicators were intensive care unit admission (81 [44.8%]), invasive ventilation (77 [42.5%]), cardiac conditions (69 [38.1%]), complications of obstetric surgery or procedures (32 [17.7%]), and postpartum hemorrhage with blood transfusion (31 [17.1%]). The rate of maternal mortality increased exponentially with the number of SMM indicators: 0 indicators (3.0 per 100 000 births), 1 (71.7 per 100 000 births), 2 (385.9 per 100 000 births), 3 (1274.2 per 100 000 births), 4 (2236.8 per 100 000 births), 5 (4285.7 per 100 000 births), and 6 or more (9422.5 per 100 000 births). Adjusted relative risks for maternal death ranged from 20.1 (95% CI, 11.6-34.7) with 1 SMM indicator to 2192.0 (95% CI, 1287.0-3735.0) with 6 or more SMM indicators compared with 0 indicators. Maternal death may be associated with the number of SMM indicators and occur in certain identifiable groups of women; targeting preventable SMM indicators or limiting their progression may reduce the number of maternal deaths.

Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the United States, 2012-2015.

To describe racial and ethnic disparities in the incidence of severe maternal morbidity during delivery hospitalizations in the United States. We conducted a pooled, cross-sectional analysis of 2012-2015 data from the National Inpatient Sample to define the prevalence of chronic conditions and incidence of severe maternal morbidity among deliveries to non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, and Native American or Alaska Native women. We used weighted multivariable logistic regression and predictive margins to generate prevalence and incidence estimates. Adjusted rate ratios and differences were calculated to quantify disparities across racial and ethnic categories. Subgroup analyses were performed to examine the incidence of severe maternal morbidity among deliveries to women with comorbid physical health conditions, behavioral health conditions, and multiple chronic conditions within each racial and ethnic category. The incidence of severe maternal morbidity was significantly higher among deliveries to women in every racial and ethnic minority category compared with deliveries among non-Hispanic white women. Severe maternal morbidity occurred in 231.1 (95% CI 223.6-238.5) and 139.2 (95% CI 136.4-142.0) per 10,000 delivery hospitalizations among non-Hispanic black and non-Hispanic white women, respectively (P<.001). When excluding cases in which blood transfusion was the only indicator of severe maternal morbidity, only deliveries to non-Hispanic black women had a higher incidence of severe maternal morbidity compared with deliveries among non-Hispanic white women: 50.2 (95% CI 47.6-52.9) and 40.9 (95% CI 39.6-42.3) per 10,000 delivery hospitalizations, respectively (risk ratio 1.2 [95% CI 1.2-1.3], risk difference 9.3 [95% CI 6.5-12.2] per 10,000 delivery hospitalizations; P<.001 for each comparison). Among deliveries to women with comorbid physical and behavioral health conditions, significant differences in severe maternal morbidity were identified among racial and ethnic minority compared with non-Hispanic white women and the largest disparities were identified among women with multiple chronic conditions. Programs for reducing racial and ethnic disparities in severe maternal morbidity may have the greatest effect focusing on women at highest risk for blood transfusion and maternity care management for women with comorbid chronic conditions, particularly multiple chronic conditions.

319. Maternal ICU admissions at the McGill University Health Centre and impact of advanced maternal age on outcomes: Retrospective chart review

Introduction Severe maternal morbidity (SMM) necessitating intensive care unit (ICU) admission is rising. Advanced maternal age (⩾35 years, AMA) is associated with SMM, but its impact on ICU outcomes is not clear. Objectives We aimed to describe characteristics of pregnant and postpartum women admitted to the ICU at our institution, and to evaluate the impact of AMA on length of stay, need for invasive intervention, number of SMM indicators, and death. Methods We conducted a retrospective chart review of ICU admissions during, or within 42 days, of pregnancy, from January 1, 2006 to December 31, 2016. Impact of AMA on outcomes will be assessed with linear and log-linear regression. Results 205 women were admitted to the ICU during pregnancy or postpartum. We report descriptive analysis on a subset of patients (n = 97). Mean age was 32.5 ± 6 years; 39 (40.1%) had AMA. Most admissions (70.1%) occurred during postpartum period. High prevalence of hypertensive disorders of pregnancy (19.6%) and gestational diabetes (13.4%) was noted. One third delivered prematurely ( Discussion The majority of maternal ICU admissions are in the postpartum period in women with at least one maternal or fetal complication. Further analyses will explore outcomes according to maternal age.

