Development of a comorbidity index for use in obstetric patients

Reduced rate of postpartum readmissions among homeless compared with non-homeless women in New York: a population-based study using serial, cross-sectional data

Objective

To assess differences in rates of postpartum hospitalisations among homeless women compared with non-homeless women.

Design

Cross-sectional secondary analysis of readmissions and emergency department (ED) utilisation among postpartum women using hierarchical regression models adjusted for age, race/ethnicity, insurance type during delivery, delivery length of stay, maternal comorbidity index score, other pregnancy complications, neonatal complications, caesarean delivery, year fixed effect and a birth hospital random effect.

Setting

New York statewide inpatient and emergency department databases (2009–2014).

Participants

82 820 and 1 026 965 postpartum homeless and non-homeless women, respectively.

Main outcome measures

Postpartum readmissions (primary outcome) and postpartum ED visits (secondary outcome) within 6 weeks after discharge date from delivery hospitalisation.

Results

Homeless women had lower rates of both postpartum readmissions (risk-adjusted rates: 1.4% vs 1.6%; adjusted OR (aOR) 0.87, 95% CI 0.75 to 1.00, p=0.048) and ED visits than non-homeless women (risk-adjusted rates: 8.1% vs 9.5%; aOR 0.83, 95% CI 0.77 to 0.90, p<0.001). A sensitivity analysis stratifying the non-homeless population by income quartile revealed significantly lower hospitalisation rates of homeless women compared with housed women in the lowest income quartile. These results were surprising due to the trend of postpartum hospitalisation rates increasing as income levels decreased.

Conclusions

Two factors likely led to lower rates of hospital readmissions among homeless women. First, barriers including lack of transportation, payment or childcare could have impeded access to postpartum inpatient and emergency care. Second, given New York State’s extensive safety net, discharge planning such as respite and sober living housing may have provided access to outpatient care and quality of life, preventing adverse health events. Additional research using outpatient data and patient perspectives is needed to recognise how the factors affect postpartum health among homeless women. These findings could aid in lowering readmissions of the housed postpartum population.

Association of Duration of Methadone or Buprenorphine Use During Pregnancy With Risk of Nonfatal Drug Overdose Among Pregnant Persons With Opioid Use Disorder in the US

This cohort study evaluates the association of the duration of methadone or buprenorphine use during pregnancy and the risk of nonfatal drug overdose among pregnant persons with opioid use disorder in the US.

Racial and Ethnic Disparities in the Management of Postdural Puncture Headache With Epidural Blood Patch for Obstetric Patients in New York State

IMPORTANCE

Characterizing and addressing racial and ethnic disparities in peripartum pain assessment and treatment is a national priority.

OBJECTIVE

To evaluate the association of race and ethnicity with the provision and timing of an epidural blood patch (EBP) for management of postdural puncture headache in obstetric patients.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used New York State hospital discharge records from January 1, 1998, to December 31, 2016, from mothers 15 to 49 years of age with a postdural puncture headache after neuraxial analgesia or anesthesia for childbirth. Statistical analysis was performed from February 2020 to February 2022.

EXPOSURES

Patients' race and ethnicity (reported as provided by each participating hospital; the method of determining race and ethnicity [ie, self-reported or not] cannot be determined from the data) were categorized into non-Hispanic White (reference group), non-Hispanic Black, Hispanic, and other race and ethnicity (including Asian and Pacific Islander, American Indian, Alaskan Native, and other).

MAIN OUTCOMES AND MEASURES

The primary outcome was the rate of EBP use. The secondary outcome was the interval (days) between hospital admission and provision of EBP. Odds ratios (ORs) and 95% CIs of EBP use associated with race and ethnicity were estimated using mixed-effect logistic regression models, adjusting for patient and hospital characteristics.

RESULTS

During the study period, 8921 patients (mean [SD] age, 30 [6] years; 1028 [11.5%] Black; 1301 [14.6%] Hispanic; 4960 [55.6%] White; and 1359 [15.2%] other race and ethnicity) with postdural puncture headache were identified among 1.9 million deliveries with a neuraxial procedure. Of these 8921 patients, 4196 (47.0%; 95% CI, 46.0%-48.1%) were managed with an EBP. A total of 2650 White patients (53.4%; 95% CI, 52.0%-54.8%) used an EBP; this rate was significantly higher than that among Hispanic patients (41.7% [543]; 95% CI, 39.9%-44.5%), Black patients (35.7% [367]; 95% CI, 32.8%-38.7%), or patients of other race and ethnicity (35.2% [478]; 95% CI, 32.6%-37.8%). Timing of EBP was at a median of 2 days (IQR, 2-3 days) after hospital admission for White patients compared with a median of 3 days (IQR, 2-4 days) for Hispanic patients, Black patients, and patients of other race and ethnicity (P < .001 for the comparison with White patients). After adjustment for patient and hospital characteristics, the EBP rate was not different between White and Hispanic patients (adjusted OR, 1.11; 95% CI, 0.94-1.30). It was significantly lower for Black patients (adjusted OR, 0.80; 95% CI, 0.67-0.94) and patients of other races and ethnicities (adjusted OR, 0.85; 95% CI, 0.73-0.99).

CONCLUSIONS AND RELEVANCE

In this study, significant racial and ethnic disparities in the management of postdural puncture headache with EBP were observed, with both lower rates and delayed timing, which may be associated with long-term adverse effects.

Ischemic Placental Disease, Preterm Delivery, and Their Association With Opioid Use During Pregnancy

Opioids affect placental development and function in animal models, but human data on their association with ischemic placental disease are limited. Using a cohort of pregnant women in the US nationwide Medicaid Analytic eXtract (2000-2014), we compared women with ≥2 opioid dispensings in pregnancy with unexposed women. Given an uncertain etiologically relevant window, we assessed exposure occurring in early pregnancy, late and not early pregnancy, and both early and late pregnancy. For placental abruption, preterm delivery, small for gestational age (SGA), and preeclampsia, we estimated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) using Cox proportional hazard models adjusting for demographic factors, indications/comorbidities, and medications. Among 1,833,871 eligible pregnancies, ≥2 opioid dispensings were filled in 6.5%. We observed an early exposure aHR of 1.34 (95% CI: 1.26, 1.43) for placental abruption, 1.21 (95% CI: 1.18, 1.23) for preterm delivery, 1.13 (95% CI: 1.09, 1.17) for SGA, and 0.95 (0.91, 0.98) for preeclampsia. Estimates for late exposure were attenuated. Early and late exposure was associated with higher aHRs for placental abruption, 1.62 (95% CI: 1.47, 1.78); preterm delivery, 1.37 (95% CI: 1.33, 1.42); and SGA, 1.26 (95% CI: 1.19, 1.33); but not preeclampsia, 0.99 (95% CI: 0.93, 1.05). Prescription opioids may modestly increase risk of placental abruption, preterm birth and SGA, but they do not appear to be associated with preeclampsia.

The impact of Covid-19 restrictions on depressive symptoms in low-risk and high-risk pregnant women: a cross-sectional study before and during pandemic

Background

The COVID-19 social restrictions have increased the risk for depression compared to the previous period in Italian women with Low-Risk Pregnancy (LRP). lLess is known about the impact of COVID-19 restrictions on High-Risk Pregnancy (HRP). This study aimed: 1) to explore levels of depression in women who become pregnant before and during COVID-19 pandemic, distinguishing between LRP and HRP; 2) to analyze the impact of COVID-19 restrictions on pregnancy experience in LRP and HRP.

Methods

A before-during COVID-19 pandemic cross-sectional study was carried out on 155 pregnant women (Mean age = 34.18), between 23 and 32 weeks of gestation. 77 women were recruited before COVID-19 pandemic (51.9% LRP; 48.1% HRP) and 78 women were recruited during COVID-19 pandemic (51.3% LRP; 48.7% HRP). HRP group was enrolled during hospitalization for high-risk pregnancy. Participants filled out Edinburgh Postnatal Depression Scale. Moreover, only COVID-19 group answered an open-ended question about the impact of restriction on pregnancy experience.

Results

HRP women reported higher levels of depressive symptoms than LRP. No difference emerged for COVID (before/during) but an interaction effect between COVID-19 and obstetric condition was found. The qualitative results showed the impact of restrictions on emotions and concerns.

Conclusion

Respect to the previous period, LRP women during COVID-19 presented an increased risk for depressive symptoms than HRP. The HRP women during COVID-19 seemed to use hospitalization as a resource to find a social support network with other pregnant women and to be reassured on the clinical ongoing of pregnancy.

Obstetric comorbidity scores and disparities in severe maternal morbidity across marginalized groups

BACKGROUND

A recently developed obstetrical comorbidity scoring system enables the comparison of severe maternal morbidity rates independent of health status at the time of birth hospitalization. However, the scoring system has not been evaluated in racial-ethnic and socioeconomic groups or used to assess disparities in severe maternal morbidity.

OBJECTIVE

This study aimed to evaluate the performance of an obstetrical comorbidity scoring system when applied across racial-ethnic and socioeconomic groups and to determine the effect of comorbidity score risk adjustment on disparities in severe maternal morbidity.

STUDY DESIGN

We analyzed a population-based cohort of live births that occurred in California during 2011 through 2017 with linked birth certificates and birth hospitalization discharge data (n=3,308,554). We updated a previously developed comorbidity scoring system to include the International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modifications diagnosis codes and applied the scoring system to subpopulations (groups) defined by race-ethnicity, nativity, payment method, and educational attainment. We then calculated the risk-adjusted rates of severe maternal morbidity (including and excluding blood transfusion-only cases) for each group and estimated the disparities for these outcomes before and after adjustment for the comorbidity score using logistic regression.

RESULTS

The obstetric comorbidity scores performed consistently across groups (C-statistics ranged from 0.68 to 0.76; calibration curves demonstrated overall excellent prediction of absolute risk). All non-White groups had significantly elevated rates of severe maternal morbidity before and after risk adjustment for comorbidities when compared with the White group (1.3% before, 1.3% after) (American Indian-Alaska Native: 2.1% before, 1.8% after; Asian: 1.5% before, 1.7% after; Black: 2.5% before, 2.0% after; Latinx: 1.6% before, 1.7% after; Pacific Islander: 2.2% before, 1.9% after; and multi-race groups: 1.7% before, 1.6% after). Risk adjustment also modestly increased disparities for the foreign-born group and government insurance groups. Higher educational attainment was associated with decreased severe maternal morbidity rates, which was largely unaffected by comorbidity risk adjustment. The pattern of results was the same whether or not transfusion-only cases were included as severe maternal morbidity.

CONCLUSION

These results support the use of an updated comorbidity scoring system to assess disparities in severe maternal morbidity. Disparities in severe maternal morbidity decreased in magnitude for some racial-ethnic and socioeconomic groups and increased in magnitude for other groups after adjustment for the comorbidity score.

