Trends in Maternal Mortality and Severe Maternal Morbidity During Delivery-Related Hospitalizations in the United States, 2008 to 2021

Postpartum Health Disparities During the Birth Hospitalization in the United States: A Scoping Review

BACKGROUND

Despite over 50% of maternal deaths occurring during the postpartum period, with significant disparities for structurally marginalized people, this is an understudied period in the reproductive life course. This review aims to describe the scope of the literature on postpartum health disparities during the birth hospitalization.

METHODS

We searched five databases (MEDLINE®, Embase, CINAHL, Web of Science, and PsychInfo) for primary research studies in the USA in English that measured a postpartum maternal outcome during the birth hospitalization and compared the outcome across at least two groups. We excluded studies that solely examined maternal mortality or severe maternal morbidity, gray literature, and review articles. We extracted data using the National Institute for Minority Health and Health Disparities (NIMHD) Research and PROGRESS-Plus Frameworks.

RESULTS

We extracted data from the 22 studies that met inclusion criteria. All studies identified a disparity. The most commonly reported PROGRESS-Plus individual characteristic was race. No studies reported occupation, parental/maternity leave, disability, gender identity, sexual orientation, culture, acculturation, religion, social capital, or social support. Postpartum outcomes and variables explored for association with those outcomes were predominantly at the individual and interpersonal levels, with limited to no examination at the community, health system, and societal level.

CONCLUSION

There is a critical gap in the literature on postpartum health disparities during the birth hospitalization. Knowledge gained from this review can guide perinatal clinicians and researchers in expanding their approach to addressing postpartum health disparities using intersectional axes of identity, socioeconomic status, and structural barriers.

Physical Assault During the Perinatal Period by Disability Status and Racial/Ethnic Background

Physical assault of women at the intersection of race/ethnicity and physical disability is not well studied. This study seeks to assess the prevalence of physical assault-related emergency department or hospital visits among women with physical disabilities during different stages of the perinatal period, stratified by racial/ethnic background. This study used 1998-2020 data from the Massachusetts Pregnancy to Early Life Longitudinal Data System. Unique singleton deliveries were classified into 10 cohorts by combining maternal physical disability status (yes/no) and racial/ethnic background (White, Black, Latinx, Asian/Pacific Islander [API], and American Indian/Alaska Native [AIAN]); nondisabled White mothers served as referent. Outcomes assessed were the presence of assaults up to 1 year before conception, during pregnancy, and up to 1 year postpartum. Compared to nondisabled White mothers, Black, Latinx, and AIAN mothers with physical disabilities were at the highest risk and experienced 16.0, 12.0, and 12.0 times the risk, respectively, of preconception assault; 15.3, 12.7, and 11.6 times the risk of prenatal assault; and 9.0, 8.2, and 9.3 times the risk of postpartum assault (p < .001 for all risk ratios). Adjusting for sociodemographic differences between groups reduced the magnitude of disparities, but Black, Latinx, and AIAN mothers with physical disabilities remained at greatest risk among all cohorts. Women with physical disabilities from minoritized racial/ethnic backgrounds experienced compounded risk of perinatal violence, with risks exceeding those of nondisabled women in the same racial/ethnic groups as well as White women with physical disabilities. Violence against women with physical disabilities, especially during pregnancy, is a major and ongoing public health crisis. Urgent needs include screening and outreach efforts to Black, Latinx, and AIAN mothers with physical disabilities.

The Interplay of Dietary Choline and Methyl Donors in Modulating Maternal Inflammation: Insights from Project Viva

BACKGROUND

Inflammation during pregnancy is an important contributor to maternal and offspring morbidity and mortality. Evidence from both nonpregnant human and animal studies suggests that dietary choline can attenuate inflammation, but this has not yet been explored in human pregnancy.

OBJECTIVES

This study explored the cross-sectional associations between maternal mid-pregnancy dietary choline intake and inflammation biomarkers, specifically IL-6, tumor necrosis factor- α (TNF-α), and C-reactive protein (CRP), while also examining the modifying effects of other methyl donor nutrients.

METHODS

We analyzed data from 640 pregnant women enrolled in Project Viva, a longitudinal cohort study in Eastern Massachusetts. We assessed mid-pregnancy maternal dietary intake via a semiquantitative food frequency questionnaire, and measured inflammatory markers in maternal blood collected concurrently, namely IL-6, TNF-α, and CRP. We employed censored and linear regression models to assess associations of z-scored choline intake with log-transformed inflammatory markers and assessed potential interactions between choline intake and intakes of other methyl donor nutrients. We assessed unadjusted models and models adjusted for sociodemographic and dietary covariates.

RESULTS

We found no main effect of choline intake with IL-6, TNF-α, or CRP levels [for example, for IL-6, β = -0.02 pg/mL, 95% confidence interval (CI): -0.08, 0.05]. However, an interaction term demonstrated that greater combined intake of choline and other methyl donor nutrients was related to lower IL-6 (for example, for betaine, β interaction =-0.08 pg/mL, 95% CI: -0.14, -0.02). We did not observe similar interaction effects or TNF-α or CRP.

CONCLUSIONS

These findings highlight the interplay between choline and other dietary methyl donors in modulating inflammation status during pregnancy, specifically through IL-6. Higher intake of methyl donor nutrients may be necessary for any anti-inflammatory effects of choline, although further studies in this area are warranted.

Improving Maternal Postpartum Access to Care through Telemedicine (IMPACT): A multi-center randomized controlled trial of postpartum interventions to improve access and outcome

BACKGROUND

Postpartum care is essential for maternal health and significantly impacts long-term health outcomes, yet it remains inadequately addressed, particularly among Non-Hispanic Black and Hispanic individuals. The primary objective of the Improving Maternal Postpartum Access to Care through Telemedicine (IMPACT) study is to compare the effectiveness of two postpartum care models on early postpartum complication detection, hospital readmission prevention, postpartum health knowledge, quality of life, and chronic medical condition management among medically underserved individuals.

METHOD

The IMPACT study is a multi-center, randomized controlled trial conducted at Parkland Hospital in Dallas, Texas, and Grady Memorial Hospital in Atlanta, Georgia. It aims to compare two postpartum care models (intensive education vs. enhanced virtual care) among 3500 Non-Hispanic Black and Hispanic postpartum individuals of lower socioeconomic status. Phase I (year 1) involves collecting baseline data and refining the study based on patient feedback. Phase II (year 2-4) continues recruiting participants and assigns them to each model randomly. Data collection spans a one-year follow-up period (1 week, 6 weeks, 3 months, 6 months, and 1 year after enrollment), including maternal health outcomes, mental health assessments, laboratory tests, and patient-reported measures.

CONCLUSION

The IMPACT study provides an innovative approach to postpartum care, utilizing telemedicine to enhance access and education for underserved populations. The study findings will have significant implications for healthcare providers and policymakers, offering evidence-based guidance for optimizing postpartum care delivery and informing clinical guidelines that can help reduce maternal health disparities.

Postpartum Hemorrhagic Morbidity with Scheduled versus Unscheduled Cesarean Delivery at Term

This study aimed to compare the composite maternal hemorrhagic outcomes (CMHOs) among term (≥37 weeks) singletons who had scheduled versus unscheduled cesarean deliveries (CDs). A subgroup analysis was done for those without prior uterine surgeries.Retrospectively, we identified all singletons at term who had CDs. The unscheduled CDs included individuals admitted with a plan for vaginal delivery with at least 1 hour of attempted labor. CMHOs included any of the following: estimated blood loss of ≥1,000 mL, use of uterotonics (excluding prophylactic oxytocin) or Bakri balloon, surgical management of hemorrhage, blood transfusion, hysterectomy, thromboembolism, admission to intensive care unit, or maternal death. Multivariable Poisson regression models with robust error variance were used to estimate adjusted relative risks (aRRs) with 95% confidence intervals (CIs).Of 8,623 deliveries in the study period, 2,691 (31.2%) had CDs at term, with 1,709 (67.3%) scheduled CDs, and 983 (36.5%) unscheduled CDs. Overall, the rate of CMHO was 23.3%, and the rate of blood transfusion was 4.1%. CMHOs were two-fold higher among unscheduled (34.5%) than scheduled CDs (16.9%; aRR = 2.18; 95% CI: 1.81-2.63). The aRRs for blood transfusion and surgical interventions to manage postpartum hemorrhage were three times higher with unscheduled than scheduled CDs. The subgroup analysis indicated that among the cohorts without prior uterine surgery, the rate of the CMHOs was significantly higher when the CD was unscheduled versus scheduled (aRR = 1.85; 95% CI: 1.45-2.37).Compared to scheduled CDs, the composite hemorrhagic adverse outcomes were significantly higher with unscheduled CDs. · Unscheduled cesareans are at higher risk of hemorrhage.. · Unscheduled cesareans are at higher risk of transfusion.. · Atony treatment is higher in unscheduled cesareans..

Algorithm to Identify Type 2 Diabetes Using Electronic Health Record and Self-Reported Data

Aims: Identifying participants with type 2 diabetes (T2D) based only on electronic health record (EHR) or self-reported data has limited accuracy. Therefore, the objective of the study was to develop an algorithm using EHR and self-reported data to identify participants with and without T2D. Methods: We included participants enrolled in the Mayo Clinic Biobank. At enrollment, participants completed a baseline questionnaire on health conditions, including T2D, and provided access to their EHR data. T2D status was based on self-report and EHR data (International Classification of Diseases codes, hemoglobin A1c [HbA1c], plasma glucose, and glucose-regulating medications) within 5 years prior to and 2 months after enrollment. Participants who self-reported T2D but lacked corroborating EHR data were categorized separately ("only self-reported T2D"). After identifying participants with T2D, we identified participants without T2D based on normal HbA1c and plasma glucose. Participants who self-reported the absence of T2D but lacked corroborating EHR data were categorized separately ("only self-reported no T2D"). Using manual chart reviews (gold standard), we calculated the positive and negative predictive values (NPV) to identify T2D. Results: Of 57,000 participants, the algorithm classified participants as having T2D (n = 6,238), no T2D (n = 38,883), "only self-reported T2D" (n = 757), and "only self-reported no-T2D" (n = 9,759). The algorithm had a high positive predictive value (96.0% [91.5%-98.5%]), NPV (100% [98.0%-100%]), and accuracy (99.5% [98.3%-99.8%]). Participant age (median [range]) ranged from 52 (18-98) years (only self-reported T2D) to 67 (19-99) years (T2D) (P < 0.0001), and the proportion of women ranged from 45.3% (T2D) to 69.6% (only self-reported no T2D) (P < 0.0001). Most participants were of the White race (84.0%-92.7%) and non-Hispanic ethnicity (97.6%-98.6%). Conclusions: In this study, we developed an algorithm to accurately identify participants with and without T2D, which may be generalizable to cohorts with linked EHR data.