Epidemiology of racial/ethnic disparities in severe maternal morbidity and mortality

The literature abounds with examples of racial/ethnic disparities in both obstetric outcomes and care. Disparities in maternal mortality are well documented with non-Hispanic blacks carrying the burden of the highest maternal mortality rates. Maternal deaths likely represent only the “tip of the iceberg” with respect to pregnancy complications, leading many to explore risk factors and disparities in severe maternal morbidity, a more common precursor to maternal mortality. This review article explores commonly cited indicators of severe maternal morbidity and includes a review of the epidemiological literature supporting or refuting disparities among each indicator.

Severe Maternal Morbidity Associated With Maternal Birthplace: A Population-Based Register Study.

This study sought to quantify the risk of severe maternal morbidity (SMM) according to maternal country of birth in Canada. The study analyzed 1 252 543 in-hospital deliveries of Ontario residents discharged between April 1, 2002, and March31,2012. The main outcome measure was a composite indicator of SMM used for surveillance. The top 10 most common component conditions were also evaluated. Maternal country of birth and other immigration characteristics were obtained through linkage with official immigration records. We used modified Poisson regression with generalized estimating equations to assess associations according to maternal country of birth. Overall, immigrant women (N= 335 544) did not differ from Canadian-born women (n= 916 999) in SMM rates (12.1 vs. 12.0 cases per 1000 deliveries, respectively). However, SMM varied substantially according to maternal region of birth, from 9.2 cases per 1000 deliveries among immigrants from Western countries to 23.0 cases per 1000 deliveries among immigrants from Sub-Saharan Africa. Even larger variations were found when immigrants were categorized by their specific countries of birth. The top 10 contributing conditions to SMM among Canadian-born women were also the main contributors among immigrant subgroups. The notable exception was HIV infection, the top contributor among immigrants from Sub-Saharan Africa, whose rate of HIV infection was 43 times that of Canadian-born women (95% CI 34.39-55.23). After excluding HIV cases, disparities in SMM were largely reduced among Sub-Saharan African women but did not disappear. There is large heterogeneity in SMM and its component conditions among Canadian immigrants depending on country of origin.

Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010

The purpose of this study was to examine racial and ethnic disparities in severe maternal morbidity during delivery hospitalizations in the United States. We identified delivery hospitalizations from 2008-2010 in State Inpatient Databases from 7 states. We used International Classification of Diseases, 9th Revision, codes to create severe maternal morbidity indicators during delivery hospitalizations. We calculated the rates of severe maternal morbidity that were measured with and without blood transfusion for 5 racial/ethnic groups: non-Hispanic white, non-Hispanic black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women. Poisson regression models were fitted to explore the associations between race/ethnicity and severe maternal morbidity after we controlled for potential confounders. Overall, severe maternal morbidity rates that were measured with and without blood transfusion were 150.7 and 64.3 per 10,000 delivery hospitalizations, respectively. Non-Hispanic black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women had 2.1, 1.3, 1.2, and 1.7 times (all P < .05), respectively, higher rates of severe morbidity that were measured with blood transfusion compared with non-Hispanic white women; similar increased rates were observed when severe morbidity was measured without blood transfusion. Other significant positive predictors of severe morbidity were age <20 and ≥30 years, self-pay or Medicaid coverage for delivery, low socioeconomic status, and presence of chronic medical conditions. Severe maternal morbidity disproportionally affects racial/ethnic minority women, especially non-Hispanic black women. There is a need for a systematic review of severe maternal morbidities at the facility, state, and national levels to guide the development of quality improvement interventions to reduce the racial/ethnic disparities in severe maternal morbidity.