Variation in guideline-based prenatal care in a commercially insured population

BACKGROUND

Despite the importance of prenatal care, quality measurement efforts have focused on the number of prenatal visits, or prenatal care adequacy, rather than the services received. It is unknown whether attending more prenatal visits is associated with receiving more guideline-based prenatal care services. The relationship between guideline-based prenatal care and patients' clinical and sociodemographic characteristics has also not been studied.

OBJECTIVE

This study aimed to measure the receipt of guideline-based prenatal care among pregnant patients and to describe the association between guideline-based prenatal care and the number of prenatal visits and other patient characteristics.

STUDY DESIGN

This was a retrospective descriptive cohort study of 176,092 pregnancy episodes between 2016 and 2019. We used de-identified administrative claims data on commercial enrollees across the United States from the OptumLabs Data Warehouse. We identified the following 8 components of prenatal care that are universally recommended by the American College of Obstetricians and Gynecologists and other guideline-issuing organizations: testing for sexually transmitted infections, obstetric laboratory test panel, urine culture, urinalysis, anatomy scan ultrasound, oral glucose tolerance test, tetanus, diphtheria, and pertussis vaccine, and group B Streptococcus test. We measured the proportion of pregnant patients who received each of these guideline-based services at the appropriate gestational age. We measured the association between guideline-based services and the number of prenatal visits and prenatal care adequacy. We described variation of guideline-based care according to patient age, comorbidities, high deductible health plan enrollment, and their county's rurality, health professional shortage area status, racial composition, median income, and educational attainment.

RESULTS

The 176,092 pregnancy episodes were mostly among patients aged 25 to 34 years (63%) with few pregnancy comorbidities (81%) and living in urban areas (92%). Guideline-based care varied by service, from 51% receiving a timely urinalysis to 90% receiving an anatomy scan and 91% completing testing for sexually transmitted infections. Patients with at least 4 prenatal visits received, on average, 6 of the 8 guideline-based services. Guideline-based care did not increase with additional prenatal visits and varied by patient characteristics. Rates of tetanus, diphtheria, and pertussis vaccination were lower in counties with high proportions of minoritized populations, lower education, and lower income.

CONCLUSION

In this commercially insured population, receipt of guideline-based care was not universal, did not increase with the number of prenatal visits, and varied by patient- and area-level characteristics. Measuring guideline-based care is feasible and may capture quality of prenatal care better than visit count or adequacy alone.

First-trimester exposure to benzodiazepines and risk of congenital malformations in offspring: A population-based cohort study in South Korea

BACKGROUND

Benzodiazepines are frequently prescribed during pregnancy; however, evidence about possible teratogenicity is equivocal. We aimed to evaluate the association between first-trimester benzodiazepine use and the risk of major congenital malformations.

METHODS AND FINDINGS

Using Korea's nationwide healthcare database, we conducted a population-based cohort study of women who gave birth during 2011 to 2018 and their live-born infants. The exposure was defined as one or more benzodiazepine prescriptions during the first trimester. We determined the relative risks (RRs) and confidence intervals (CIs) of overall congenital malformations and 12 types of organ-specific malformations. Infants were followed from birth to death or 31 December 2019, whichever came first (up to 8 years of age). Propensity score fine stratification was employed to control for 45 potential confounders. Among a total of 3,094,227 pregnancies, 40,846 (1.3%) were exposed to benzodiazepines during the first trimester (mean [SD] age, 32.4 [4.1] years). The absolute risk of overall malformations was 65.3 per 1,000 pregnancies exposed to benzodiazepines versus 51.4 per 1,000 unexposed pregnancies. The adjusted RR was 1.09 (95% CI 1.05 to 1.13, p < 0.001) for overall malformations and 1.15 (1.10 to 1.21, p < 0.001) for heart defects. Based on mean daily lorazepam-equivalent doses, the adjusted RRs for overall malformations and heart defects were 1.05 (0.99 to 1.12, p = 0.077) and 1.12 (1.04 to 1.21, p = 0.004) for <1 mg/day and 1.26 (1.17 to 1.36, p < 0.001) and 1.31 (1.19 to 1.45, p < 0.001) for >2.5 mg/day doses, respectively, suggesting a dose-response relationship. A small but significant increase in risk for overall and heart defects was detected with several specific agents (range of adjusted RRs: 1.08 to 2.43). The findings were robust across all sensitivity analyses, and negative control analyses revealed a null association. Study limitations include possible exposure misclassification, residual confounding, and restriction to live births.

CONCLUSIONS

In this large nationwide cohort study, we found that first-trimester benzodiazepine exposure was associated with a small increased risk of overall malformations and heart defects, particularly at the higher daily dose. The absolute risks and population attributable fractions were modest. The benefits of benzodiazepines for their major indications must be considered despite the potential risks; if their use is necessary, the lowest effective dosage should be prescribed to minimize the risk.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04856436.

Reloadable Stapler Use during Peripartum Hysterectomy for Placenta Accreta Spectrum: A Novel Surgical Technique and Case Series

OBJECTIVE

This study aimed to describe a novel surgical technique for the management of antenatally suspected placenta accreta spectrum (PAS).

STUDY DESIGN

This is a retrospective, case series of patients with suspected PAS undergoing peripartum hysterectomy with a reloadable articulating stapler at a tertiary care center.

RESULTS

Eighteen patients with antenatally suspected PAS were identified and underwent peripartum hysterectomy with the aid of a reloadable stapler. Mean gestational age at delivery was 34^4/7 ± 1^1/7 weeks. Mean total operative time (skin-to-skin) was 117.3 ± 39.3 minutes, and 79.8 ± 19.8 minutes for the hysterectomy. Mean blood loss for the entire case was 1,809 ± 868 mL. Mean blood loss for the hysterectomy was 431 ± 421 mL. Mean units of intraoperative red blood cells transfused was 3 ± 1 units. Mean units of postoperative red blood cells transfused was 1 ± 0.5 units. Five cases were complicated by urological injury (two intentional cystotomies). Four patients were admitted to the intensive care unit (ICU) for a mean of ≤24 hours. Mean postoperative LOS was 4.11 ± 1.45 days. Three patients had final pathology that did not demonstrate PAS while four were consistent with accreta, six increta, and five percreta.

CONCLUSION

Use of a reloadable articulating stapler device as part of the surgical management of antenatally suspected PAS results in a shorter operative time (117 ± 39 minutes vs. 140-254 minutes previously reported), lower average blood loss (1,809 ± 868 mL vs. 2,500-5,000 mL previously reported) and shorter LOS (4.11 ± 1.45 days vs. 9.8 ± 13.5 days previously reported) compared with traditional cesarean hysterectomy. The reloadable stapling device offers an advantage of more rapidly achieving hemostasis in the surgical management of PAS.

KEY POINTS

· PAS is associated with severe maternal morbidity.. · Decreased operative time and blood loss have many clinical benefits.. · Reloadable stapler use for PAS decreases operative time.. · Reloadable stapler use for PAS decreases operative blood loss..

Discontinuation and re-initiation of antidepressants during pregnancy: A nationwide cohort study

BACKGROUND

Women tend to discontinue antidepressants during pregnancy. We examined the rate of and factors associated with antidepressant discontinuation and re-initiation during pregnancy.

METHODS

We conducted a nationwide cohort study using Korea's healthcare database. The study cohort included women who were aged 15-50 years, gave birth during 2013-2017, had ≥1 depression diagnosis, ≥2 antidepressant prescriptions within 6 months (one within one month of preconception). Cox proportional hazards model was used to evaluate factors associated with antidepressant discontinuation and re-initiation during pregnancy.

RESULTS

Among 5207 pregnancies, 4954 (95.1%) discontinued antidepressants during pregnancy, which included 4657 (89.4%) in the first trimester, 1810 (38.9%) of whom re-initiated them during pregnancy or postpartum period. The risk of antidepressant discontinuation increased in women with substance-related disorders (HR 1.17, 95% CI 1.01-1.35), but decreased in women receiving medical aid (0.53, 0.46-0.62) and patients suggestive of severe depression, such as psychiatric comorbidities and long-term antidepressant use before pregnancy. Antidepressant re-initiation occurred frequently in medical aid recipients (1.25, 1.06-1.47), nulliparous women (1.11, 1.01-1.22), and women with severe symptoms.

CONCLUSIONS

We found high rates of antidepressant discontinuation and re-initiation during pregnancy. Although women suggestive of severe symptoms were less likely to discontinue antidepressants during pregnancy, they were more likely to re-initiate them during their perinatal period, which warrants more detailed guidelines on perinatal depression.

Use of Labor Neuraxial Analgesia for Vaginal Delivery and Severe Maternal Morbidity

Importance

Addressing severe maternal morbidity (SMM) is a public health priority in the US. Use of labor neuraxial analgesia for vaginal delivery is suggested to reduce the risk of postpartum hemorrhage (PPH), the leading cause of preventable severe maternal morbidity.

Objective

To assess the association between the use of labor neuraxial analgesia for vaginal delivery and SMM.

Design, Setting, and Participants

In this population-based cross-sectional study, women aged 15 to 49 years undergoing their first vaginal delivery were included. Data were taken from hospital discharge records from New York between January 2010 and December 2017. Data were analyzed from November 2020 to November 2021.

Exposures

Neuraxial analgesia (ie, epidural or combined spinal-epidural) vs no neuraxial analgesia.

Main Outcomes and Measures

The primary outcome was SMM, as defined by the US Centers for Disease Control and Prevention, and the secondary outcome was PPH. Adjusted odds ratios (aORs) and 95% CIs of SMM associated with neuraxial analgesia were estimated using the inverse propensity score-weighting method and stratified according to race and ethnicity (non-Hispanic White vs racial and ethnic minority women, including non-Hispanic Asian or Pacific Islander, non-Hispanic Black, Hispanic, and other race and ethnicity) and to the comorbidity index for obstetric patients (low-risk vs high-risk women). The proportion of the association of neuraxial analgesia with the risk of SMM mediated through PPH was estimated using mediation analysis.

Results

Of 575 524 included women, the mean (SD) age was 28 (6) years, and 46 065 (8.0%) were non-Hispanic Asian or Pacific Islander, 88 577 (15.4%) were non-Hispanic Black, 104 866 (18.2%) were Hispanic, 258 276 (44.9%) were non-Hispanic White, and 74 534 (13.0%) were other race and ethnicity. A total of 400 346 women (69.6%) were in the low-risk group and 175 178 (30.4%) in the high-risk group, and 272 921 women (47.4%) received neuraxial analgesia. SMM occurred in 7712 women (1.3%), of which 2748 (35.6%) had PPH. Before weighting, the incidence of SMM was 1.3% (3486 of 272 291) with neuraxial analgesia compared with 1.4% (4226 of 302 603) without neuraxial analgesia (risk difference, -0.12 per 100; 95% CI, -0.17 to -0.07). After weighting, the aOR of SMM associated with neuraxial analgesia was 0.86 (95% CI, 0.82-0.90). Decreased risk of SMM associated with neuraxial analgesia was similar between non-Hispanic White women and racial and ethnic minority women and between low-risk and high-risk women. More than one-fifth (21%; 95% CI, 14-28) of the observed association of neuraxial analgesia with the risk of SMM was mediated through the decreased risk of PPH.