Molecular subtyping of hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP), including preeclampsia, affect 1 in 6 pregnancies, are major contributors to maternal morbidity and mortality, yet lack precision medicine strategies. Analyzing transcriptomic data from a prospectively-collected diverse cohort (n = 9102), this study reveals distinct RNA subtypes in maternal blood, reclassifying clinical HDP phenotypes like early/late-onset preeclampsia. The placental gene PAPPA2 strongly predicts the most severe forms of preeclampsia in individuals without pre-existing high risk factors, months before symptoms, and its overexpression correlates with earlier delivery in a dose-dependent manner. Further, molecular subtypes characterized by immune genes are upregulated in less severe forms of HDP. These results reclassify HDP clinical phenotypes into two distinct molecular subtypes, placental-associated or immune-associated. Validation performance for placental-associated HDP yields an AUC of 0.88 in the advanced maternal age population without pre-existing high risk factors. Molecular subtypes create new opportunities to apply precision-based medicine in maternal health.

The Childbirth Experience Survey (CBEX): An Analysis of Qualitative Survey data

BACKGROUND

In collaboration with community research partners, a national cross-sectional online Childbirth Experience Survey (CBEX) of pregnant and postpartum birthing people was administered in 2016. The linked antepartum-postpartum survey included items across 18 domains (e.g., labor management, pain management, newborn care and feeding), and identified 23 childbirth-specific postpartum patient-reported outcomes (PROs) that were associated with hospital satisfaction. CBEX was implemented in 16 California hospitals to identify hospital-specific opportunities for improvement in care. We analyzed postpartum qualitative survey responses (1) to evaluate the content validity to test the representativeness of existing CBEX domains, (2) to assess for any potential new domains or topics of interest within existing domains, and (3) to use these data to provide hospitals with actionable information for practice improvement.

METHODS

This was an analysis of qualitative survey data based on the following CBEX item: "Is there anything else you would like to share about your birth experience?" Patients could provide multiple comments. Using Atlas.ti Version 8, we mapped participant responses to the 18 existing CBEX domains.

RESULTS

Of 525 surveys completed between Oct 2018 and Sept 2020, 172 patients responded to the qualitative item. A total of 235 comments were analyzed and all were able to be mapped to the 18 domains. Qualitative responses highlighted subtleties within several CBEX domains: (1) labor management: pressure from the care team to have a labor induction; (2) pain management: epidural effectiveness, timing, dosage, and education; (3) empathy and respect: issues related to students and residents; and (4) newborn feeding: rough physical handling of patients by nurses, specifically during lactation consults.

DISCUSSION

CBEX survey data is currently being utilized in hospitals to inform childbirth-specific quality improvement initiatives. By capturing detailed voluntary participant responses, CBEX provides the opportunity to document and explore nuanced aspects of the childbirth experience and subtleties that may be contributing to maternal dissatisfaction.

Maternal and Infant Morbidity and Mortality in Relation to Delivery Mode in a Large U.S. Health Care Claims Database in 2019 and 2020

This study aimed to provide contemporary data on maternal and infant outcomes after delivery to better understand risks of cesarean section (CS).Data for deliveries in 2019 and 2020 were obtained from a large U.S. commercial health care claims database. Maternal morbidity measures included 20 severe maternal morbidity (SMM) outcomes and seven additional obstetric and mental health outcomes. Infant morbidity measures included eight outcomes related to respiratory health, digestive health, atopic dermatitis, and birth trauma. Outcome prevalence was ascertained at 42 days (maternal only) and 360 days after delivery. Logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) for prevalence adjusted for risk factors for delivery mode and each outcome. Analyses were conducted for 2019 and 2020 to assess the influence of the coronavirus disease 2019 pandemic.A total of 436,991 deliveries were identified (145,061 CS; 291,930 vaginal). The prevalence of SMM was 3.3% at 42 days and 4.1% at 360 days. The covariate-adjusted odds of SMM were higher among CS than vaginal deliveries at 42 days (OR: 2.0, 95% CI: 1.9, 2.1) and 360 days (OR: 1.7, 95% CI: 1.7, 1.8). There were 226,983 infants available for analysis of outcomes at 360 days. Most adverse infant outcomes were more prevalent at 360 days among CS than vaginal deliveries, and the covariate-adjusted odds of any adverse infant outcome at 360 days were higher among CS than vaginal deliveries (OR: 1.2; 95% CI: 1.1, 1.3). Respiratory morbidity was most affected by delivery mode. Maternal and infant mortality up to 360 days was rare. Similar trends were observed in the 2019 and 2020 cohorts.This observational study, performed using recent data obtained from a large U.S. commercial claims database, provides contemporary evidence of risks to mothers and infants of CS relative to vaginal delivery. · In a large commercially insured population, one-third of deliveries were by CS.. · Most maternal and infant outcomes were more prevalent among CS deliveries than vaginal deliveries.. · Respiratory conditions were most strongly related to delivery mode among infants.. · Maternal and infant mortality up to 360 days was rare in this population.. · Results were similar in 2019 and 2020, indicating a small impact of the COVID-19 pandemic..

Implementing Communication Boards at the Bedside to Improve Patient-Centered Care in an Inpatient Obstetric Unit

OBJECTIVE

To implement use of custom whiteboards to improve bedside communication and shared knowledge between clinicians and patients.

DESIGN

Quality improvement project using a seven-step evidence-based practice framework and Plan-Do-Study-Act cycles to redesign custom communication boards for specific patient (antepartum, labor, postpartum) populations.

SETTING/LOCAL PROBLEM

Two California university medical center inpatient obstetric units where Hospital Consumer Assessment of Healthcare Providers and Systems scores in nursing communication had trended down at a time when whiteboards were being underused in patient rooms.

PARTICIPANTS

Staff of approximately 170 nurses, 30 physicians, and 8 midwives.

INTERVENTION/MEASUREMENTS

The project was implemented from January 2020 through July 2020; the first phase was completed in the postpartum unit, and the second phase was completed in the antepartum unit. Staff surveys and board use audits were used to collect preimplementation and postimplementation data. Third-phase labor boards were designed but were not yet implemented due to budget constraints.

RESULTS

Project data supported that the new boards encouraged more complete information and facilitated bedside communication better than the previous iteration.

CONCLUSION

A customized communication board designed for a specific patient population is an effective tool to promote patient-centered care. Communication boards can reinforce safe nursing practice, facilitate discussion, and improve the patient experience.

Racial and Ethnic Disparities in Low-Risk Unplanned Cesarean Birth: Disaggregating Asian Data

BACKGROUND

Cesarean outcomes are rarely investigated by Asian ethnicities when examining variation among low-risk, first-time birthing parents. We analyzed a clinical birth dataset of Northwestern U.S. hospitals to evaluate disparities in unplanned cesarean births among disaggregated Asian ethnicities.

METHODS

This cross-sectional study used chart-abstracted birth data from 2017 through 2021. Analysis restrictions included hospitals reporting for the full timeframe, and patients who were nulliparous, term, singleton, vertex presentation, allowed to labor without a scheduled cesarean birth, and not intrapartum transfers or community births. Adjusted and unadjusted multi-level logistic regression compared the primary outcome of unplanned cesarean birth by race and Asian ethnicities.

RESULTS

A total of 40,160 births met inclusion criteria; 21.3% were Asian. Overall, the laboring cesarean rate was 23.1%, ranging from 33.9% for South Asians to 17.0% for East Asians. Compared to Whites, South Asians (OR 1.84, CI 1.66-2.04), Southeast Asians (OR 1.28, CI 1.05-1.55), and Asian unspecified (OR 1.27, CI 1.18-1.37) had significantly higher unadjusted odds of cesarean birth while East Asians had significantly lower odds (OR 0.73, CI 0.63-0.86). Odds for South Asian cesarean birth were more than doubled that of White births (aOR 2.18, CI 1.95-2.44) in the adjusted model.

CONCLUSIONS

After controlling for known risk factors, South Asians had elevated odds for unplanned cesarean birth compared to other races and ethnicities, despite lower risk factor incidence. Medical systems should collect disaggregated race and ethnicity data to provide pregnancy management insights for reducing inequities in low-risk unplanned cesarean births.

Emergency department use during pregnancy by medicaid type

BACKGROUND

Emergency department (ED) use is common among patients with Medicaid insurance during pregnancy. However, it is unknown how ED utilization differs among those with different types of Medicaid such as Emergency Medicaid, with which access to outpatient care is more restricted.

OBJECTIVE

We sought to compare differences in ED use during between pregnant persons with Emergency Medicaid and Traditional Medicaid and pregnancy outcomes by ED utilization.

STUDY DESIGN

This was a retrospective cohort study of all births among Medicaid enrollees in South Carolina from 2010 to 2019. The main comparator was type of Medicaid. Our primary outcome was an ED visit during pregnancy. Secondary outcomes included average number of visits, perinatal outcomes, and prenatal and hospital charges.

RESULTS

There were 240,597 births that met inclusion criteria for this analysis. Over the study period, the proportion of patients with at least one ED visit increased for all groups. A higher proportion of patients with Traditional Medicaid had at least one ED visit compared with Emergency Medicaid (58.2% versus 22.7%). Patients who had at least one ED visit were more likely to be younger, of Black race, live rurally, nulliparous, have lower or higher body mass index, and have a higher prevalence of pre-existing medical co-morbidities.

CONCLUSION

We found that individuals with Traditional Medicaid were more likely to have an antenatal ED visit than individuals with Emergency Medicaid.

Reduced odds of severe maternal morbidity associated with the US Affordable Care Act dependent coverage provision

BACKGROUND

Continuous perinatal health insurance coverage is a policy intervention that may help reduce severe maternal morbidity (SMM) and racial and ethnic disparities in SMM in the United States. The Affordable Care Act Dependent Coverage Provision (DCP) allowed young adults to remain on their parent's private health insurance plan until their 26th birthday but its effectiveness in reducing SMM has not been evaluated.

OBJECTIVE

To assess the association of the DCP with SMM during delivery hospitalization.

STUDY DESIGN

Difference-in-differences analysis of US delivery hospitalizations from January 2006 to September 2015, stratified according to maternal race and ethnicity. The outcome was SMM exclusive of blood transfusion only, as defined by the Centers for Disease Control and Prevention criteria. The exposure was maternal age categorized into 21 to 25 years (covered by the DCP) and 27 to 31 years (not covered the DCP). The intervention was the DCP categorized into pre- and post-DCP periods (January 2006-September 2010 and October 2010-September 2015, respectively).