Conclusions and Relevance

Findings from this study suggest that use of neuraxial analgesia for vaginal delivery is associated with a 14% decrease in the risk of SMM. Increasing access to and utilization of labor neuraxial analgesia may contribute to improving maternal health outcomes.

A Comprehensive Analysis of the Costs of Severe Maternal Morbidity

INTRODUCTION

The objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases.

METHODS

California linked birth certificate-patient discharge data for 2009 through 2011 (n = 1,262,862) with complete costs and LOS were used in a secondary data analysis. Cost-to-charge ratios were used to estimate costs from charges, adjusting for inflation. Physician payments were estimated from the mean payments for specific diagnosis-related groups. Generalized linear models estimated the association between SMM and costs and LOS.

RESULTS

Excluding readmissions and physician costs, SMM was associated with a 60% increase in hospital costs (marginal effect [ME], $3,550) and a 33% increase in LOS (ME 0.9 days). These increased to 70% (ME $5,806) and 46% (ME 1.3 days) when physician costs and readmissions were included. The effects of SMM were roughly one-half as large for patients who only required a blood transfusion (49% [ME $4,056] and 31% [ME 0.9 days]) as for patients who had another indicator for SMM (93% [ME $7,664] and 62% [ME 1.7 days]).

CONCLUSIONS

Postpartum hospital readmissions and physician costs are important and previously unreported contributors to the costs of SMM. Excess costs and LOS associated with SMM vary considerably by indication. Cost effects were larger than the LOS effects, indicating that SMM increases treatment intensity beyond increasing LOS, and decreasing SMM may have broader health and cost benefits than previously understood.

Disparities in Obstetric Readmissions: A Multistate Analysis, 2007-2014

OBJECTIVE

Hospital readmissions are generally higher among racial-ethnic minorities and patients of lower socioeconomic status. However, this has not been widely studied in obstetrics. The aim of the study is to determine 30-day postpartum readmission rates by patient-level social determinants of health: race ethnicity, primary insurance payer, and median income, independently and as effect modifiers.

STUDY DESIGN

Using state inpatient databases from the health care cost and utilization project from 2007 to 2014, we queried all deliveries. To produce accurate estimates of the effects of parturients' social determinants of health on readmission odds while controlling for confounders, generalized linear mixed models (GLMMs) were used. Additional models were generated with interaction terms to highlight any associations and their effect on the outcome. Adjusted odds ratios (aOR) with 95% confidence intervals are reported.

RESULTS

There were 5,129,867 deliveries with 79,260 (1.5%) 30-day readmissions. Of these, 947 (1.2%) were missing race ethnicity. Black and Hispanic patients were more likely to be readmitted within 30 days of delivery, as compared with White patients (p < 0.001 and p < 0.05, respectively). Patients with government insurance were more likely to be readmitted than those with private insurance (p < 0.001). Patients living in the second quartile of median income were also more likely to be readmitted than those living in other quartiles (p < 0.05). Using GLMMs, we observed that Black patients with Medicare were significantly more likely to get readmitted as compared with White patients with private insurance (aOR 2.78, 95% CI 2.50-3.09, p < 0.001). Similarly, Black patients living in the fourth (richest) quartile of median income were more likely to get readmitted, even when compared with White patients living in the first (poorest) quartile of median income (aOR 1.48, 95% CI 1.40-1.57, p < 0.001).

CONCLUSION

Significant racial-ethnic disparities in obstetric readmissions were observed, particularly in Black patients with government insurance and even in Black patients living in the richest quartile of median income.

KEY POINTS

· Using generalized linear mixed models, we observed significant interactions.. · Government-insured Black patients were 2.78X more likely to be readmitted.. · The wealthiest Black patients were still 1.48X more likely to be readmitted..

Morbidity of late-season influenza during pregnancy

BACKGROUND

In the Northern Hemisphere, influenza season typically starts in December and lasts through March. Pregnant people are at increased risk for influenza-related morbidity and mortality. Potentially, new viral strains or reduced provider suspicion leading to delayed diagnosis of late-season influenza could result in an increased risk of severe infection.

OBJECTIVE

This study aimed to assess the incidence and morbidity associated with late-season influenza in pregnancy, compared with influenza in other seasons.

STUDY DESIGN

This was a retrospective cohort study using the 2007-2018 National Inpatient Sample. Pregnant patients with discharge diagnosis codes consistent with influenza infection were compared on the basis of hospital admission quarter (quarter 1: October to December; quarter 2: January to March; quarter 3: April to June; quarter 4: July to September), with quarter 3 defined as "late-season." The primary outcome was the severe maternal morbidity composite defined by the Centers for Disease Control and Prevention. The secondary outcomes included sepsis, shock, acute renal failure, acute heart failure, temporary tracheostomy, and invasive mechanical ventilation. Associations between outcomes and quarter of infection were adjusted for age, hospitalization type (antepartum, delivery, or postpartum), and comorbid conditions using relative risk regression, weighted to reflect the National Inpatient Sample design.

RESULTS

Of 7355 hospitalizations, corresponding to a weighted national estimate of 36,042, 2266 (30.8%) occurred in quarter 1, 4051 (55.0%) in quarter 2, 633 (8.6%) in quarter 3, and 405 (5.5%) in quarter 4. A nonsignificant trend toward higher rates of severe maternal morbidity was seen in the "late-season" compared with other quarters (13.9% [quarter 3] vs 10.5% [quarter 1] vs 12.1% [quarter 2] vs 13.6% [quarter 4]; P=.07). Moreover, sepsis was more common in patients with late-season influenza (8.0% [quarter 3] vs 4.8% [quarter 1] vs 5.8% [quarter 2] vs 5.9% [quarter 4]; P=.03). In the adjusted analyses, patients with late-season influenza had a 1.34 (95% confidence interval, 1.01-1.78) higher risk of severe maternal morbidity and 1.57 (95% confidence interval, 1.06-2.32) higher risk of sepsis than patients with influenza in quarter 1.

CONCLUSION

Influenza infection between April and June, that is, late-season influenza, is associated with a higher risk of severe maternal morbidity and sepsis in pregnant patients. Obstetrical providers must continue to have awareness and suspicion for influenza infection during these months.

Evaluating adherence to American College of Obstetricians and Gynecologists guidelines at the first obstetric visit

Objective:

This is a prospective observational cohort study with the objective of assessing adherence to the American College of Obstetricians and Gynecologists guidelines regarding the first prenatal visit and determining what patient and provider factors are associated with high adherence in a faculty obstetric clinic at an academic medical center.

Methods:

The American College of Obstetricians and Gynecologists guidelines recommend addressing 72 topics early in prenatal care. A research assistant observed the first prenatal encounter and noted which topics were discussed during the visit. Patient and clinic characteristics were also collected. The primary outcome was the percentage of topics covered at each visit. After analyzing all encounters, patient encounters that scored above the median score were compared with encounters scoring below the median using bivariate comparisons with respect to patient and clinic characteristics. A multivariable Poisson regression model with robust error variance was performed on characteristics with a p value of ⩽0.2.

Results:

Fifty-one patient encounters met inclusion criteria and the median score for topics covered was 74%. Patients with chronic disease were more likely to have a higher percentage of topics covered (odds ratio 1.67, 95% confidence interval: 0.91–3.09). Patients who completed a prenatal questionnaire were also more likely to have a higher percentage (odds ratio 2.28, 95% confidence interval: 1.00–5.15) as well as patients who had nurse-led education integrated into their visit during (odds ratio 1.82, 95% confidence interval: 1.19–2.78). Patient satisfaction had no correlation with the number of topics covered.

Conclusion:

The number of topics to cover at the first prenatal visit has expanded creating challenges for patients and providers. Integration of prenatal questionnaires and nurse-led education has the potential to address gaps in antenatal care.

Can Ensemble Machine Learning Improve the Accuracy of Severe Maternal Morbidity Screening in a Perinatal Database?

BACKGROUND

Severe maternal morbidity (SMM) is an important maternal health indicator, but existing tools to identify SMM have substantial limitations. Our objective was to retrospectively identify true SMM status using ensemble machine learning in a hospital database and to compare machine learning algorithm performance with existing tools for SMM identification.

METHODS

We screened all deliveries occurring at Magee-Womens Hospital, Pittsburgh, PA (2010-2011 and 2013-2017) using the Centers for Disease Control and Prevention list of diagnoses and procedures for SMM, intensive care unit admission, and/or prolonged postpartum length of stay. We performed a detailed medical record review to confirm case status. We trained ensemble machine learning (SuperLearner) algorithms, which "stack" predictions from multiple algorithms to obtain optimal predictions, on 171 SMM cases and 506 non-cases from 2010 to 2011, then evaluated the performance of these algorithms on 160 SMM cases and 337 non-cases from 2013 to 2017.

RESULTS

Some SuperLearner algorithms performed better than existing screening criteria in terms of positive predictive value (0.77 vs. 0.64, respectively) and balanced accuracy (0.99 vs. 0.86, respectively). However, they did not perform as well as the screening criteria in terms of true-positive detection rate (0.008 vs. 0.32, respectively) and performed similarly in terms of negative predictive value. The most important predictor variables were intensive care unit admission and prolonged postpartum length of stay.

CONCLUSIONS

Ensemble machine learning did not globally improve the ascertainment of true SMM cases. Our results suggest that accurate identification of SMM likely will remain a challenge in the absence of a universal definition of SMM or national obstetric surveillance systems.

Trends in and Maternal Outcomes of Delivery Hospitalizations of Patients With an Asthma Diagnosis

OBJECTIVE

To characterize asthma prevalence and outcomes during U.S. delivery hospitalizations.

METHODS

For this repeated cross-sectional analysis, deliveries to women aged 15-54 years with asthma were identified in the 2000-2018 National Inpatient Sample, which approximates a 20% stratified sample of all hospitalizations nationally. Temporal trends in asthma were analyzed using joinpoint regression to estimate the average annual percent change with 95% CIs. The association of asthma with other comorbid conditions was analyzed. The relationship between asthma and several adverse maternal outcomes was analyzed with unadjusted and adjusted logistic regression models, with unadjusted odds ratios and adjusted odds ratios (aORs) as measures of effect. Risk for and trends in a composite of rare, but severe, respiratory complications also were analyzed.

RESULTS

An estimated 73,109,790 delivery hospitalizations from 2000 to 2018 were included in the analysis, of which 2,221,644 (3.0%) had a diagnosis of asthma. (Unweighted, the study sample included 15,213,024 deliveries, of which 462,276 [3.0%] had a diagnosis of asthma.) Asthma diagnoses rose from 1.2% in 2000 to 5.3% in 2018, representing an average annual percent change of 8.3% (95% CI 7.4-9.2%). Asthma was more common among women with obesity and chronic hypertension. In adjusted analyses, asthma was associated with severe maternal morbidity (aOR 1.50, 95% CI 1.45-1.55), preeclampsia and gestational hypertension (aOR 1.29, 95% CI 1.26-1.30), postpartum hemorrhage (aOR 1.21, 95% CI 1.19-1.24), cesarean delivery (aOR 1.16, 95% CI 1.15-1.18), gestational diabetes (aOR 1.20, 95% CI 1.18-1.21), venous thromboembolism (aOR 1.79, 95% CI 1.65-1.95), and preterm delivery (aOR 1.27, 95% CI 1.25-1.29). From 2000 to 2018, severe respiratory complications decreased from 72 per 10,000 deliveries with asthma to 14 per 10,000 deliveries with asthma (average annual percent change -9.4%, 95% CI -13.3% to -5.3%). This decreasing risk was offset on a population level by an increase in the risk of asthma.

CONCLUSION

Asthma is increasing during deliveries, is associated with adverse maternal outcomes, and is associated with comorbid conditions. Severe respiratory complications are decreasing proportionately among deliveries with asthma, but are stable on a population basis.

Pregnancy and posttraumatic stress disorder: associations with infant outcomes and prenatal care utilization

BACKGROUND

Posttraumatic stress disorder (PTSD) affects 3.6-9.7% of women, and has been associated with adverse outcomes in pregnancy; however, associations with prenatal care (PNC) utilization are not clear.

OBJECTIVE

To evaluate associations of PTSD in pregnancy with PNC utilization and adverse infant outcomes in an active-duty military population (a population with universal health insurance).

METHODS

This was a retrospective cohort study of pregnant active-duty service members in Department of Defense Birth and Infant Health Research program data from 2007 to 2014. Administrative medical encounter data were used to define PTSD cases and outcomes of interest. Descriptive statistics and multivariable log-binomial regression compared PNC utilization and adverse infant outcomes (preterm birth, small for gestational age [SGA], major birth defects) among service members with current PTSD (defined as PTSD in the year prior to pregnancy or during pregnancy) to those without current PTSD.

RESULTS

Of the 103,221 singleton live births identified, 1657 (1.6%) were born to active-duty service members diagnosed with current PTSD. Service members with PTSD were more likely to initiate PNC in the first trimester (93.5% vs. 90.2%) and score adequate plus on the Adequacy of Prenatal Care Utilization Index (63.2% vs. 40.0%) compared to service members without PTSD. PTSD case status was not associated with preterm birth, SGA, or major birth defects, regardless of the adjustment set used (fully adjusted RR 0.96, 95% CI 0.82-1.13; RR 1.08, 95% CI 0.79-1.48; and RR 1.03, 95% CI 0.79-1.34, respectively).

CONCLUSION

For pregnant service members with current PTSD, no associations with adverse infant outcomes were noted, and these patients initiated care earlier and had higher PNC utilization scores compared to pregnant service members without current PTSD. Universal health care coverage and utilization of PNC in this population may mitigate adverse pregnancy outcomes observed in civilian populations of patients with PTSD.

Use of interrupted time-series analysis to characterise antibiotic prescription fills across pregnancy: a Norwegian nationwide cohort study

OBJECTIVES

Antibiotics are the most frequently prescribed medications for pregnant and breastfeeding women. We applied interrupted time-series analysis (ITSA) to describe antibiotic prescription fills patterns in pregnant women and examined recurrent antibiotic fills in subsequent pregnancies.

DESIGNS

A population-based drug utilisation study.

SETTING

Norwegian primary care.

PARTICIPANTS

653 058 pregnancies derived from Medical Birth Registry of Norway linked to the Norwegian Prescription Database (2006-2016).

MAIN OUTCOME MEASURE

Proportion of pregnancies exposed to antibiotics aggregated by week in pregnancy time windows.

STATISTICAL ANALYSES

We descriptively analysed antibiotic prescription fills patterns and components in pregnant women. The changes in antibiotic fills in pregnancy time windows were assessed using ITSA. Interruptions points at week 4 to week 7 into pregnancy and delivery were used. Factors associated with antibiotic fills during pregnancy were identified using generalised estimating equations for Poisson regression. Recurrent antibiotic use was estimated using proportion of women who filled antibiotic prescription in a subsequent pregnancy.

RESULTS

Antibiotics were filled in 27.6% pregnancies. The ITSA detected an immediate decrease of 0.07 percentage points (95% CI -0.13 to -0.01) in the proportion of exposed pregnancies at 4 weeks after conception, mainly among women taking folic acid before pregnancy. This proportion increased shortly after delivery (immediate change=1.61 percentage points (95% CI 0.31 to 2.91)) then decreased gradually afterwards (change in slope=-0.19 percentage points, 95% CI -0.34 to -0.05)). The strongest factor associated with antibiotic fills during pregnancy was having recurrent urinary tract infections (adjusted OR=2.65, 95% CI 2.59 to 2.72). Women who had filled antibiotics during a pregnancy were up to three times more likely to fill antibiotics in the subsequent pregnancies.

CONCLUSIONS

ITSA highlighted important impact of pregnancy and delivery on antibiotic fillings. Having antibiotic fills in a pregnancy was associated with recurrent antibiotic fills in subsequent ones.

Comparison of Delivery-Related, Early and Late Postpartum Severe Maternal Morbidity Among Individuals With Commercial Insurance in the US, 2016 to 2017

This cross-sectional study assesses the relative rates and characteristics of early and late postpartum severe maternal morbidity overall and among racial and ethnic groups and individuals with perinatal mood and anxiety disorder.

Hospital Readmission Following Delivery With and Without Severe Maternal Morbidity

Background: The relationship between severe maternal morbidity (SMM) events during inpatient delivery and subsequent hospital readmission is not well understood. Materials and Methods: This was a retrospective cohort study of women with a live inpatient delivery during 2016 recorded in MarketScan® databases for commercially insured and Medicaid populations. Live inpatient births were identified by the International Classification of Diseases, 10th Revision diagnostic and procedural codes, Current Procedural Terminology, and Diagnosis-Related Group codes. The incidence of hospital readmission within 30 days following a delivery discharge, and primary discharge diagnoses, were determined by SMM status. The association with hospital readmission of SMM status, delivery type, gestation type, and maternal age was determined in multivariable logistic regression analyses, adjusted for pregnancy-related complications and preexisting comorbidities. Results: In the Commercial population there were 1,927 hospital readmissions, for an incidence rate of 11.7 per 1,000 discharges. The readmission rate was 12 times greater for women with SMM than for women without SMM during delivery. The most frequent discharge diagnoses among women readmitted were other complications of the puerperium, endometritis, and infection of obstetric surgical wound of women without SMM during delivery. In multivariable analysis, SMM during delivery was strongly associated with readmission in the Commercial population. Results for the Medicaid population were similar. Conclusion: SMM during delivery hospitalization increased the risk of readmission more than 10 times. The most frequent discharge diagnoses following readmission included obstetric infection and endometritis in women without SMM, and eclampsia in women with SMM during delivery. Awareness of these findings could help health care providers prevent future episodes.

Severe Maternal Morbidity and Maternal Mortality in Women With Intellectual and Developmental Disabilities

INTRODUCTION

Despite increased attention on severe maternal morbidity and maternal mortality, scant research exists on adverse maternal outcomes in women with disabilities. This study compares the rates of severe maternal morbidity and maternal mortality in women with and without intellectual and developmental disabilities.

METHODS

This study used 2004-2017 Healthcare Cost and Utilization Project Nationwide Inpatient Sample data. Analyses were conducted in 2019‒2020. The risk of severe maternal morbidity with and without blood transfusion and maternal mortality during delivery among women with and without intellectual and developmental disabilities were compared using modified Poisson regression analysis.

RESULTS

This study identified 32,324 deliveries to women with intellectual and developmental disabilities. Per 10,000 deliveries, 566 deliveries with severe maternal morbidity occurred in women with intellectual and developmental disabilities compared with 239 in women without intellectual and developmental disabilities. Women with intellectual and developmental disabilities had greater risk of both severe maternal morbidity (risk ratio=2.36, 95% CI=2.06, 2.69) and nontransfusion severe maternal morbidity (risk ratio=2.95, 95% CI=2.42, 3.61) in unadjusted analyses, which was mitigated in adjusted analyses for sociodemographic characteristics (risk ratio=1.74, 95% CI=1.47, 2.06; risk ratio=1.85, 95% CI=1.42, 2.41) and the expanded obstetric comorbidity index (risk ratio=1.23, 95% CI=1.04, 1.44; risk ratio=1.31, 95% CI=1.02, 1.68). The unadjusted incidence of maternal mortality in women with intellectual and developmental disabilities was 284 per 100,000 deliveries, nearly 4-fold higher than in women without intellectual and developmental disabilities (69 per 100,000 deliveries; risk ratio=4.07, 95% CI=2.04, 8.12), and the risk remained almost 3-fold higher after adjustment for sociodemographic characteristics (risk ratio=2.86, 95% CI=1.30, 6.29) and the expanded obstetric comorbidity index (risk ratio=2.30, 95% CI=1.05, 5.29).

CONCLUSIONS

Women with intellectual and developmental disabilities are at increased risk of severe maternal morbidity and maternal mortality. These findings underscore the need for enhanced monitoring of the needs and maternal outcomes of women with intellectual and developmental disabilities in efforts to improve maternal health.

Association between antidepressant use in pregnancy and gestational diabetes mellitus: Results from the Norwegian Mother, Father and Child Cohort Study

PURPOSE

This study sought to determine the association between gestational diabetes mellitus (GDM) and antidepressant exposure during early-mid pregnancy, overall and according to antidepressant affinity to the histamine-1 (H₁ ) receptor.

METHODS

Data originate from the nation-wide, Norwegian Mother, Father and Child Cohort Study conducted in 1999-2008, linked to the national Medical Birth Registry. The study included 6647 pregnancies within women with depressive/anxiety disorders during and/or 6 months prior to pregnancy. Pregnancies exposed in early-mid gestation to antidepressants having low (group 1, n = 814) or high (group 2, n = 77) affinity to the H₁ receptor were compared to non-medicated (n = 5756). We fit crude and weighted modified Poisson regression models using inverse probability of treatment weighting (IPTW).

RESULTS

Overall, 84 (1.3%) of the pregnancies developed GDM. Relative to non-medicated pregnancies, the risk of GDM was slightly lower in antidepressant group 1 exposed (1.3% vs 1.1%), but more elevated in those exposed to group 2 antidepressants (3.9%). In the weighted analysis, there was no evidence for an association between antidepressant group 1 exposure in early-mid pregnancy and risk of GDM [relative risk (RR): 0.69, 95% confidence interval: 0.31-1.51].