RESULTS

Of the 4,007,937 delivery hospitalizations in the sample, 22,540 (56.2 per 10,000) recorded SMM. For birthing people aged 21 to 25 years (covered by the DCP), the mean SMM rate was 48.9 per 10,000 during the pre-DCP period and 58.2 per 10,000 during the post-DCP period (crude difference: 9.3 per 10,000). For birthing people aged 27 to 31 years (not covered the DCP), the mean SMM rate was 53.4 per 10,000 during the pre-DCP period and 63.6 per 10,000 during the post-DCP period (crude difference: 10.2 per 10,000). Implementation of DCP was associated with a 1.2% (95% CI: -3.6, 1.3) relative decrease in the mean SMM rate (adjusted odds ratio (aOR): 0.988; 95% CI: 0.964, 1.013). For non-Hispanic White people, the DCP was associated with a 10.7% (95% CI: 7.1, 14.2) relative decrease in the mean SMM rate (aOR: 0.893; 95% CI: 0.858, 0.929). The DCP was associated with an increase in the proportion of privately insured (aOR: 1.225; 95% CI: 1.220, 1.231), a decrease in the proportion of Medicaid beneficiaries (aOR: 0.853; 95% CI: 0.849, 0.856), and a decrease in the proportion of uninsured (aOR: 0.807; 95% CI: 0.798, 0.816).

CONCLUSIONS

Maternal health benefit of the DCP appears to be limited to non-Hispanic White birthing people.

Structural Racism, Geographies of Opportunity, and Maternal Health Inequities: A Dynamic Conceptual Framework

Addressing the grave racial inequities in maternal health requires a new generation of research that better operationalizes root causes of these outcomes. Recent frameworks improving the conceptualization of structural racism have illuminated the need for better conceptual clarity when investigating neighborhoods as a site of structural marginalization for Black birthing populations as well. In particular, better conceptualization of dynamic feedback in how neighborhoods are constructed and experienced, especially as they embed vicious cycles of place-based racialization, is integral to producing conceptually relevant and translatable evidence to address inequities in Black maternal health. This study presents a newly developed framework that integrates dynamic insight on neighborhood contexts from multiple disciplines to better conceptualize how it operates during the childbearing window to drive inequitable maternal morbidity rates among Black birthing people. I also compare and contrast this framework with existing frameworks based on how they represent key domains of social and structural determinants, neighborhood context, and dynamic feedback. Illustrating the strengths and weaknesses of each framework can improve researchers' ability to leverage these frameworks when developing project-specific conceptual models on structural racism, neighborhood context, and Black maternal health. Building a comparative repository of frameworks, in conjunction with developing new frameworks, will improve the field's capacity to follow best practices of rooting research in conceptually explicit models that improve operationalization and translation of evidence to eventually eliminate racial inequities in maternal health.

Relationship between nurse staffing during labor and cesarean birth rates in U.S. hospitals

BACKGROUND

Cesarean birth increases risk of maternal morbidity and mortality.

PURPOSE

Examine the relationship between labor and delivery staffing and hospital cesarean and vaginal birth after cesarean (VBAC) rates.

METHODS

Survey of U.S. labor nurses in 2018 and 2019 on adherence to AWHONN nurse staffing standards with data linked to American Hospital Association Survey data, patient discharge data, and cesarean birth and VBAC rates.

FINDINGS

In total, 2,786 nurses from 193 hospitals in 23 states were included. Mean cesarean rate was 27.3% (SD 5.9, range 11.7%-47.2%); median VBAC rate 11.1% (IQR 1.78%-20.2%; range 0%-40.1%). There was relatively high adherence to staffing standards (mean, 3.12 of possible 1-4 score). After adjusting for hospital characteristics, nurse staffing was an independent predictor of hospital-level cesarean and VBAC rates (IRR 0.89, 95% CI 0.84-0.95 and IRR 1.58, 95% CI 1.25-1.99, respectively).

DISCUSSION

Better nurse staffing predicted lower cesarean birth rates and higher VBAC rates.

CONCLUSION

Hospitals should be accountable for providing adequate nurse staffing during childbirth.

Application of Predictive Analytics in Pregnancy, Birth, and Postpartum Nursing Care

ABSTRACT

Predictive analytics has emerged as a promising approach for improving reproductive health care and patient outcomes. During pregnancy and birth, the ability to accurately predict risks and complications could enable earlier interventions and reduce adverse events. However, there are challenges and ethical considerations for implementing predictive models in perinatal care settings. We introduce major concepts in predictive analytics and describe application of predictive modeling to perinatal care topics such as fertility, preeclampsia, labor onset, vaginal birth after cesarean, uterine rupture, induction outcomes, postpartum hemorrhage, and postpartum mood disorders. Although some predictive models have achieved adequate accuracy (AUC 0.7-0.9), most require additional external validation across diverse populations and practice settings. Bias, particularly racial bias, remains a key limitation of current models. Nurses and advanced practice nurses, including nurse practitioners certified registered nurse anesthetists, and nurse-midwives, play a vital role in ensuring high-quality data collection and communicating predictive model outputs to clinicians and users of the health care system. Addressing the ethical challenges and limitations of predictive analytics is imperative to equitably translate these tools to support patient-centered perinatal care.

Severe maternal morbidity contributed by obstetric hemorrhage: Maryland, 2020-2022

BACKGROUND

Obstetric hemorrhage is the leading cause of maternal mortality and severe maternal morbidity (SMM) in Maryland and nationally. Currently, through a quality collaborative, the state is implementing the Alliance for Innovation on Maternal Health (AIM) patient safety bundle on obstetric hemorrhage.

OBJECTIVE

To describe SMM events contributed by obstetric hemorrhage and their preventability in Maryland.

STUDY DESIGN

This cross-sectional study used data from hospital-based SMM surveillance and review program in Maryland. Hospital-based SMM criteria include admission to an intensive care unit and/or transfusion of 4 or more units of blood products (of any type) during pregnancy or within 42 days postpartum. A total of 193 obstetric hemorrhage events that met the surveillance definition were identified in hospitals participating in SMM surveillance since inception on August 1, 2020 until December 31, 2022. We compared patient and delivery characteristics, practices done well, and recommendations for care improvement among patients with severe obstetric hemorrhage deemed preventable and non-preventable by hospital-based review committees. For obstetric hemorrhage events deemed preventable, we further identified factors that contributed to the SMM outcome at the provider, system, and patient levels.

RESULTS

Uterine atony was the leading cause of obstetric hemorrhage events (37.8%), followed by uterine rupture, laceration and intra-abdominal bleeding (23.8%). Sixty-six (34.2%) obstetric hemorrhage events were preventable. Patients with preventable obstetric hemorrhage were significantly more likely to have an emergency than planned cesarean delivery and less likely to have a placental complication or >1500 mL blood loss volume. Hospital-based review committees determined that 81.8%, 30.3%, and 22.7% of preventable events could have been prevented or made less severe through changes to provider, system, or patient factors, respectively. Recommendations following event reviews aligned with the Alliance for Innovation on Maternal Health Obstetric Hemorrhage Patient Safety Bundle, particularly regarding elements in the Recognition and Prevention and Response domains.

CONCLUSION

About one-third of SMM events contributed by obstetric hemorrhages were deemed preventable. Of AIM bundle elements, assessing hemorrhage risk on admission to labor and delivery, peripartum, and upon transition to postpartum care together with rapid, unit-standardized management of hemorrhage are likely to benefit more than half of patients with preventable SMM contributed by obstetric hemorrhage.

Peripartum maternal outcomes in individuals with systemic lupus erythematosus in a real-world electronic health record cohort

OBJECTIVE

Few studies have examined peripartum maternal outcomes in systemic lupus erythematosus (SLE). Using a de-identified electronic health record (EHR) cohort of individuals with and without SLE, we compared rates of peripartum maternal outcomes including maternal infections, blood transfusions, hospital length of stay, and SLE flares.

METHODS

We identified deliveries among individuals with SLE and individuals without autoimmune disease using a previously validated algorithm. Peripartum maternal infection was assessed up to 6 weeks postpartum. Using Chi-square and Mann-Whitney U tests, we compared peripartum outcomes in SLE and control deliveries. We performed mixed effects models to estimate the association of SLE case status with peripartum outcomes. We assessed for SLE flares up to 6 months postpartum using chart review of rheumatology notes and the 2009 revised SELENA Flare Index. We evaluated SLE medications prescribed during pregnancy and at time of delivery on peripartum outcomes.

RESULTS

We identified 185 deliveries to 142 individuals with SLE and 468 deliveries to 241 control individuals without autoimmune diseases. Mean length of hospital stay was longer for individuals with SLE compared to controls (3.1 ± 2.0 vs. 2.4 ± 1.0 days, p < 0.001). In a mixed effects model, peripartum infection was significantly associated with SLE case status (OR = 6.18, 95 % CI 2.73 - 13.98, p < 0.01), Cesarean section (OR = 5.00, 95 % CI 2.16 - 11.57, p < 0.01), and age at delivery (OR = 0.92, 95 % CI 0.86 - 0.99, p = 0.03) after adjusting for race. Transfusion was also significantly associated with SLE case status (OR = 9.05, 95 % CI 3.24-25.32, p < 0.01) and Black race (OR = 6.64, 95 % CI 1.47 - 30.02, p = 0.01) after adjusting for Cesarean section and age at delivery. We observed a postpartum flare rate of 32 % among individuals with SLE with 13 % characterized as mild, 41 % moderate, and 46 % severe. Antimalarial use in the postpartum period was associated with lower flare rate (43 % vs. 63 %, p = 0.04).

CONCLUSIONS

Individuals with SLE have increased rates of blood transfusions, longer hospital stays, and more frequent infections compared to control individuals in the peripartum period. We observed a postpartum flare rate of 32 %, and antimalarial use was associated with lower flare rate. Our findings demonstrate that the peripartum period remains a high-risk time for individuals with SLE with an ongoing need for close monitoring.

Mental health disparities among maternal populations following heatwave exposure in North Carolina (2011-2019): a matched analysis

Background

The increasing incidence of extreme heat due to climate change poses a significant threat to maternal mental health in the U.S. We examine the association of acute exposure to heatwaves with maternal mental health conditions in North Carolina from 2011 to 2019.

Methods

We incorporate a matched analysis design using NC Hospital Discharge Data to examine emergency department admissions for psychiatric conditions during the warm season (May to September), matching heatwave periods with non-heatwave unexposed periods at the zip code tabulation area (ZCTA) level. We stratify the sample to examine effect modification across the rural-urban continuum, physiographic regions, measurements of neighborhood racial and economic inequality, and individual-level sociodemographic factors (e.g., age, race/ethnicity, and insurance type).