CONCLUSIONS

Gestational use of antidepressants with low H₁ receptor affinity, mainly SSRIs and SNRIs, does not pose a substantial risk of GDM in women with depressive/anxiety disorders in pregnancy, compared to no use.

Escalating Care on Labor and Delivery

Maternal morbidity and mortality are rising due in part to the rising prevalence of chronic illness, socioeconomic and racial disparities, and advanced maternal age. Prevention of maternal adverse outcomes requires prompt escalation of care to facilities with appropriate capabilities including intensive care services. The development of obstetrical-specific risk assessment tools and protocolized care for the most common causes of maternal intensive care unit (ICU) admission has helped to reduce preventable complications. However, significant work remains to address barriers to the escalation of maternal care and minimize delays in appropriate management.

Development and Validation of an Obstetric Comorbidity Risk Score for Clinical Use

Background: A comorbidity summary score may support early and systematic identification of women at high risk for adverse obstetric outcomes. The objective of this study was to conduct the initial development and validation of an obstetrics comorbidity risk score for automated implementation in the electronic health record (EHR) for clinical use. Methods: The score was developed and validated using EHR data for a retrospective cohort of pregnancies with delivery between 2010 and 2018 at Kaiser Permanente Northern California, an integrated health care system. The outcome used for model development consisted of adverse obstetric events from delivery hospitalization (e.g., eclampsia, hemorrhage, death). Candidate predictors included maternal age, parity, multiple gestation, and any maternal diagnoses assigned in health care encounters in the 12 months before admission for delivery. We used penalized regression for variable selection, logistic regression to fit the model, and internal validation for model evaluation. We also evaluated prenatal model performance at 18 weeks of pregnancy. Results: The development cohort (n = 227,405 pregnancies) had an outcome rate of 3.8% and the validation cohort (n = 41,683) had an outcome rate of 2.9%. Of 276 candidate predictors, 37 were included in the final model. The final model had a validation c-statistic of 0.72 (95% confidence interval [CI] 0.70-0.73). When evaluated at 18 weeks of pregnancy, discrimination was modestly diminished (c-statistic 0.68 [95% CI 0.67-0.70]). Conclusions: The obstetric comorbidity score demonstrated good discrimination for adverse obstetric outcomes. After additional appropriate validation, the score can be automated in the EHR to support early identification of high-risk women and assist efforts to ensure risk-appropriate maternal care.

Common Combinations of Pregestational Diagnosis and Pregnancy Complications

Objective Single pregestational diagnoses have been demonstrated to be associated with pregnancy-related complications. But, the effect of multiple diagnoses is understudied. The objective of this study is to determine the most common combinations of pregestational diagnoses and to determine if specific combinations increase the risk of pregnancy-related complications. Study design We performed a cross-sectional study of the 2016 Healthcare Cost and Utilization Project's National Inpatient Sample (HCUP NIS) database. Inclusion criteria were: Diagnosis-related groups assumed to be associated with delivery, and three or fewer International Classification of Diseases, Tenth Revision (ICD-10), clinical modification codes with a prevalence greater than or equal to 0.5%, or clinically important risk factors in Bateman's co-morbidity index. Chi-squared analysis of combinations of pregestational diagnoses was performed to assess the relative risk of pregnancy-related complications. Results The 2016 database included 255,233 delivered pregnancies. The most common combinations of pregestational diagnoses involved advanced maternal age, prior cesarean delivery, obesity, and tobacco use. Most combinations did not demonstrate an increased risk for complications greater than the risk with a single diagnosis. In those with statistically significant risk, all were 3-fold or less except we noted a 4.4-fold higher risk (95% CI: 3.16-6.15) of preeclampsia in obese patients of advanced maternal age compared to patients who were only of advanced maternal age. Conclusion Our results revealed that common combinations of pregestational diagnoses, in general, do not increase the risk for common pregnancy-related complications greater than the risk with a single diagnosis. This is reassuring, given that women entering pregnancy with multiple co-morbidities are becoming more common.

Association of Epilepsy and Severe Maternal Morbidity

OBJECTIVE

To evaluate severe maternal morbidity (SMM) among patients with epilepsy and patients without epilepsy.

METHODS

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.

RESULTS

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.

CONCLUSION

Severe maternal morbidity was significantly increased in patients with epilepsy, and SMM indicators across all organ systems contributed to this.

Derivation and external validation of risk stratification models for severe maternal morbidity using prenatal encounter diagnosis codes

OBJECTIVE

We sought to develop a prediction model using prenatal diagnosis codes that could help clinicians objectively stratify a women's risk for delivery-related morbidity.

STUDY DESIGN

We performed a prospective cohort study of women delivering at a single academic medical center between 2016 and 2019. Diagnosis codes from outpatient encounters were extracted from the electronic health record. Standard and common machine-learning methods for variable selection were compared. The performance characteristics from the selected model in the training data set-a LASSO model with a lambda that minimized the Bayes information criteria-were compared in a testing and external validation set.

RESULTS

The model identified a group of women, those in the highest decile of predicted risk, who were at a two to threefold increased risk of maternal morbidity.

CONCLUSION

As EHR data becomes more ubiquitous, other data types generated from the prenatal period may improve the model's performance.

Maternal Sepsis: A Review of National and International Guidelines

OBJECTIVE

 Sepsis is a life-threatening syndrome caused by the body's response to infection. The Global Maternal Sepsis Study (GLOSS) suggests sepsis plays a larger role in maternal morbidity and mortality than previously thought. We therefore sought to compare national and international guidelines for maternal sepsis to determine their consistency with each other and the Third International Consensus for Sepsis and Septic Shock (SEPSIS-3).

STUDY DESIGN

 Using Cochrane Database of Systematic Reviews, PubMed, Google Scholar, and organization Web sites, we identified seven guidelines on maternal sepsis in the English language-The American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Society of Obstetric Medicine of Australia and New Zealand, Royal College of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland Institute of Obstetricians and Gynaecologists, and World Health Organization. Guidelines were reviewed to ascertain the commonality and variation, if any, in definitions of maternal sepsis, tools and criteria utilized for diagnosis, obstetric warning systems used, as well as evaluation and management of maternal sepsis. These variables were also compared with SEPSIS-3.

RESULTS

 All guidelines provided definitions consistent with a version of the SEPSIS, although the specific version utilized were varied. Clinical variables and tools employed for diagnosis of maternal sepsis were also varied. Evaluation and management of maternal sepsis and septic shock were similar.

CONCLUSION

 In conclusion, national and international maternal sepsis guidelines were incongruent with each other and SEPSIS-3 in diagnostic criteria and tools but similar in evaluation and management recommendations.

KEY POINTS

· Definitions for maternal sepsis and septic shock are varied.. · Maternal sepsis guidelines differ in proposed criteria and tools.. · Maternal sepsis guidelines have similar management recommendations..

Neighbourhood material deprivation and severe maternal morbidity: a population-based cohort study in Ontario, Canada

OBJECTIVES

Rates of age-associated severe maternal morbidity (SMM) have increased in Canada, and an association with neighbourhood income is well established. Our aim was to examine SMM trends according to neighbourhood material deprivation quintile, and to assess whether neighbourhood deprivation effects are moderated by maternal age.

DESIGN, SETTING AND PARTICIPANTS

A population-based retrospective cohort study using linked administrative databases in Ontario, Canada. We included primiparous women with a live birth or stillbirth at ≥20 weeks' gestational age.

PRIMARY OUTCOME

SMM from pregnancy onset to 42 days postpartum. We calculated SMM rate differences (RD) and rate ratios (RR) by neighbourhood material deprivation quintile for each of four 4-year cohorts from 1 April 2002 to 31 March 2018. Log-binomial multivariable regression adjusted for maternal age, demographic and pregnancy-related variables.

RESULTS

There were 1 048 845 primiparous births during the study period. The overall rate of SMM was 18.0 per 1000 births. SMM rates were elevated for women living in areas with high material deprivation. In the final 4-year cohort, the RD between women living in high vs low deprivation neighbourhoods was 3.91 SMM cases per 1000 births (95% CI: 2.12 to 5.70). This was higher than the difference observed during the first 4-year cohort (RD 2.09, 95% CI: 0.62 to 3.56). SMM remained associated with neighbourhood material deprivation following multivariable adjustment in the pooled sample (RR 1.16, 95% CI: 1.11 to 1.21). There was no evidence of interaction with maternal age.

CONCLUSION

SMM rate increases were more pronounced for primiparous women living in neighbourhoods with high material deprivation compared with those living in low deprivation areas. This raises concerns of a widening social gap in maternal health disparities and highlights an opportunity to focus risk reduction efforts toward disadvantaged women during pregnancy and postpartum.

Development and internal validation of a model predicting severe maternal morbidity using pre-conception and early pregnancy variables: a population-based study in Ontario, Canada

BACKGROUND

Improvement in the prediction and prevention of severe maternal morbidity (SMM) - a range of life-threatening conditions during pregnancy, at delivery or within 42 days postpartum - is a public health priority. Reduction of SMM at a population level would be facilitated by early identification and prediction. We sought to develop and internally validate a model to predict maternal end-organ injury or death using variables routinely collected during pre-pregnancy and the early pregnancy period.

METHODS

We performed a population-based cohort study using linked administrative health data in Ontario, Canada, from April 1, 2006 to March 31, 2014. We included women aged 18-60 years with a livebirth or stillbirth, of which one birth was randomly selected per woman. We constructed a clinical prediction model for the primary composite outcome of any maternal end-organ injury or death, arising between 20 weeks' gestation and 42 days after the birth hospital discharge date. Our model included variables collected from 12 months before estimated conception until 19 weeks' gestation. We developed a separate model for parous women to allow for the inclusion of factors from previous pregnancy(ies).

RESULTS

Of 634,290 women, 1969 experienced the primary composite outcome (3.1 per 1000). Predictive factors in the main model included maternal world region of origin, chronic medical conditions, parity, and obstetrical/perinatal issues - with moderate model discrimination (C-statistic 0.68, 95% CI 0.66-0.69). Among 333,435 parous women, the C-statistic was 0.71 (0.69-0.73) in the model using variables from the current (index) pregnancy as well as pre-pregnancy predictors and variables from any previous pregnancy.

CONCLUSIONS

A combination of factors ascertained early in pregnancy through a basic medical history help to identify women at risk for severe morbidity, who may benefit from targeted preventive and surveillance strategies including appropriate specialty-based antenatal care pathways. Further refinement and external validation of this model are warranted and can support evidence-based improvements in clinical practice.

Evaluating for disparities in prenatal genetic counseling

BACKGROUND

Guidelines recommend that all pregnant women should be offered prenatal genetic counseling, which includes discussions of aneuploidy and carrier screening. Previous studies have demonstrated racial and ethnic disparities in the completion of prenatal genetic testing, but few studies have evaluated for disparities in the offering of these tests. Prenatal genetic screening is a covered provision of Colorado Medicaid. We hypothesized that in the absence of a financial barrier, disparities in prenatal genetic counseling would be eliminated.

OBJECTIVE

To evaluate disparities in prenatal genetic counseling by directly assessing if patients received counseling at the time of their first prenatal visit.

STUDY DESIGN

This retrospective cross-sectional study included patients presenting for their first prenatal visit at <20 weeks' gestation. Patients who completed prenatal genetic testing were classified as counseled, and the remaining patients' medical records were reviewed. Moreover, patients were divided into 2 groups based on their counseling status (yes or no), separately for aneuploidy and carrier screening.

RESULTS

Of 1103 patients who met the inclusion criteria, 97.2% were counseled for aneuploidy screening, whereas 73.3% were counseled on carrier screening. For aneuploidy, younger age, Black race, a relationship status of single, and presentation at a later gestational age were associated with lack of aneuploidy counseling on univariate analysis. After multivariable analysis, only maternal age (odds ratio, 1.09; 95% confidence interval, 1.01-1.19) and gestational age (odds ratio, 0.84; 95% confidence interval, 0.76-0.93) were statistically significantly associated with aneuploidy counseling. Treatment by a physician care team, having a comorbidity score of ≥1, and presenting at a later gestational age were associated with not receiving carrier screening counseling (univariate analysis). Multivariable analysis indicated significant associations with gestational age (odds ratio, 0.90; 95% confidence interval, 0.86-0.94) and having a comorbidity (odds ratio, 0.72; 95% confidence interval, 0.55-0.94).

CONCLUSION

Prenatal genetic counseling was less likely to be provided to women who present for prenatal care at a later gestational age. This finding was of concern because women who are less privileged were more likely to present to prenatal care at a later gestational age. Providing access to early prenatal care and developing specialized care pathways for women entering prenatal care in the second trimester of pregnancy could address disparities in prenatal genetic counseling.

Utilization and Outcomes of Extracorporeal Membrane Oxygenation in Obstetric Patients in the United States, 1999-2014: A Retrospective Cross-Sectional Study

BACKGROUND

Utilization of extracorporeal membrane oxygenation (ECMO) for adult critically ill patients is increasing, but data in obstetric cohorts are scant. This study analyzed ECMO utilization and maternal outcomes in obstetric patients in the United States.

METHODS

Data were abstracted from the 1999-2014 National Inpatient Sample (NIS), a 20% US national representative sample. ECMO hospitalizations (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 39.65) in patients ≥15 years of age were categorized into obstetric ECMO and nonobstetric ECMO. Obstetric patients included 4 categories: (1) loss or termination of pregnancy, (2) delivery (term or preterm), (3) postdelivery hospitalization, and (4) pregnancy without an obstetrical outcome. Possible underlying causes for obstetric ECMO were identified by analysis of ICD-9-CM codes in individual records. In-hospital death was abstracted from the NIS, and ECMO complications were identified using ICD-9-CM algorithms. Statistical significance in time-effect was assessed using weighted regression models.

RESULTS

During the 16-year study period, 20,454 adult ECMO cases were identified, of which 331 occurred in obstetric patients (1.6%; 95% confidence interval [CI], 1.4-1.8). Obstetric ECMO utilization rate was 4.7 per million obstetric discharges (95% CI, 4.2-5.2). The top 3 possible indications were sepsis (22.1%), cardiomyopathy (16.6%), and aspiration pneumonia (9.7%). Obstetric ECMO utilization rate increased significantly during the study period from 1.1 per million obstetric discharges in 1999-2002 (95% CI, 0.6-1.7) to 11.2 in 2011-2014 (95% CI, 9.6-12.9), corresponding to a 144.7% increase per 4-year period (95% CI, 115.3-178.1). Compared with nonobstetric ECMO, obstetric ECMO was associated with decreased in-hospital all-cause mortality (adjusted odds ratio [aOR] 0.78; 95% CI, 0.66-0.93). In-hospital all-cause mortality for obstetric ECMO decreased from 73.7% in 1999-2002 (95% CI, 48.8-90.8) to 31.9% in 2011-2014 (95% CI, 25.2-39.1), corresponding to a 26.1% decrease per 4-year period (95% CI, 10.1-39.3). Compared with nonobstetric ECMO, obstetric ECMO was associated with significantly increased risk of both venous thromboembolism without associated pulmonary embolism (aOR 1.83; 95% CI, 1.06-3.15) and of nontraumatic hemoperitoneum (aOR 4.32; 95% CI, 2.41-7.74).

CONCLUSIONS

During the study period, obstetric ECMO utilization has increased significantly and maternal prognosis improved.

The value of intrapartum factors in predicting maternal morbidity

BACKGROUND

The rates of severe maternal morbidity and mortality in the United States exceed those in other high-income nations. To aid providers and hospitals in recognizing the risk factors, there have been multiple attempts to develop stratification systems for morbidity based on maternal comorbidities. However, most women giving birth are healthy and do not have comorbidities to suggest that they are at an increased risk for severe maternal morbidity. There are small but inherent maternal risks to labor, and the events after admission may further influence a woman's risk for morbidity even for those initially at a low risk.

OBJECTIVE

To determine if the incorporation of intrapartum factors known at the start of the second stage of labor improves the predictive performance of a comorbidity-based risk tool for severe maternal morbidity.

STUDY DESIGN

This is a retrospective cohort study of women at 8 hospitals in a single health system between July 1, 2016, and June 30, 2020. The women had term, singleton gestations and were admitted in labor and reached the second stage. The primary outcome was severe maternal morbidity. We compared logistic regression models using a validated risk-scoring tool (the Expanded Obstetric Comorbidity Score, which uses diagnosis codes for maternal comorbidities and pregnancy characteristics to predict maternal morbidity) with a model that included the Expanded Obstetric Comorbidity Score combined with parity and intrapartum factors. The intrapartum factors included labor induction or augmentation, length of labor, prolonged rupture of membranes, the presence of meconium-stained amniotic fluid, and gestational age. The hospitals were divided into a training (n=4) and testing (n=4) set to evaluate the predictive model performance. Discrimination was assessed by calculating the area under the receiver operating curve and calibration via calibration plots. Similar model comparisons were performed in a subgroup of women, who the Expanded Obstetric Comorbidity Score predicted to be at low risk for morbidity.

RESULTS

This analysis included 33,770 deliveries from the 8 hospitals; severe maternal morbidity occurred in 498 (1.5%) deliveries. The model performance is reported among the testing set (n=15,350). Using the Expanded Obstetric Comorbidity Score alone, the area under the receiver operating curve was 0.676 (95% confidence interval, 0.636-0.716) and 155 (71%) events occurred among individuals above the median predicted risk. When combining intrapartum factors, the area under the receiver operating curve increased to 0.729, (95% confidence interval, 0.693-0.764) and 171 (78%) events occurred among individuals above the median predicted risk. The significant factors that were associated with severe maternal morbidity in this combined model included the Expanded Obstetric Comorbidity Score, length of labor, and the presence of meconium-stained amniotic fluid. The area under the receiver operating curve for the model with intrapartum factors was significantly higher than the models using the Expanded Obstetric Comorbidity Score alone (P<.001).

CONCLUSION

The incorporation of intrapartum factors along with a validated risk tool (Expanded Obstetric Comorbidity Score) improved the ability to predict severe maternal morbidity at the start of the second stage. These findings emphasize the evolution of a woman's risk during her labor course and suggests that the prediction of maternal risk can be improved by considering intrapartum factors.

Obstetrical unit closures and racial and ethnic differences in severe maternal morbidity in the state of New Jersey

BACKGROUND

In the United States, racial disparities in maternal morbidity and mortality are pronounced and persistent. Although the maternal mortality ratio and the severe maternal morbidity rates have increased over the past 30 years, the number of obstetrical units in the country has simultaneously diminished. Black women are 3 times more likely to die during childbirth than White women and twice as likely to suffer severe maternal morbidity (or a near miss). Between 2003 and 2013, 366 (10%) obstetrical units closed, and rural obstetrical unit closures were more likely in the Black communities. The state of New Jersey has the highest Black maternal mortality rate (131.8/100,000 live births) of all states reporting these data. Very few studies have examined the role that urban obstetrical unit closures play in racial and ethnic disparities in maternal health outcomes.

OBJECTIVE

To analyze racial differences in severe maternal morbidity in New Jersey hospitals among women experiencing the loss of their nearest obstetrical unit during the years 2006-2015.

STUDY DESIGN

This study used data on all births in New Jersey hospitals (2006-2015) by women living in ZIP code tabulation areas that lost their nearest obstetrical unit during that period. Severe maternal morbidity was measured using a composite variable for severe illness during hospitalizations (eg, acute heart failure, acute renal disease, disseminated intravascular coagulation, sepsis) identified using the International Classification of Diseases, Ninth Revision. Logistic regression models were used to analyze the associations between race and ethnicity on the individual likelihood of severe maternal morbidity, adjusting for annual trends, individual socioeconomic characteristics, age, preexisting conditions, and delivery hospital characteristics (ie, percentage of Black patients >25% [Black-serving hospital] and percentage of Medicaid discharges in the delivery obstetrical unit).

RESULTS

There were 227,412 delivery hospitalizations among women who lived in the 124 New Jersey ZIP code tabulation areas that lost the nearest obstetrical unit from 2006 to 2015. Black women had the highest severe maternal morbidity rates, increasing from 1.2% in 2006 to 2.3% in 2015. The Black-White gap remained similar in magnitude over the period, as White women's severe maternal morbidity rates increased from 0.7% to 1.4%. However, for Hispanic women, the severe maternal morbidity increased dramatically from 0.7% in 2006 to 2.4% in 2013, followed by a decreasing trend during 2013-2015. When adjusting for individual factors, the odds of severe maternal morbidity among all women was greater if they delivered after the loss of the nearest obstetrical unit (adjusted odds ratio, 1.55; 95% confidence interval, 1.30-1.86). Hispanic women experienced the greatest increase in severe maternal morbidity, regardless of whether they delivered before or after the closure of their nearest obstetrical unit. For all women, delivering in a Black-serving obstetrical unit was associated with a greater likelihood of individual severe maternal morbidity (adjusted odds ratio, 1.36; 95% confidence interval, 1.19-1.56).

CONCLUSION

Racial and ethnic disparities in severe maternal morbidity persist and might be exacerbated by nearby obstetrical unit closures. In New Jersey ZIP codes with obstetrical unit loss, the Hispanic-White gap in the severe maternal morbidity widened substantially, and the rates were also higher among women who delivered in Black-serving hospitals. Policymakers should take steps to prevent obstetrical unit closures and to ensure that the resources available at Black-serving obstetrical units are at least on par with those of other institutions.