Findings

Our sample of 324,928 emergency department visits by pregnant individuals has a mean age of 25.8 years (SD: 5.84), with 9.3% (n = 30,205) identifying as Hispanic. Relative risk (RR) estimates and 95% confidence intervals (CI) indicate significant increases in maternal mental health burdens following heatwave exposure. Acute heatwave periods were associated with a 13% higher risk of severe mental illness (RRSMI: 1.13, CI: 1.08-1.19, p: <0.0001), while prolonged exposure to moderate-intensity heatwaves was associated with 37% higher risk (RRSMI: 1.37, CI: 1.19-1.58, p: <0.001). Individual factors (e.g., advanced maternal age and insurance providers) and neighborhood-level characteristics, like low socioeconomic status, racialized and economic segregation, rurality, and physiographic region, further modified the risk of adverse maternal mental health outcomes.

Interpretation

Our results add to the growing evidence of the impact of extreme heat on maternal mental health, particularly among vulnerable subpopulations. Additionally, findings emphasize the influence of socioeconomic and environmental contexts on mental health responses to heatwave exposure.

Funding

This work was supported by the Faculty Early Career Development Program (CAREER) award (grant #2044839) from the National Science Foundation and the National Institute of Environmental Health Sciences (NIEHS) award (grant #5R03ES035170-02).

Leveraging Machine Learning to Predict and Assess Disparities in Severe Maternal Morbidity in Maryland

BACKGROUND

Severe maternal morbidity (SMM) is increasing in the United States. The main objective of this study is to test the use of machine learning (ML) techniques to develop models for predicting SMM during delivery hospitalizations in Maryland. Secondarily, we examine disparities in SMM by key sociodemographic characteristics.

METHODS

We used the linked State Inpatient Database (SID) and the American Hospital Association (AHA) Annual Survey data from Maryland for 2016-2019 (N = 261,226 delivery hospitalizations). We first estimated relative risks for SMM across key sociodemographic factors (e.g., race, income, insurance, and primary language). Then, we fitted LASSO and, for comparison, Logit models with 75 and 18 features. The selection of SMM features was based on clinical expert opinion, a literature review, statistical significance, and computational resource constraints. Various model performance metrics, including the area under the receiver operating characteristic curve (AUC), accuracy, precision, and recall values were computed to compare predictive performance.

RESULTS

During 2016-2019, 76 per 10,000 deliveries (1976 of 261,226) were in patients who experienced an SMM event. The Logit model with a full list of 75 features achieved an AUC of 0.71 in the validation dataset, which marginally decreased to 0.69 in the reduced model with 18 features. The LASSO algorithm with the same 18 features demonstrated slightly superior predictive performance and an AUC of 0.80. We found significant disparities in SMM among patients living in low-income areas, with public insurance, and who were non-Hispanic Black or non-English speakers.

CONCLUSION

Our results demonstrate the feasibility of utilizing ML and administrative hospital discharge data for SMM prediction. The low recall score is a limitation across all models we compared, signifying that the algorithms struggle with identifying all SMM cases. This study identified substantial disparities in SMM across various sociodemographic factors. Addressing these disparities requires multifaceted interventions that include improving access to quality care, enhancing cultural competence among healthcare providers, and implementing policies that help mitigate social determinants of health.

The Association of the Coronavirus Disease-2019 Pandemic With Disparities in Maternal Outcomes

BACKGROUND

In the United States, Black and Hispanic patients have substantially worse maternal outcomes than non-Hispanic White patients. The goals of this study were to evaluate the association between the coronavirus disease-2019 (COVID-19) pandemic and maternal outcomes, and whether Black and Hispanic patients were disproportionately affected by the pandemic compared to White patients.

METHODS

Multivariable logistic regression was used to examine in the United States the association between maternal outcomes (severe maternal morbidity, mortality, failure-to-rescue, and cesarean delivery) and the weekly hospital proportion of COVID-19 patients, and the interaction between race, ethnicity, payer status, and the hospital COVID-19 burden using US national data from the Vizient Clinical Database between 2017 and 2022.

RESULTS

Among 2484,895 admissions for delivery, 457,992 (18.4%) were non-Hispanic Black (hereafter referred to as Black), 537,867 (21.7% were Hispanic), and 1489,036 (59.9%) were non-Hispanic White (hereafter referred to as White); mean (standard deviation [SD]) age, 29.9 (5.8). Mortality (adjusted odds ratio [AOR], 2.72; 95% confidence interval [CI], 1.28-5.8; P = .01) and failure-to-rescue (AOR, 2.89; 95% CI, 1.36-6.13, P = .01), increased during weeks with a COVID-19 burden of 10.1% to 20.0%, while rates of severe maternal morbidity and cesarean delivery were unchanged. Compared to White patients, Black and Hispanic patients had higher rates of severe maternal morbidity ([Black: OR, 1.97; 95% CI, 1.85-2.11, P < .001]; [Hispanic: OR, 1.37;95% CI, 1.28-1.48, P < .001]), mortality ([Black: OR, 1.92; 95% CI, 1.29-2.86, P < .001]; [Hispanic: OR, 1.51;95% CI, 1.01-2.24, P = .04]), and cesarean delivery ([Black: OR, 1.58; 95% CI, 1.54-1.63, P < .001]; [Hispanic: OR, 1.09;95% CI, 1.05-1.13, P < .001]), but not failure-to-rescue. Except for Black patients without insurance (1.3% of the patients), the pandemic was not associated with increases in maternal disparities. Odds of mortality (AOR, 1.96; 95% CI, 1.22-3.16, P = .01) and failure-to-rescue (AOR, 3.67; 95% CI, 1.67-8.07, P = .001) increased 2.0 and 3.7-fold, respectively, in Black patients without insurance compared to White patients with private insurance for each 10% increase in the weekly hospital COVID-19 burden.

CONCLUSIONS

In this national study of 2.5 million deliveries in the United States, the COVID-19 pandemic was associated with increases in maternal mortality and failure-to-rescue but not in severe maternal morbidity or cesarean deliveries. While the pandemic did not exacerbate disparities for Black and Hispanic patients with private or Medicaid insurance, uninsured Black patients experienced greater increases in mortality and failure-to-rescue compared to insured White patients.

Individual and County-Level Factors Associated with Severe Maternal Morbidity at Delivery: An Investigation of a Privately Insured Population in the United States, 2008 to 2018

OBJECTIVE

 Few studies have explored the impact of county-level variables on severe maternal morbidity (SMM) subtypes. To address this gap, this study used a large commercial database to examine the associations between individual- and county-level factors and SMM.

STUDY DESIGN

 This retrospective cohort study used data from the Optum's deidentified Clinformatics Data Mart Database from 2008 to 2018. The primary outcomes of this study were any SMM, nontransfusion SMM, and nine specific SMM subtypes. Temporal trends in the prevalence of SMM and SMM subtypes were assessed using Joinpoint Regression. Multilevel logistic regression models were used to investigate the association of individual- and county-level factors with SMM.

RESULTS

 Between 2008 and 2018, there was not a significant change in the prevalence of any SMM (annual percent change [APC]: -0.9, 95% confidence interval [CI]: -2.2, 0.5). Significant increases in prevalence were identified for three SMM subtypes: other obstetric (OB) SMM (APC: 10.3, 95% CI: 0.1, 21.5) from 2013 to 2018, renal SMM (APC: 8.5, 95% CI: 5.5, 11.6) from 2008 to 2018, and sepsis (APC: 23.0, 95% CI: 6.5, 42.1) from 2014 to 2018. Multilevel logistic regression models revealed variability in individual and county risk factors across different SMM subtypes. Adolescent mothers (odds ratio [OR]: 2.10, 95% CI: 1.29, 3.40) and women in the 40 to 55 (OR: 1.67, 95% CI: 1.12, 2.51) age group were found to be at significant risk of other OB SMM and renal SMM, respectively. For every increase in rank within a county's socioeconomic social vulnerability index (SVI), the risk of respiratory SMM increased 2.8-fold, whereas an increase in rank in the racial/ethnic minority SVI was associated with a 1.6-fold elevated risk of blood transfusion.

CONCLUSION

 This study underscores the complex association between individual and county factors associated with SMM, emphasizing the need for multifaced approaches to improve maternal care.

KEY POINTS

· No increase in composite SMM rates from 2008 to 2018.. · Increases in obstetric SMM subtypes and sepsis.. · Risk factor profiles may differ across SMM subtypes.. · Key risk factors: age, comorbidities, prenatal care.. · County socioeconomic status associated with respiratory SMM risk..

Temporal changes in hospital readmissions for postpartum hypertension in the US, 2010 to 2019; a serial cross-sectional analysis

BACKGROUND

Hypertension is the most common primary diagnosis associated with postpartum readmissions within 42 days of delivery hospitalization. In the United States, nearly half of the cases of eclampsia, a severe form of preeclampsia, develop during the postpartum period, and the postpartum onset of hypertensive disorders of pregnancy, like antepartum hypertension poses long-term health risks to pregnant individuals, including an increased likelihood of developing overall cardiovascular disease, coronary heart disease, heart failure, and chronic hypertension. In this paper, we estimate the trends in the incidence of readmissions for postpartum hypertension within 42 days of delivery discharge in the US, disaggregated by median household income.

METHODS AND FINDINGS

Using National Readmissions Database, we calculated the readmission rates for postpartum hypertension, both overall and stratified by ZIP Code median household income for each year between 2010 and 2019. We also calculated the percentage change and average annual growth rate (AAGR) in the rate of readmissions for postpartum hypertension between 2010 and 2019 for each income group. We then used a logistic regression model to compare the temporal changes in readmission for postpartum hypertension between the lowest and the highest income quartiles. The estimated incidence of postpartum hypertension readmissions doubled for all the income groups between 2010 and 2019 (0.36% vs. 0.8%). While the incidence of postpartum hypertension cases was higher among the lowest-income quartile, the increase in postpartum hypertension readmissions between 2010 and 2019 was greater in the highest-income quartile. Moreover, the incidence of postpartum hypertension readmissions rose faster in pregnant patients without a history of hypertension compared to those with a history of hypertension (AAGR 8.3% vs. 5.1%).

CONCLUSION

The increasing postpartum hypertension readmission burden suggests rising future health risks among mothers and a growing cost burden to the U.S. healthcare system. The higher rate of increase in postpartum hypertension readmissions among people without a history of hypertension calls for blood pressure checking in the postpartum period for all patients regardless of risk status.

Severe Maternal Morbidity Associated With Chronic Hypertension, Preeclampsia, and Gestational Hypertension

Importance

Chronic hypertension and preeclampsia are leading risk enhancers for maternal-neonatal morbidity and mortality. Severe maternal morbidity (SMM) indicators include heart, kidney, and liver disease, but studies have not excluded patients with preexisting diseases that define SMM. Thus, SMM risks for uncomplicated chronic hypertension specific to preeclampsia remain unclear.

Objective

To determine SMM rates and estimate relative risks associated with hypertensive disorders of pregnancy among patients with and without chronic hypertension unencumbered by preexisting vascular or end organ diseases.

Design, Setting, and Participants

This retrospective cohort study used longitudinal health data from electronic health records from patients within a community-based, integrated health care system in northern California. The study cohort selected 263 518 pregnant patients without pregestational heart, kidney, or liver disease entering prenatal care at 14 weeks' gestation or earlier and delivering a singleton stillbirth or live birth in 2009 to 2019. The data were analyzed between February 2022 and March 2024.

Exposures

Five joint subgroups combining chronic hypertension status and the hypertensive disorders developing during pregnancy, defined as follows: (1) chronic hypertension with superimposed preeclampsia, (2) chronic hypertension and no preeclampsia, (3) no chronic hypertension with preeclampsia, (4) gestational hypertension, and (5) no chronic hypertension and no preeclampsia or gestational hypertension (reference group).

Main Outcomes and Measures

The main outcome was SMM rates at delivery hospitalization (cases per 10 000 births) using the Centers for Disease Control and Prevention criteria (≥1 of 21 indicators to define SMM) obtained from electronic health records. Modified Poisson regression models estimated crude and adjusted relative risks (aRRs) and 95% CIs of SMM associated with the chronic hypertension and developing hypertensive disorders of pregnancy groups vs the reference group (no chronic hypertension and no preeclampsia or gestational hypertension) adjusted for clinical, sociodemographic, social, and behavioral covariates.

Results

The analysis included a total of 263 518 pregnant patients (mean [SD] age at delivery, 31.0 [5.3] years), including 249 892 patients without chronic hypertension (4.7% developed preeclampsia) and 13 626 patients with chronic hypertension (31.5% developed superimposed preeclampsia). The highest SMM rates occurred in the no chronic hypertension with preeclampsia (934.3 [95% CI, 882.3-988.3] cases per 10 000 births) and the chronic hypertension with superimposed preeclampsia (898.3 [95% CI, 814.5-987.8] cases per 10,000 births) groups. Lower SMM rates occurred in the chronic hypertension and no preeclampsia (195.1 [95% CI, 168.0-225.2] cases per 10,000 births), gestational hypertension (312.7 [95% CI, 281.6-346.1] cases per 10,000 births), and no chronic hypertension and no preeclampsia or gestational hypertension (165.8 [95% CI, 160.6-171.2] cases per 10,000 births) groups (P < .001). Compared with the no chronic hypertension and no preeclampsia or gestational hypertension group, risks of SMM were significantly higher for the chronic hypertension with superimposed preeclampsia group (aRR, 4.97 [95% CI, 4.46-5.54]), no chronic hypertension with preeclampsia group (aRR, 5.12 [95% CI, 4.79-5.48]), chronic hypertension and no preeclampsia group (aRR, 1.17 [95% CI, 1.003-1.36]; P = .046), and the gestational hypertension group (aRR, 1.78 [95% CI 1.60-1.99]).

Conclusions and Relevance

This cohort study found that the highest SMM rates at delivery hospitalization occurred for preeclampsia superimposed on chronic hypertension and preeclampsia without chronic hypertension, while gestational hypertension had intermediate rates of SMM. The patients with chronic hypertension who did not develop preeclampsia had SMM rates that were nearly the same as the lowest-risk patients without chronic hypertension who did not develop preeclampsia or gestational hypertension. These findings provide evidence that prevention of preeclampsia among patients with uncomplicated chronic hypertension is paramount to mitigating maternal morbidity.

Is severe maternal morbidity a risk factor for postpartum hospitalization with mental health or substance use disorder diagnoses? Findings from a retrospective cohort study in Maryland: 2016-2019

BACKGROUND

Perinatal mental health conditions and substance use are leading causes, often co-occurring, of pregnancy-related and pregnancy-associated deaths in the United States. This study compares odds of hospitalization with a mental health condition or substance use disorder or both during the first year postpartum between patients with and without severe maternal morbidity (SMM) during delivery hospitalization.

METHODS

Data are from the Maryland's State Inpatient Database and include patients with a delivery hospitalization during 2016-2018 (n = 197,749). We compare rate of hospitalization with a mental health condition or substance use disorder or both at 42 days and 43 days to 1 year postpartum by occurrence of SMM during the delivery hospitalization. We use multivariable logistic regression to derive the odds of hospitalization with each outcome for patients by SMM status, adjusted for patient sociodemographic characteristics, presence of mental health condition or substance use disorder diagnoses during the delivery hospitalization, and delivery outcome. All SMM, mental health conditions, and substance use disorders are identified using ICD-10 diagnosis and procedure codes.

RESULTS

Overall, 5,793 patients (2.9%) who delivered during 2016-2018 experienced hospitalization in the year following delivery. Among these patients, 24.3% (n = 1,410) had a mental health condition diagnosis, 10.6% (n = 619) had a substance use disorder diagnosis, and 9.8% (n = 570) had co-occurring mental health condition and substance use disorder diagnoses. Patients with SMM had 3.7 times the adjusted odds (95% CI 2.7, 5.2) of hospitalization with a mental health condition diagnosis, 2.7 times the odds (95% CI 1.6, 4.4) of a hospitalization with substance use disorder diagnosis, and 3.0 times the odds (95% CI 1.8, 4.8) of hospitalization with co-occurring mental health condition and substance use disorder diagnoses during the first-year postpartum.

CONCLUSION

Patients who experience SMM during their delivery hospitalization had higher odds of hospitalization with a mental health condition, substance use disorder, and co-occurring mental health condition and substance use disorder in the one-year postpartum period. Treatment and support resources for mental health and substance use providers --including enhanced screening and personal introduction of providers -- should be made available to patients with SMM upon discharge after delivery, and evidence-based interventions to improve mental health and reduce substance use should be prioritized in these patients.

Delivery-Related Maternal Morbidity and Mortality Among Patients With Cardiac Disease

OBJECTIVE

To assess the risk of severe maternal morbidity (SMM) and mortality among pregnant patients with cardiovascular disease (CVD).

METHODS

This was a retrospective cohort study of U.S. delivery hospitalizations from 2010 to 2020 using weighted population estimates from the National Inpatient Sample database. The primary objective was to evaluate the risk of SMM and maternal mortality among patients with CVD at delivery hospitalization. International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes were used to identify delivery hospitalizations, CVD, and SMM events. Multivariable logistic regression analyses were performed to compare SMM and mortality risk among patients with CVD and those without CVD. Given the substantial racial and ethnic disparities in SMM, mortality, and CVD burden, secondary objectives included evaluating SMM and mortality across racial and ethnic groups and assessing the population attributable fraction within each group. Lastly, subgroup analyses of SMM by underlying CVD diagnoses (eg, congenital heart disease, chronic heart failure) were performed. Variables used in the regression models included socioeconomic and demographic maternal characteristics, maternal comorbidities, and pregnancy-specific complications.

RESULTS

Among 38,374,326 individuals with delivery hospitalizations, 203,448 (0.5%) had CVD. Patients with CVD had an increased risk of SMM (11.6 vs 0.7%, adjusted odds ratio [aOR] 12.5, 95% CI, 12.0-13.1) and maternal death (538 vs 5 per 100,000 delivery hospitalizations, aOR 44.1, 95% CI, 35.4-55.0) compared with those without CVD. Patients with chronic heart failure had the highest SMM risk (aOR 354.4, 95% CI, 301.0-417.3) among CVD categories. Black patients with CVD had a higher risk of SMM (aOR 15.9, 95% CI, 14.7-17.1) than those without CVD with an adjusted population attributable fraction of 10.5% (95% CI, 10.0-11.0%).

CONCLUSION

CVD in pregnancy is associated with increased risk of SMM and mortality, with the highest risk of SMM among patients with chronic heart failure. Although CVD affects less than 1% of the pregnant population, it contributes to nearly 1 in 10 SMM events in the United States.

A Study of Cesarean Deliveries From a Single Midwestern Residency Program: Total Surgical Time, Incision-to-Delivery Time, and Neonatal Apgar Scores

BACKGROUND

Cesarean delivery surgical quality indicators and outcomes support the surgical skills of family medicine physicians. These data have educational and clinical implications yet are largely unexplored. Our study updated cesarean surgical times, incision-to-delivery time, and neonatal Apgar scores from a midwestern family medicine residency program.

METHODS

All cesarean deliveries performed by family medicine faculty from January 2012 to March 2021 were reviewed. Total surgical time, incision-to-delivery time, Apgar scores at 1 and 5 min, and maternal demographic information were recorded.

RESULTS

320 cesarean deliveries were reviewed. The average total surgical procedure time was 64.3 min (SD = 17.9) and incision-to-delivery time was 9.5 min (SD = 4.9). The average 1-min Apgar score was 7.5 (SD = 1.8) and the average 5-min Apgar score was 8.7 (SD = 1.0). There were no significant correlations between 1- and 5-min Apgar scores and procedure times.

CONCLUSION

Cesarean delivery quality indicators from family medicine faculty are updated and appear similar to those reported previously in studies that did not include the presence of learners. This EMR-based study provides baseline information for future surgical cesarean delivery quality improvement and outcomes research.

Emergency department use during pregnancy by Medicaid type

Background

Emergency department (ED) use is common among patients with Medicaid insurance during pregnancy. However, it is unknown how ED utilization differs among those with different types of Medicaid such as Emergency Medicaid, with which access to outpatient care is more restricted.

Objective

We sought to compare differences in ED use during between pregnant persons with Emergency Medicaid and Traditional Medicaid and pregnancy outcomes by ED utilization.

Study Design

This was a retrospective cohort study of all births among Medicaid recipients in South Carolina from 2010 to 2019. The main comparator was type of Medicaid. Our primary outcome was an ED visit during pregnancy. Secondary outcomes included average number of visits, perinatal outcomes, and prenatal and hospital charges.

Results

There were 240,597 births that met inclusion criteria for this analysis. Over the study period, the proportion of patients with at least one ED visit increased for all groups. A higher proportion of patients with Traditional Medicaid had at least one ED visit compared with Emergency Medicaid (58.2% versus 22.7%). Patients who had at least one ED visit were more likely to be younger, of Black race, live rurally, nulliparous, have lower or higher body mass index, and have a higher prevalence of pre-existing medical co-morbidities.

Conclusion

We found that individuals with Traditional Medicaid were more likely to have an antenatal ED visit than individuals with Emergency Medicaid.

Outcome reporting in studies on critically ill obstetric patients: A systematic review

Introduction

This systematic review is the first step in the process of standardizing outcome reporting through the development of a core outcome set for research on critically ill obstetric patients (COSCO).