Long and short interpregnancy intervals increase severe maternal morbidity

BACKGROUND

Severe maternal morbidity is a composite variable that includes adverse maternal outcomes during pregnancy that are associated with maternal mortality. Previous literature has shown that interpregnancy interval is associated with preterm birth, fetal growth restriction, and low birthweight, but the association of interpregnancy interval and composite severe maternal morbidity is not well studied.

OBJECTIVE

We sought to determine the relationship between interpregnancy interval (stratified as <6, 6-11, 12-17, 18-23, 24-59, and ≥60 months) and severe maternal morbidity, which we considered both with and without blood transfusion.

STUDY DESIGN

This was a retrospective cohort study of multiparous women 15 to 54 years old with singleton, nonanomalous births between 23 and 42 weeks gestation in California (2007-2012). We defined severe maternal morbidity as the composite score of a published list of the International Classification of Diseases, ninth Revision, diagnoses and procedure codes, provided by the Centers for Disease Control and Prevention. We used chi-square tests for categorical variables, and multivariable logistic regression models were used to determine the association of interpregnancy interval (independent variable) with severe maternal morbidity (dependent variable), adjusted for maternal race and ethnicity, age, education, body mass index, insurance, prenatal care, smoking status, and maternal comorbidity index score.

RESULTS

Here, 1,669,912 women met the inclusion criteria, and of these women, 14,529 (0.87%) had severe maternal morbidity and 4712 (0.28%) had nontransfusion severe maternal morbidity. Multivariable logistic regression models showed that compared with women with 18 to 23 months interpregnancy interval, women with an interpregnancy interval of <6 months (adjusted odds ratio, 1.23; 95% confidence interval, 1.14-1.34) and ≥60 months (adjusted odds ratio, 1.11; 95% confidence interval, 1.04-1.19) had significantly higher adjusted odds of severe maternal morbidity. The odds of nontransfusion severe maternal morbidity is higher in women with long interpregnancy intervals (≥60 months) after controlling for the same potential confounders (adjusted odds ratio, 1.17, 95% confidence interval, 1.04-1.31). In addition, we found significantly higher odds of requiring ventilation (adjusted odds ratio, 1.34; 95% confidence interval, 1.03-1.75) and maternal sepsis (adjusted odds ratio, 2.08; 95% confidence interval, 1.31-3.31) in women with long interpregnancy interval.

CONCLUSION

The risk of severe maternal morbidity was higher in women with short interpregnancy interval (<6 months) and long interpregnancy interval (≥60 months) compared with women with normal interpregnancy interval (18-23 months). The risk of nontransfusion severe maternal morbidity was significantly higher in women with long interpregnancy interval (≥60 months). Interpregnancy interval is a modifiable risk factor, and counseling women to have an adequate gap between pregnancies may be an important strategy to decrease the risk of severe maternal morbidity.

Hospital Quality of Care and Racial and Ethnic Disparities in Unexpected Newborn Complications

OBJECTIVES

To investigate racial and ethnic differences in unexpected, term newborn morbidity and the influence of hospital quality on disparities.

METHODS

We used 2010-2014 birth certificate and discharge abstract data from 40 New York City hospitals in a retrospective cohort study of 483 834 low-risk (term, singleton, birth weight ≥2500 g, without preexisting fetal conditions) neonates. We classified morbidity according to The Joint Commission's unexpected newborn complications metric and used multivariable logistic regression to compare morbidity risk among racial and ethnic groups. We generated risk-standardized complication rates for each hospital using mixed-effects logistic regression to evaluate quality, ranked hospitals on this measure, and assessed differences in the racial and ethnic distribution of births across facilities.

RESULTS

The unexpected complications rate was 48.0 per 1000 births. Adjusted for patient characteristics, morbidity risk was higher among Black and Hispanic infants compared with white infants (odds ratio: 1.5 [95% confidence interval 1.3-1.9]; odds ratio: 1.2 [95% confidence interval 1.1-1.4], respectively). Among the 40 hospitals, risk-standardized complications ranged from 25.3 to 162.8 per 1000 births. One-third of Black and Hispanic women gave birth in hospitals ranking in the highest-morbidity tertile, compared with 10% of white and Asian American women (P < .001).

CONCLUSIONS

Black and Hispanic women were more likely to deliver in hospitals with high complication rates than were white or Asian American women. Findings implicate hospital quality in contributing to preventable newborn health disparities among low-risk, term births. Quality improvement targeting routine obstetric and neonatal care is critical for equity in perinatal outcomes.

Severe Maternal Morbidity: A Comparison of Definitions and Data Sources

Severe maternal morbidity (SMM) is a composite outcome measure that indicates serious, potentially life-threatening maternal health problems. There is great interest in defining SMM using administrative data for surveillance and research. In the United States, one common way of defining SMM at the population level is an index developed by the Centers for Disease Control and Prevention. Modifications to this index (e.g., exclusion of maternal blood transfusion) have been proposed; some research defines SMM using an index introduced by Bateman et al. (Obstet Gynecol. 2013;122(5):957-965). Birth certificate data are also increasingly being used to define SMM. We compared commonly used US definitions of SMM among all California births (2007-2012) using the kappa (κ) statistic and other measures. We also evaluated agreement between maternal morbidity fields on the birth certificate as compared with health insurance claims data. Concordance between the 7 definitions of SMM analyzed was generally low (i.e., κ < 0.41 for 13 of 21 two-way comparisons). Low concordance was particularly driven by the presence/absence of transfusion and claims data versus birth certificate definitions. Low agreement between administrative data-based definitions of SMM highlights that results can be expected to differ between them. Further research on validity of SMM definitions, using more fine-grained data sources, is needed.

Validation of Postpartum Hemorrhage Admission Risk Factor Stratification in a Large Obstetrics Population

OBJECTIVE

This study aimed to evaluate the performance of the California Maternal Quality Care Collaborative (CMQCC) admission risk criteria for stratifying postpartum hemorrhage risk in a large obstetrics population.

STUDY DESIGN

Using detailed electronic health record data, we classified 261,964 delivery hospitalizations from Kaiser Permanente Northern California hospitals between 2010 and 2017 into high-, medium-, and low-risk groups based on CMQCC criteria. We used logistic regression to assess associations between CMQCC risk groups and postpartum hemorrhage using two different postpartum hemorrhage definitions, standard postpartum hemorrhage (blood loss ≥1,000 mL) and severe postpartum hemorrhage (based on transfusion, laboratory, and blood loss data). Among the low-risk group, we also evaluated associations between additional present-on-admission factors and severe postpartum hemorrhage.

RESULTS

Using the standard definition, postpartum hemorrhage occurred in approximately 5% of hospitalizations (n = 13,479), with a rate of 3.2, 10.5, and 10.2% in the low-, medium-, and high-risk groups. Severe postpartum hemorrhage occurred in 824 hospitalizations (0.3%), with a rate of 0.2, 0.5, and 1.3% in the low-, medium-, and high-risk groups. For either definition, the odds of postpartum hemorrhage were significantly higher in medium- and high-risk groups compared with the low-risk group. Over 40% of postpartum hemorrhages occurred in hospitalizations that were classified as low risk. Among the low-risk group, risk factors including hypertension and diabetes were associated with higher odds of severe postpartum hemorrhage.

CONCLUSION

We found that the CMQCC admission risk assessment criteria stratified women by increasing rates of severe postpartum hemorrhage in our sample, which enables early preparation for many postpartum hemorrhages. However, the CMQCC risk factors missed a substantial proportion of postpartum hemorrhages. Efforts to improve postpartum hemorrhage risk assessment using present-on-admission risk factors should consider inclusion of other nonobstetrical factors.

Delivery risks and outcomes associated with grand multiparity

BACKGROUND

There is limited recent US national data on risk for adverse outcomes associated with grand multiparity.

OBJECTIVE

To examine the association between grand multiparity and severe maternal morbidity (SMM) and other adverse outcomes during delivery hospitalizations in the United States.

METHODS

This repeat cross-sectional study evaluated delivery hospitalizations from 2000 through the third quarter of 2015 to women aged 15-54 in the National (Nationwide) Inpatient Sample database. Temporal trends in deliveries to women with grand multiparity were analyzed using the Cochran-Armitage trend test. The primary outcome studied was SMM, a composite of adverse outcomes defined by the Centers for Disease Control and Prevention. The exposure of interest was grand multiparity diagnosis during delivery hospitalization. Other adverse outcomes analyzed included placental abruption, preterm delivery, postpartum hemorrhage, disseminated intravascular coagulation, shock, hysterectomy, pulmonary edema and acute heart failure, transfusion of blood or blood products, hypertensive diseases of pregnancy, cesarean delivery, eclampsia, and acute renal failure. Log linear regression models were performed to determine the relationship between grand multiparity and adverse outcomes with measures of association demonstrated as unadjusted (RR) and adjusted risk ratios (aRR) with 95%CIs.

RESULTS

From 2000 to 2015, there were an estimated 62,672,862 hospital deliveries with 386,019 deliveries in the setting of grand multiparity. The number of deliveries with a grand multiparity diagnosis increased over the study period from 4.2 per 1000 deliveries in 2000 to 8.6 per 1000 in 2015 (p < .01). Women with grand multiparity were more likely to be older, have comorbidities, be Hispanic or non-Hispanic Black, be from a lower ZIP code income quartile, have Medicaid insurance, and present to an urban teaching hospital for delivery (p < .01 for all). On univariable analysis, grand multiparity was associated with SMM (RR 1.27, 95%CI 1.23-1.32). However, in adjusted analyses accounting for hospital, clinical, and demographic factors, women with grand multiparity were at lower risk of SMM (aRR 0.93, 95%CI 0.89, 0.96). On analysis of individual adverse outcomes, grand multiparity was associated with a higher risk of placental abruption (RR 1.28, 95%CI 1.24-1.31), preterm delivery (RR 1.17, 95%CI 1.16-1.18), postpartum hemorrhage (RR 1.30, 95%CI 1.28-1.32), disseminated intravascular coagulation (RR 1.23, 95%CI 1.16-1.31), shock (RR 2.50, 95%CI 2.20-2.85), hysterectomy (RR 3.20, 95%CI 3.30, 3.41), pulmonary edema and acute heart failure (RR 1.33, 95%CI 1.24-1.42), and transfusion of blood or blood products (RR 1.74, 95%CI 1.70-1.79). Conversely, grand multiparity was associated with a lower risk of hypertensive diseases of pregnancy (RR 0.85, 95%CI 0.84-0.86), cesarean delivery (RR 0.96, 95%CI 0.95-0.96), and eclampsia (RR 0.69, 95%CI 0.60-0.79). There was no significant association between grand multiparity and acute renal failure.

CONCLUSIONS

Delivery hospitalizations with a grand multiparity diagnosis were not associated with increased risk for SMM in adjusted analysis. Grand multiparity was associated with increased risk for hysterectomy and shock although absolute increased risk for these complications was small.