Methods

A five-database search was performed to identify randomized and non-randomized studies published before November 2017, on patients admitted to intensive care or high-dependency units during or immediately after pregnancy. Reported outcomes were categorized into domains and definitions were documented.

Results

Of the 12,581 citations reviewed, 136 studies were included. The most reported outcome domains were maternal all-cause mortality (n = 128, 94.5%), resource use (n = 116, 85.6%), and clinical/physiological outcomes (n = 111, 82.8%). Outcomes related to functioning/life impact and adverse effects of treatment were only reported in four (2.9%) studies. There was inconsistency in outcome definitions.

Conclusions

This review identified considerable variation in outcome reporting and definitions and generated an outcome list to consider in COSCO development.

Time-Dependent Material Properties and Composition of the Nonhuman Primate Uterine Layers Through Gestation

The uterus is central to the establishment, maintenance, and delivery of a healthy pregnancy. Biomechanics is an important contributor to pregnancy success, and alterations to normal uterine biomechanical functions can contribute to an array of obstetric pathologies. Few studies have characterized the passive mechanical properties of the gravid human uterus, and ethical limitations have largely prevented the investigation of mid-gestation periods. To address this key knowledge gap, this study seeks to characterize the structural, compositional, and time-dependent micro-mechanical properties of the nonhuman primate (NHP) uterine layers in nonpregnancy and at three time-points in pregnancy: early 2nd, early 3rd, and late 3rd trimesters. Distinct material and compositional properties were noted across the different tissue layers, with the endometrium-decidua being the least stiff, most viscous, least diffusible, and most hydrated layer of the NHP uterus. Pregnancy induced notable compositional and structural changes to the endometrium-decidua and myometrium, but no micro-mechanical property changes. Further comparison to published human data revealed notable similarities across species, with minor differences noted for the perimetrium and nonpregnant endometrium. This work provides insights into the material properties of the NHP uterus and demonstrates the validity of NHPs as a model for studying certain aspects of human uterine biomechanics.

Atrial Fibrillation Impacts Inpatient Mortality, Length of Stay, Resource Utilization, Blood Transfusion, and Endotracheal Intubation in Cesarean Sections, Natural Spontaneous Deliveries, and Instrumental Deliveries: A Nationwide Analysis (2016-2020)

BACKGROUND

Atrial fibrillation (AF) is rare during pregnancy and current data on the impact of AF during delivery is scarce. In this study, we aim to analyze the impact of AF in patients who underwent delivery via cesarean section (CS), natural spontaneous delivery (NSD), or instrumental delivery (ID).

METHODS

This study analyzed discharge data from the National Inpatient Sample (NIS) from 2016 to 2020. Using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Procedure Coding System (ICD-10-PCS) codes, this study identified patients who underwent CS, NSD, or ID with a secondary diagnosis of AF. The study then compared these patients with patients who underwent CS, NSD, or ID without a secondary diagnosis of AF to analyze various outcomes. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included length of stay, total hospital charges, blood transfusions, and respiratory failure requiring endotracheal intubation. STATA v.13 (StataCorp LLC, College Station, TX) was used for univariate and multivariate analysis.

RESULTS

A total of 17,785,980 patients underwent CS, NSD, or ID. Of these deliveries, 6,000 patients had a secondary diagnosis of AF. Patients with AF had almost 20 times more of a chance of dying while admitted compared to those without AF (OR: 19.12; 95% CI: 4.33-84.45; p < 0.001). Furthermore, the AF cohort stayed for one and a half days longer in the hospital (regression coefficient: 1.55; 95% CI: 1.16-1.94; p < 0.001), spent 19,294.05 more dollars (regression coefficient: 19294.05; 95% CI: 14658.17-23929.93; p < 0.001), were subjected 2.68 times more to blood transfusions (OR: 2.68; 95% CI: 1.89-3.8; p < 0.001), and had a higher rate of respiratory complications requiring endotracheal intubation (OR: 15.86; 95% CI: 7.83-32.15; p < 0.001).

CONCLUSION

AF has a substantial negative impact on inpatient outcomes for pregnant patients during delivery. Further research is needed to explore these negative impacts to improve maternal care.

A Counterfactual Analysis of Impact of Cesarean Birth in a First Birth on Severe Maternal Morbidity in the Subsequent Birth

BACKGROUND

It is known that cesarean birth affects maternal outcomes in subsequent pregnancies, but specific effect estimates are lacking. We sought to quantify the effect of cesarean birth reduction among nulliparous, term, singleton, vertex (NTSV) births (i.e., preventable cesarean births) on severe maternal morbidity (SMM) in the second birth.

METHODS

We examined birth certificates linked with maternal hospitalization data (2007-2019) from California for NTSV births with a second birth (N = 779,382). The exposure was cesarean delivery in the first birth and the outcome was SMM in the second birth. We used adjusted Poisson regression models to calculate risk ratios and population attributable fraction for SMM in the second birth and conducted a counterfactual impact analysis to estimate how lowering NTSV cesarean births could reduce SMM in the second birth.

RESULTS

The adjusted risk ratio for SMM in the second birth given a prior cesarean birth was 1.7 (95% confidence interval: 1.5, 1.9); 15.5% (95% confidence interval: 15.3%, 15.7%) of this SMM may be attributable to prior cesarean birth. In a counterfactual analysis where 12% of the California population was least likely to get a cesarean birth instead delivered vaginally, we observed 174 fewer SMM events in a population of individuals with a low-risk first birth and subsequent birth.

CONCLUSION

In our counterfactual analysis, lowering primary cesarean birth among an NTSV population was associated with fewer downstream SMM events in subsequent births and overall. Additionally, our findings reflect the importance of considering the cumulative accrual of risks across the reproductive life course.

Role of Doulas in Improving Maternal Health and Health Equity Among Medicaid Enrollees, 2014‒2023

Objectives. To assess the relationship between doula utilization and health outcomes of females enrolled in Medicaid-affiliated plans in the United States. Methods. In this retrospective, observational cohort study, we used Medicaid claims data from a national health insurer to compare health outcomes between females who used and who did not use a doula (2014-2023). We conducted propensity score matching using a 1:1 case‒control match, without replacement, and fit logistic regressions to analyze the relative risks for maternal health outcomes. Results. The study population included 722 matched pairs with and without a doula. Results indicate females with doulas had a 47% lower risk of cesarean delivery and a 29% lower risk of preterm birth, and were 46% more likely to attend a postpartum checkup (all differences P < .05). Conclusions. Doula care is associated with improved health outcomes among Medicaid enrollees. Public Health Implications. Doulas have garnered increasing interest from policymakers as a strategy to address increasing trends in maternal morbidity and persistent health disparities. This study provides evidence from Medicaid enrollees across the United States that doula care can improve maternal health. (Am J Public Health. 2024;114(11):1275-1285. https://doi.org/10.2105/AJPH.2024.307805).

African Immigrant Women's Experiences of Maternity Care in the United States

OBJECTIVE

The purpose of this study was to explore maternity care experiences of African immigrant women during the perinatal period including factors affecting access to and use of care.

METHODS

We used Sandelowski's (2010) qualitative descriptive approach to examine how African immigrant women from various countries of origin and with diverse ethnic backgrounds experienced and navigated the maternity care system in the United States during pregnancy and childbirth. We conducted semi-structured interviews with 15 African immigrant women living in the Columbus, Ohio area. Participants were recruited using purposive and snowball sampling between February 2021 and May 2021. Interviews were recorded, transcribed, and analyzed using a reflexive thematic analysis approach.

FINDINGS

Four major themes defined the experiences of our study participants: access to information, patient-clinician relationships, experiences of discrimination , and costs of maternity care .

CLINICAL IMPLICATIONS

Findings highlight key barriers to providing quality and acceptable maternity care to African immigrant women at multiple levels. This group's unique barriers underlie the importance of incorporating their diverse experiences into maternity care models and clinical practice. Further research is needed to evaluate and improve maternity care for African immigrant women.

Maternal implications of fetal anomalies: a population-based cross-sectional study

BACKGROUND

Although it is well-known that the presence of fetal anomalies is associated with maternal morbidity, granular information on these risks by type of anomaly is not available.

OBJECTIVE

To examine adverse maternal outcomes according to the type of fetal anomaly.

STUDY DESIGN

This was a repeated cross-sectional analysis of US vital statistics Live Birth/Infant Death linked data from 2011 to 2020. All pregnancies at 20 weeks or greater were included. Our primary outcome was severe maternal morbidity (SMM), defined as any maternal intensive care unit admission, transfusion, uterine rupture, or hysterectomy. Outcomes were compared between pregnancies with a specific type of fetal anomaly and pregnancies without any fetal anomaly. Fetal anomalies that were available in the dataset included anencephaly, meningomyelocele/spina bifida, cyanotic congenital heart disease, congenital diaphragmatic hernia, omphalocele, gastroschisis, cleft lip and/or palate, hypospadias, limb anomaly, and chromosomal disorders. If a fetus had more than one anomaly, it was classified as multiple anomalies. Adjusted relative risks (aRR) with 99% confidence intervals (99% CI) were calculated using modified Poisson regression. Adjusted risk differences (aRDs) were calculated using the marginal standardization form of predictive margins.

RESULTS

Of 35,760,626 pregnancies included in the analysis, 35,655,624 pregnancies had no fetal anomaly and 105,002 had isolated or multiple fetal anomalies. Compared to pregnancies without fetal anomaly, all fetal anomalies were associated with an increased risk of SMM except for gastroschisis and limb anomaly in order of aRRs (99% CI): 1.58 (1.29-1.92) with cleft lip and/or palate; 1.75 (1.35-2.27) with multiple anomalies; 1.76 (1.18-2.63) with a chromosomal disorder; 2.19 (1.82-2.63) with hypospadias; 2.20 (1.51-3.21) with spina bifida; 2.39 (1.62-3.53) with congenital diaphragmatic hernia; 2.66 (2.27-3.13) with congenital heart disease; 3.15 (2.08-4.76) with omphalocele; and 3.27 (2.22-4.80) with anencephaly. Compared to pregnancies without fetal anomaly, all fetal anomalies were associated with an increased absolute risk of SMM except for gastroschisis and limb anomaly in order of aRDs (99% CI): 0.26 (0.12-0.40) with cleft lip and/or palate, 0.34 (0.13-0.55) with multiple anomalies, 0.34 (0.02-0.66) with a chromosomal disorder, 0.54 (0.36-0.72) with hypospadias, 0.54 (0.17-0.92) with spina bifida, 0.63 (0.21-1.05) with congenital diaphragmatic hernia, 0.75 (0.56-0.95) with congenital heart disease, 0.97 (0.38-1.56) with omphalocele, and 1.03 (0.46-1.59) with anencephaly.

CONCLUSION

The presence of fetal anomalies is associated with adverse maternal health outcomes. The risk of SMM varies according to the type of fetal anomaly. Counseling mothers about the maternal implications of fetal anomalies is paramount to help them make informed decisions regarding their pregnancy outcome.

Risk of short-term cardiovascular disease in relation to the mode of delivery in singleton pregnancies: a retrospective cohort study

Background

Cardiovascular disease (CVD) is increasing in prevalence and affects up to 4% of pregnancies in otherwise healthy persons. The specific factors that drive the development of CVD in pregnant people are poorly characterised. This study aimed to determine whether the mode of delivery in singletons affects the risk of cardiovascular morbidity and mortality within one year in patients without prior CVD.

Methods

We designed a retrospective cohort study utilising the Nationwide Readmissions Database (NRD) to identify singleton delivery hospitalisations in the United States from Jan 1, 2010 to Nov 30, 2018. International Classification of Disease (ICD) versions 9 and 10 codes were used to identify patients with readmission for CVD within the calendar year of index delivery. Patients aged 15-54 who underwent a singleton vaginal or caesarean delivery were included. Patients with pre-existing CVD hospitalisations before or during delivery, ectopic pregnancies, or abortive outcomes were excluded. Participant data was retrieved from the NRD database. The primary outcome was hospital readmission, defined by ICD 9 and 10 codes for fatal or non-fatal CVD in the same calendar year as delivery. Cox proportional hazard regression models were used to adjust for confounders. These included maternal age, hospital bed size, hospital type, hospital teaching status, income quartile, insurance, and year of delivery. Additional sub-analyses were performed adjusting for hypertensive disorders of pregnancy and diabetes mellitus.

Findings

Of the 14,179,299 singleton deliveries, 32% (n = 4,553,492) underwent a caesarean. CVD readmissions occurred in 255.2 per 100,000 (n = 11,710) caesarean deliveries compared with 133.9 per 100,000 (n = 12,507) vaginal deliveries (rate difference [RD], 121.4, 95% confidence interval [CI], 114.8-127.9; hazard ratio [HR] adjusted for all confounders including hypertensive disorders of pregnancy and diabetes mellitus was 1.42, 95% CI 1.35-1.50). This association was highest in the first 0-29 days following delivery (HR 1.68, 95% CI 1.59-1.78). The risk of readmission for CVD persisted for one year.

Interpretation

These findings suggest that caesarean delivery of singletons is associated with a higher risk of cardiovascular morbidity in patients without pre-existing CVD. This risk was highest in the first month but remained elevated for one year after delivery. These findings add to the accumulating evidence that undergoing caesarean delivery may have long-standing health implications and support the extension of the post-partum surveillance period. Limitations of this study include the lack of adjustment for body mass index, race, and parity. We were also unable to determine the reason for the caesarean delivery.

Funding

None.

Severe Maternal Morbidity: The Impact of Race on Tricare Beneficiaries

Maternal morbidity and mortality rates in the United States have increased in the last two decades with a disproportionate impact on women of color. While numerous factors contribute to the inequities in pregnancy-related mortality, access to health insurance is among the most significant. Military Tricare models universal health care access; however, in studies looking at births in military treatment facilities, disparities still exist for women of color. This study analyzed maternal delivery outcomes for all women with Tricare coverage, including deliveries in the civilian sector. We analyzed data from 6.2 million births in the Centers for Disease Control (CDC) Wide-ranging Online Data for Epidemiology Research (WONDER) Linked Birth/Infant Death Records for 2017-2019. Data included all-cause morbidity (transfusions, perineal lacerations, uterine rupture, unplanned hysterectomy, and ICU admissions), severe maternal morbidity (SMM) excluding lacerations, and SMM excluding transfusion. Risk ratios were calculated by comparing overall maternal morbidity rates between Tricare, Medicaid, self-pay, and private insurance. In addition, risk ratios were calculated between insurance types stratified by race. In conclusion, there is an increased risk for women identifying as racial minorities for SMM and SMM excluding transfusion. While Tricare coverage seems to decrease the risk, the decrease is not significant and disparities in outcomes persist among women identifying as minorities. The risk of severe maternal morbidity remains elevated for women of color despite access to Tricare health insurance.

Diversity, Equity, and Inclusion: Obstetrics and Gynecologist Hospitalists' Impact on Maternal Mortality

Obstetrics and gynecology hospitalists play a vital role in reducing maternal morbidity and mortality by providing immediate access to obstetric care, especially in emergencies. Their presence in hospitals ensures timely interventions and expert management, contributing to better outcomes for mothers and babies. This proactive approach can extend beyond hospital walls through education, advocacy, and community outreach initiatives aimed at improving maternal health across diverse settings.

The Role of the Obstetrics and Gynecology Hospitalist in the Changing Landscape of Obstetrics and Gynecology Practice

As the field of obstetrics and gynecology (Ob/Gyn) evolves, the role of the Ob/Gyn hospitalists has become increasingly integrated into the framework of the specialty. Ob/Gyn hospitalists take on essential responsibilities as competent clinicians in emergent situations and as hospital leaders: maintaining standard of care, collaborating with community practitioners and care teams, promoting diversity, equity, and inclusion practices, and contributing to educational initiatives. The impact of the Ob/Gyn hospitalists is positive for patients, fellow clinicians, and institutions. As the field continues to change and the Ob/Gyn hospitalist develops as an established subspecialty, further research evaluating its role remains essential.

Prevalence of Hypertensive Disorders of Pregnancy and Gestational Diabetes Mellitus by Race and Ethnicity in Illinois, 2018 to 2020

PURPOSE

Use administrative discharge data from 2018 to 2020 to determine if there are differences in the prevalence of hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) by race and ethnicity in Illinois.

STUDY DESIGN AND METHODS

This retrospective cross-sectional study used administrative discharge records from all patients who had live births in Illinois over a 3-year period; 2018, 2019, 2020. Multivariate analyses were performed to control for covariates and determine if associations vary by race and ethnicity for HDP and GDM.

RESULTS

A total of 287,250 discharge records were included. Multivariate analyses showed that after adjusting for covariates, non-Hispanic Black women had 1.60 increased odds of HDP compared to non-Hispanic White women (OR, 1.60; 95% CI, 1.55-1.65). Hispanic women (OR, 1.45; 95% CI, 1.40-1.50), Asian/Pacific Islander women (OR, 2.07; 95% CI, 1.97-2.17), and American Indian/Alaska Native women (OR, 1.43; 95% CI, 1.17-1.74) had an increased odds of GDM compared to non-Hispanic White women.

CLINICAL IMPLICATIONS

Women of color were at increased odds for HDP and GDM in Illinois. To eliminate poor maternal outcomes in women of color at risk for HDP and GDM, more culturally congruent health equity practices, policies, and comprehensive care interventions must be adopted.

Community level factors and racial inequities in delivery hospitalizations involving severe maternal morbidity in the United States, 2016-2019

The objective of this study was to evaluate the racial and ethnic disparities in delivery hospitalizations involving severe maternal morbidity (SMM) by location of residence and community income. We used the 2016 to 2019 Healthcare Cost and Utilization Project National Inpatient Sample. International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to identify delivery hospitalizations with SMM. Using logistic regression models, we examined the association between race and ethnicity and delivery hospitalizations involving SMM. In adjusted analyses, the models were stratified by location of residence and community income and adjusted for patient and hospital characteristics. In rural areas, non-Hispanic Black women (AOR 1.50; 95% CI 1.25-1.79) and women of other races (AOR 1.32; 95% CI 1.03-1.69) had an increased odds of experiencing a delivery hospitalization involving SMM when compared to non-Hispanic White women. In micropolitan areas, non-Hispanic Black women (AOR 1.88; 95% CI 1.79-1.97), non-Hispanic Asian/Pacific Islander women (AOR 1.54; 95% CI 1.16-2.05), and women of other races (AOR 1.31; 95% CI 1.03-1.67) had an increased odds of experiencing a delivery hospitalization involving SMM when compared to non-Hispanic White women. Non-Hispanic Black women also had increased odds of experiencing a delivery hospitalization involving SMM in communities with the lowest income (quartile 1) (AOR 1.59; 95% CI 1.49-1.66), middle income (quartiles 2 and 3) (AOR 1.81; 95% CI 1.72-1.91), and highest income (AOR 2.09; 95% CI 1.90-2.29) when compared to non-Hispanic White women. We found that location of residence and community income are associated with racial and ethnic differences in SMM in the United States. These factors, outside of individual factors assessed in previous studies, provide a better understanding of some of the structural and systemic factors that may contribute to SMM.

Pregnancy with endometriosis: Assessment of national-level trends, characteristics, and maternal morbidity at delivery

OBJECTIVE

To examine pregnancy characteristics and maternal morbidity at delivery among pregnant patients with a diagnosis of endometriosis.

STUDY DESIGN

This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample. Study population was 17,796,365 hospital deliveries from 2016 to 2020, excluded adenomyosis and uterine myoma. The exposure was endometriosis diagnosis. Main outcome measures were clinical and pregnancy characteristics and severe maternal morbidity at delivery related to endometriosis, assessed with multivariable regression model.

RESULTS

Endometriosis was diagnosed in 17,590 patients. The prevalence of endometriosis increased by 24 % from one in 1,191 patients in 2016 to one in 853 patients in 2020 (adjusted-odds ratio [aOR] 1.24, 95% confidence interval [CI] 1.19-1.30). Clinical and pregnancy characteristics that had greater than two-fold association to endometriosis included polycystic ovary syndrome, placenta previa, cesarean delivery, maternal age of ≥30 years, prior pregnancy loss, and anxiety disorder. Pregnant patients with endometriosis were more likely to have the diagnosis of measured severe maternal morbidity during the index hospitalization for delivery (47.8 vs 17.3 per 1,000 deliveries, aOR 1.91, 95%CI 1.78-2.06); these associations were more prominent following vaginal (aOR 2.82, 95%CI 2.41-3.30) compared to cesarean (aOR 1.85, 95%CI 1.71-2.00) deliveries. Among the individual morbidity indicators, endometriosis was most strongly associated with thromboembolism (aOR 5.05, 95%CI 3.70-6.91), followed by sepsis (aOR 2.39, 95%CI 1.85-3.09) and hysterectomy (aOR 2.18, 95%CI 1.85-2.56). When stratified for endometriosis anatomical site, odds of thromboembolism was increased in endometriosis at distant site (aOR 9.10, 95%CI 3.76-22.02) and adnexa (aOR 7.37, 95%CI 4.43-12.28); odds of sepsis was most increased in endometriosis at multi-classifier locations (aOR 7.33, 95%CI 2.93-18.31) followed by pelvic peritoneum (aOR 5.54, 95%CI 2.95-10.40); and odds of hysterectomy exceeded three-fold in endometriosis at adnexa (aOR 3.00, 95%CI 2.30-3.90), distant site (aOR 5.36, 95%CI 3.48-8.24), and multi-classifier location (aOR 4.46, 95%CI 2.11-9.41).