Perinatal use of triptans and other drugs for migraine-A nationwide drug utilization study

OBJECTIVE

To characterize nationwide utilization patterns of migraine pharmacotherapy before, during, and after pregnancy in women with triptan use.

METHODS

Population-based data were obtained by linking the Medical Birth Registry of Norway and the Norwegian Prescription Database from 2006 to 2017. We included 22,940 pregnancies among 19,669 women with at least one filled triptan prescription, a proxy for migraine, in the year before pregnancy or during pregnancy. The population was classified into four groups: i) continuers; ii) discontinuers; iii) initiators, and vi) post-partum re-initiators. Participant characteristics and prescription fills for other drugs such as analgesics, antinauseants, and preventive drugs among the groups were examined, along with an array of triptan utilization parameters.

RESULTS

In total, 20.0% of the women were classified as triptan continuers, 54.1% as discontinuers, 8.0% as initiators, and 17.6% as re-initiators. Extended use of triptans (≥15 daily drug doses/month) occurred among 6.9% of the continuers in the first trimester. The top 10% of triptan continuers and initiators accounted for 41% (95% CI: 39.2% - 42.5%) and 33% (95% CI: 30.3% - 35.8%) of the triptan volume, respectively. Triptan continuers and initiators had similar patterns of acute co-medication during pregnancy, but use of preventive drugs was more common among the continuers before, during, and after pregnancy.

CONCLUSION

Among women using triptans before and during pregnancy, one in four continued triptan treatment during pregnancy, and extended triptan use was relatively low. Triptan discontinuation during and in the year after pregnancy was common. Use of other acute migraine treatments was higher among both continuers and initiators of triptans. Women using preventive migraine treatment were most commonly triptan continuers and re-initiators after pregnancy. Prescribing to and counseling of women with migraine should be tailored to the condition severity and their information needs to promote optimal migraine management in pregnancy.

Patterns of Use of a Price Transparency Tool for Childbirth Among Pregnant Individuals With Commercial Insurance

IMPORTANCE

When introduced a decade ago, patient-facing price transparency tools had low use rates and were largely not associated with changes in spending. Little is known about how such tools are used by pregnant individuals in anticipation of childbirth, a shoppable service with increasing out-of-pocket spending.

OBJECTIVE

To measure changes over time in the patterns and characteristics of use of a price transparency tool by pregnant individuals, and to identify the association between price transparency tool use, coinsurance, and childbirth spending.

DESIGN, SETTING, AND PARTICIPANTS

This descriptive cross-sectional study of 2 cohorts used data from a US commercial health insurance company that launched a web-based price transparency tool in 2010. Data on all price transparency tool queries for 2 periods (January 1, 2011, to December 31, 2012, and January 1, 2015, to December 31, 2016) were obtained. The sample included enrollees aged 19 to 45 years who had a delivery episode during 2 periods (November 1, 2011, to December 31, 2012, or November 1, 2015, to December 31, 2016) and were continuously enrolled for the 10 months prior to delivery (N = 253 606).

EXPOSURES

Access to a web-based price transparency tool that provided individualized out-of-pocket price estimates for vaginal and cesarean deliveries.

MAIN OUTCOMES AND MEASURES

The primary outcomes were searches on the price transparency tool by delivery mode (vaginal or cesarean), timing (first, second, or third trimester), and individual characteristics (age at childbirth, rurality, pregnancy risk status, coinsurance exposure, area educational attainment, and area median household income). Another outcome was the association of out-of-pocket childbirth spending with price transparency tool use.

RESULTS

The sample included 253 606 pregnant individuals, of whom 131 224 (51.7%) were in the 2011 to 2012 cohort and 122 382 (48.3%) were in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, the mean (SD) age was 31 years (5.2 years) and most individuals had coinsurance for delivery (94 251 [77.0%]). Price searching increased from 5.9% in the 2011 to 2012 cohort to 13.0% in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, 43.9% of searchers' first price query was in their first trimester. The adjusted probability of searching was lower for individuals with a high-risk pregnancy due to a previous cesarean delivery (11.5%; 95% CI, 11.0%-12.1%) vs individuals with low-risk pregnancy (13.4%; 95% CI, 12.9%-14.0%). Use increased monotonically with coinsurance, from 9.2% (95% CI, 8.7%-9.8%) among individuals with no coinsurance to 15.0% (95% CI, 14.4%-15.5%) among individuals with 11% or higher coinsurance. After adjusting for covariates, searching was positively associated with out-of-pocket delivery episode spending. Among patients with 11% coinsurance or higher, early and late searchers spent more out of pocket ($59.57 [95% CI, $33.44-$85.96] and $73.33 [95% CI, $32.04-$115.29], respectively), compared with never searchers.

CONCLUSIONS AND RELEVANCE

The results of this cross-sectional study indicate that the proportion of pregnant individuals who sought price information before childbirth more than doubled within the first 6 years of availability of a price transparency tool. These findings suggest that price information may help individuals anticipate their out-of-pocket childbirth costs.

Evaluation of a telemedicine program managing high-risk pregnant women with pre-existing diabetes in Arkansas's Medicaid program

OBJECTIVE

We aim to evaluate the effects of the telemedicine program, High-Risk Pregnancy Program at University of Arkansas for Medical Sciences (UAMS), on health services utilization and medical expenditures among pregnant women with pre-existing diabetes and their newborns.

RESEARCH DESIGN AND METHODS

The study sample was selected from the Arkansas Medicaid claims linked to infant birth/death certificates and UAMS telemedicine records from 2013 through 2016. We used propensity score matching based on participants' characteristics to create three groups - UAMS telemedicine care, UAMS in-person care, and non-UAMS prenatal care. We compared inpatient and outpatient care services, medication use and caesarean section rates, severe maternal morbidity, infant mortality and preterm birth rates and medical expenditures.

RESULTS

The UAMS telemedicine group had fewer inpatient admissions (1.18 vs 1.31; 95% CI: -0.27, 0.00), lower insulin use rates (41.86% vs 59.88%; 95% CI: -29.00%, -7.05%) and lower maternal care expenditures ($7,846 vs $10,644; 95% CI: -$4,089, -$1,507) compared with the UAMS in-person care group. Women receiving UAMS telemedicine had more prenatal care visits (10.45 vs 8.57; 95% CI: -2.96, -0.81), higher insulin use rates (41.86% vs 26.74%: 95% CI: 4.63%, 25.60%) and similar maternal care expenditures ($7,846 vs $7,051), compared with those receiving non-UAMS in-person care. Caesarean section, severe maternal morbidity, and infant mortality rates were similar across the three groups.

CONCLUSION

UAMS telemedicine was associated with improved utilization of prenatal care among pregnant women with pre-existing diabetes. Telemedicine services did not differ from usual in-person services in clinical outcomes and medical expenditures.

Racial and Ethnic Disparities in Death Associated With Severe Maternal Morbidity in the United States: Failure to Rescue

OBJECTIVE

To analyze racial and ethnic disparities in failure to rescue (ie, death) associated with severe maternal morbidity and describe temporal trends.

METHODS

This was a retrospective cohort study using administrative data. Data for delivery hospitalizations with severe maternal morbidity, as defined by the Centers for Disease Control and Prevention, were abstracted from the 1999-2017 National Inpatient Sample. Race and ethnicity were categorized into non-Hispanic White (reference), non-Hispanic Black, Hispanic, other, and missing. The outcome was failure to rescue from severe maternal morbidity. Disparities were assessed using the failure-to-rescue rate ratio (ratio of the failure-to-rescue rate in the racial and minority group to the failure-to-rescue rate in White women), adjusted for patient and hospital characteristics. Temporal trends in severe maternal morbidity and failure to rescue were assessed.

RESULTS

During the study period, 73,934,559 delivery hospitalizations were identified, including 993,864 with severe maternal morbidity (13.4/1,000; 95% CI 13.3-13.5). Among women with severe maternal morbidity, 4,328 died (4.3/1,000; 95% CI 4.2-4.5). The adjusted failure-to-rescue rate ratio was 1.79 (95% CI 1.77-1.81) for Black women, 1.39 (95% CI 1.37-1.41) for women of other race and ethnicity, 1.43 (95% CI 1.42-1.45) for women with missing race and ethnicity data, and 1.08 (95% CI 1.06-1.09) for Hispanic women. During the study period, the severe maternal morbidity rate increased significantly in each of the five racial and ethnic groups but started declining in 2012. Meanwhile, the failure-to-rescue rate decreased significantly during the entire study period.

CONCLUSION

Despite improvement over time, failure to rescue from severe maternal morbidity remains a major contributing factor to excess maternal mortality in racial and ethnic minority women.

The prediction of morbidity related to vaginal delivery in nulliparous women - A secondary analysis from the genesis multicenter trial

OBJECTIVE

In the prospective multicenter Genesis study, we developed a prediction model for Cesarean delivery (CD) in term nulliparous women. The objective of this secondary analysis was to determine whether the Genesis model has the potential to predict maternal and neonatal morbidity associated with vaginal delivery.

STUDY DESIGN

The national prospective Genesis trial recruited 2,336 nulliparous women with a vertex presentation between 39 + 0- and 40 + 6-weeks' gestation from seven tertiary centers. The prediction model used five parameters to assess the risk of CD: maternal age, maternal height, body mass index, fetal head circumference and fetal abdominal circumference. Simple and multiple logistic regression analyses were used to develop the Genesis model. The risk score calculated using this model were correlated with maternal and neonatal morbidity in women who delivered vaginally: postpartum hemorrhage (PPH), obstetric anal sphincter injury (OASI), shoulder dystocia, one- and five-minute Apgar score ≤ 7, neonatal intensive care (NICU) admission, cephalohematoma, fetal laceration, nerve palsy and fractures. The morbidities associated with spontaneous vaginal delivery were compared with those associated with operative vaginal delivery (OVD). The likelihood ratios for composite morbidity and the morbidity associated with OVD based on the Genesis risk scores were also calculated.

RESULTS

A total of 1,845 (79%) nulliparous women had a vaginal delivery. A trend of increasing intervention and morbidity was observed with increasing Genesis risk score, including OVD (p < 0.001), PPH (p < 0.008), NICU admission (p < 0.001), low Apgar score at one-minute (p < 0.001) and OASI (p = 0.009). The morbidity associated with OVD was significantly higher compared to spontaneous vaginal delivery, including NICU admission (p < 0.001), PPH (p = 0.022), birth injury (p < 0.001), shoulder dystocia (p = 0.002) and Apgar score of<7 at one-minute (p < 0.001). The positive likelihood ratios for composite outcomes (where the OVD was excluded) increases with increasing risk score from 1.005 at risk score of 5% to 2.507 for risk score of>50%.

CONCLUSION

In women who ultimately achieved a vaginal birth, we have shown more maternal and neonatal morbidity in the setting of a Genesis nomogram-determined high-risk score for intrapartum CD. Therefore, the Genesis prediction tool also has the potential to predict a more morbid vaginal delivery.