CONCLUSION

The results of this nationwide analysis suggest that pregnancy with endometriosis is uncommon but gradually increasing over time in the United States. The data also suggest that endometriosis during pregnancy is associated with increased risk of severe maternal morbidity at delivery, especially for thromboembolism, sepsis, and hysterectomy. These morbidity risks differed by the anatomical location of endometriosis.

"We don't really address the trauma": Patients' Perspectives on Postpartum Care Needs after Severe Maternal Morbidities

OBJECTIVES

This qualitative study explored experiences of 15 women in New York City who suffered physical, emotional, and socioeconomic consequences of severe maternal morbidity (SMM). This study aimed to increase our understanding of additional burdens these mothers faced during the postpartum period.

METHODS

Qualitative analysis of in-depth interviews (n = 15) with women who had given birth in NYC hospitals and experienced SMM. We focused on how experiences of SMM impacted postpartum recoveries. Grounded theory methodology informed analysis of participants' one-on-one interviews. To understand the comprehensive experience of postpartum recovery after SMM, we drew on theories about social stigma, reproductive equity, and quality of care to shape constant-comparative analysis and data interpretation.

FINDINGS

Three themes were generated from data analysis: 'Caring for my body' defined by challenges during physical recuperation, 'caring for my emotions' which highlighted navigation of mental health recovery, and 'caring for others' defined by care work of infants and other children. Most participants identified as Black, Latinx and/or people of color, and reported the immense impacts of SMM across aspects of their lives while receiving limited access to resources and insufficient support from family and/or healthcare providers in addressing postpartum challenges.

CONCLUSIONS FOR PRACTICE

Findings confirm the importance of developing a comprehensive trauma-informed approaches to postpartum care as a means of addressing SMM consequences.

Machine learning: a new era for cardiovascular pregnancy physiology and cardio-obstetrics research

The maternal cardiovascular system undergoes functional and structural adaptations during pregnancy and postpartum to support increased metabolic demands of offspring and placental growth, labor, and delivery, as well as recovery from childbirth. Thus, pregnancy imposes physiological stress upon the maternal cardiovascular system, and in the absence of an appropriate response it imparts potential risks for cardiovascular complications and adverse outcomes. The proportion of pregnancy-related maternal deaths from cardiovascular events has been steadily increasing, contributing to high rates of maternal mortality. Despite advances in cardiovascular physiology research, there is still no comprehensive understanding of maternal cardiovascular adaptations in healthy pregnancies. Furthermore, current approaches for the prognosis of cardiovascular complications during pregnancy are limited. Machine learning (ML) offers new and effective tools for investigating mechanisms involved in pregnancy-related cardiovascular complications as well as the development of potential therapies. The main goal of this review is to summarize existing research that uses ML to understand mechanisms of cardiovascular physiology during pregnancy and develop prediction models for clinical application in pregnant patients. We also provide an overview of ML platforms that can be used to comprehensively understand cardiovascular adaptations to pregnancy and discuss the interpretability of ML outcomes, the consequences of model bias, and the importance of ethical consideration in ML use.

Multiple marginalized identities: A qualitative exploration of intersectional perinatal experiences of birthing people of color with substance use disorder in Massachusetts

INTRODUCTION

Racial and ethnic inequities persist in receipt of prenatal care, mental health services, and addiction treatment for pregnant and postpartum individuals with substance use disorder (SUD). Further qualitative work is needed to understand the intersectionality of racial and ethnic discrimination, stigma related to substance use, and gender bias on perinatal SUD care from the perspectives of affected individuals.

METHODS

Peer interviewers conducted semi-structured qualitative interviews with recently pregnant people of color with SUD in Massachusetts to explore the impact of internalized, interpersonal, and structural racism on prenatal, birthing, and postpartum experiences. The study used a thematic analysis to generate the codebook and double coded transcripts, with an overall kappa coefficient of 0.89. Preliminary themes were triangulated with five participants to inform final theme development.

RESULTS

The study includes 23 participants of diverse racial/ethnic backgrounds: 39% mixed race/ethnicity (including 9% with Native American ancestry), 30% Hispanic or Latinx, 26% Black/African American, 4% Asian. While participants frequently names racial and ethnic discrimination, both interpersonal and structural, as barriers to care, some participants attributed poor experiences to other marginalized identities and experiences, such as having a SUD. Three unique themes emerged from the participants' experiences: 1) Participants of color faced increased scrutiny and mistrust from clinicians and treatment programs; 2) Greater self-advocacy was required from individuals of color to counteract stereotypes and stigma; 3) Experiences related to SUD history and pregnancy status intersected with racism and gender bias to create distinct forms of discrimination.

CONCLUSION

Pregnant and postpartum people of color affected by perinatal SUD faced pervasive mistrust and unequal standards of care from mostly white healthcare staff and treatment spaces, which negatively impacted their treatment access, addiction medication receipt, postpartum pain management, and ability to retain custody of their children. Key clinical interventions and policy changes identified by participants for antiracist action include personalizing anesthetic plans for adequate peripartum pain control, minimizing reproductive injustices in contraceptive counseling, and addressing misuse of toxicology testing to mitigate inequitable Child Protective Services (CPS) involvement and custody loss.

Planning for the forgotten fourth trimester of pregnancy: A parallel group randomized control trial to test a postpartum planning intervention vs. standard prenatal care

BACKGROUND

Black and brown birthing people experience persistent disparities in adverse maternal health outcomes, partially due to inadequate perinatal care. The goal of this study is to design and evaluate a patient-centered intervention for obstetric patients with one or more cardiometabolic risk factors for severe maternal morbidity [gestational diabetes, diabetes mellitus, hypertensive disorders of pregnancy (chronic hypertension, preeclampsia, eclampsia, or gestational hypertension), or preconception obesity (BMI > 30)] to promote postpartum visit attendance.

METHODS

To address identified unmet needs for postpartum support and barriers to postpartum care, we developed 20 thematic postpartum planning modules, each with corresponding patient educational materials, community resources, care coordination protocols, and clinician support tools (decision aids, electronic medical record prompts and fields). During prenatal care encounters, a research coordinator delivers the educational content (in English or Spanish), facilitates the participant's planning and shared decision-making, provides the participant with resources, and documents decisions in the electronic medical record. We will randomize 320 eligible patients with a 1:1 ratio to the intervention or standard prenatal care and evaluate the impact on postpartum visit attendance at 4-12 weeks and secondary outcomes (postpartum mental health, perceived future maternal and cardiometabolic risk, contraceptive use, primary care use, readmission, and patient satisfaction with care).

DISCUSSION

Through engagement with patients and community stakeholders, we developed a guideline-based, locally tailored intervention to address drivers of engagement with postpartum care for high-risk obstetric patients. If demonstrated to be effective, the educational materials and electronic medical record based-tool can be adapted to other settings.

TRIAL REGISTRATION

This trial was registered on ClinicalTrials.gov (NCT05430815) on June 23, 2022.

Is severe maternal morbidity a risk factor for postpartum hospitalization with mental health or substance use disorder diagnoses? Findings from a retrospective cohort study in Maryland: 2016-2019

BACKGROUND

Perinatal mental health conditions and substance use are leading causes, often co-occurring, of pregnancy-related and pregnancy-associated deaths in the United States. This study compares odds of hospitalization with a mental health condition or substance use disorder or both during the first year postpartum between patients with and without severe maternal morbidity (SMM) during delivery hospitalization.

Methods

Data are from the Maryland's State Inpatient Database and include patients with a delivery hospitalization during 2016-2018 (n = 197,749). We compare rate of hospitalization with a mental health condition or substance use disorder or both at 42 days and 42 days to 1 year postpartum by occurrence of SMM during the delivery hospitalization. We use multivariable logistic regression to derive the odds of hospitalization with each outcome for patients by SMM status, adjusted for patient sociodemographic characteristics, presence of mental health condition or substance use disorder diagnoses during the delivery hospitalization, and delivery outcome. SMM, mental health conditions, and substance use disorders are identified using ICD-10 diagnosis and procedure codes.

RESULTS

Overall, 5,793 patients (2.9%) who delivered during 2016-2018 experienced hospitalization in the year following delivery. Among these patients, 24.3% (n = 1,410) had a mental health condition diagnosis, 10.6% (n = 619) had a substance use disorder diagnosis, and 9.8% (n = 570) had co-occurring mental health condition and substance use disorder diagnoses. Patients with SMM had 3.7 times the odds (95% CI 2.7, 5.2) of hospitalization with a mental health condition diagnosis, 2.7 times the odds (95% CI 1.6, 4.4) of a hospitalization with substance use disorder diagnosis, and 3.0 times the odds (95% CI 1.8, 4.8) of hospitalization with co-occurring mental health condition and substance use disorder diagnoses during the first-year postpartum adjusting for covariates.

CONCLUSION

Patients who experience SMM during their delivery hospitalization had higher odds of hospitalization with a mental health condition, substance use disorder, and co-occurring mental health condition and substance use disorder in the one-year postpartum period. Treatment and support resources for mental health and substance use providers --including enhanced screening and warm handoffs -- should be made available to patients with SMM upon discharge after delivery, and evidence-based interventions to improve mental health and reduce substance use should be prioritized in these patients.

Impact of hyponatremia in preeclamptic patients with severe features

Hyponatremia, though common in women with preeclampsia, has not been well studied. Our primary objectives are to assess the clinical characteristics and emergency therapy applied to subjects diagnosed with preeclampsia. We hypothesize that hyponatremia present in preeclamptic patients with severe features is associated with greater use of emergency hypertensives, antenatal steroids, and cesarean delivery. This is a retrospective descriptive study utilizing an electronic health record database (TriNetX ®). We collected and evaluated the following data of subjects aged 15 to 54 years with preeclampsia with severe features diagnosis: demographics, diagnostic codes, medication codes, procedure codes, deaths, and laboratory results. A total of 2,901 subjects [215 (7.4%)] with a sodium level below 134 mEq/L and [2686 (92.6%)] with a sodium level above 135 mEq/L were included. A higher proportion of subjects in the below 134 sodium group received emergency antihypertensives [165 (76.7%) versus 1811 (67.4%), p = 0.01], antenatal steroids [103 (47.9%) versus 953 (35.5%), p = 0.001], and cesarean section [27 (12.6%) versus 97 (3.6%), p = <0.001]. We found that hyponatremia may be associated with emergency antihypertensive use, antenatal steroid use, and cesarean section in patients with preeclampsia with severe features. Future research is needed to determine if routine sodium levels assessed in preeclamptic subjects with severe features identify subjects at risk of receiving these treatments.