A Gap in Care? Postpartum Women Presenting to the Emergency Room and Getting Readmitted

Socioeconomic, Demographic, and Clinical Factors Associated with Postpartum Readmission

Purpose: To determine if socioeconomic, demographic, and clinical characteristics are associated with postpartum readmission. Methods: A retrospective cohort study evaluating all pregnant patients that delivered at seven hospitals within a large academic health system in New York between January 1, 2018 and March 1, 2020. Demographic information, medical comorbidities, and characteristics of antepartum, intrapartum, and postpartum care were compared between patients who were readmitted within 6 weeks postpartum and those who were not. Postpartum patients who presented to the emergency department but remained less than 23 hours were excluded. Patient ZIP codes were linked to data from the United States Census Bureau's American Community Survey and used as a proxy for neighborhood socioeconomic status. Mixed effects logistic regression was used to evaluate factors associated with an increased risk of postpartum readmission while adjusting for potential confounders. Results: A total of 57,507 delivery hospitalizations were evaluated, and 1,481 (2.5%) patients were readmitted. Black race (aOR: 1.56, 95% CI: 1.30-1.86, p < 0.001) and public health insurance (aOR: 1.19, 95% CI: 1.05-1.35, p = 0.007) were associated with an increased likelihood of postpartum readmission. Chronic hypertension (aOR: 2.83, 95% CI: 2.33-3.44, p < 0.001), body mass index >25 kg/m2 (aOR: 1.22, 95% CI: 1.05-1.42, p = 0.01), gestational weight gain >40 lb (aOR: 1.19, 95% CI: 1.01-1.40, p = 0.04), and administration of blood products (aOR: 2.18, 95% CI: 1.68-2.82, p < 0.001) were associated with an increased odd of readmission. Neighborhood characteristics were not associated with postpartum readmission. Conclusion: Efforts to reduce postpartum readmissions should focus on high-risk populations. Specific sociodemographic and clinical characteristics are associated with this complication.

Management of Postpartum Preeclampsia and Hypertensive Disorders (MOPP): Postpartum Tight vs Standard Blood Pressure Control

BACKGROUND

It is unknown whether tightly controlled blood pressure in the postpartum period will improve outcomes.

OBJECTIVES

The purpose of this study was to assess the effect of a lower treatment threshold (≥130/80 mm Hg) for initiating and titrating antihypertensive medication on reducing emergency department visits in postpartum patients with hypertension.

METHODS

A prospective cohort of postpartum patients was recruited in a multicenter study between March 2023 and March 2024 and treated to maintain blood pressure <130/80 mm Hg using remote blood pressure monitoring. These patients were compared to a propensity score-matched retrospective cohort from February 2021 to February 2023 who were treated to maintain blood pressures <150/100 mm Hg. Eligible patients were 18 or older with a diagnosis of hypertensive disorder. The primary outcome was an emergency department visit for hypertension.

RESULTS

There were 392 patients enrolled in the interventional cohort and 1,204 patients identified in the retrospective cohort. After the propensity score match, 276 and 429 patients remained in the prospective and retrospective groups, respectively. Emergency department visits for hypertensive disorders occurred in 10 patients (3.6%) in the intervention and 36 patients (8.4%) in the retrospective cohort (risk difference -4.8; 95% CI: -8.2 to -1.3; doubly robust OR: 0.32; 95% CI: 0.10-1.01). At 6 weeks postpartum, compared to the retrospective group, the intervention group had systolic and diastolic blood pressure that was 4.4 mm Hg (95% CI: -6.8 to -2.0) and 3.1 mm Hg (95% CI: -4.9 to -1.2) lower, respectively.

CONCLUSIONS

Tighter blood pressure control was associated with reduced postpartum emergency department visits for hypertensive disorders.

Near-miss and maternal sepsis mortality: A qualitative study of survivors and support persons

BACKGROUND

Prior studies have shown that maternal deaths due to sepsis occur due to delays in recognition, treatment, and escalation of care through medical chart reviews. This study was conducted to obtain the patient perspective for near-miss and maternal mortality cases due to sepsis.

OBJECTIVE

To identify quality improvement opportunities for improving maternal sepsis through patient and support person experiences.

STUDY DESIGN

Twenty semi-structured interviews and three follow-up focus groups with patients who experienced critical illness from maternal sepsis in the United States and their support persons (when available) were conducted from May 23, 2022, through October 14, 2022. In this qualitative study, data were analyzed using inductive thematic analysis.

RESULTS

In this qualitative study of patients with maternal sepsis and their support persons, four main quality improvement themes were identified. The themes were the following: (1) participants reported a lack of awareness of pregnancy-related warning signs and symptoms of when to seek care, (2) many of the presenting symptoms participants experienced were not typical of expected warning signs of maternal sepsis, such as severe pain, overwhelming tiredness, and lack of fever (3) participant concerns were met with dismissal leading to delays in diagnosis, (4) participants experienced long-term sequelae but had difficulty receiving screening and referrals for treatment.

CONCLUSIONS

The findings of this study suggest that standardized patient education about the warning signs of maternal sepsis and provider education about the presentation of maternal sepsis, improved listening to patients, and follow-up for sequalae of sepsis are needed.

"Health challenges and midwifery support for new mothers after childbirth: A cross-sectional study in Sweden"

OBJECTIVE

This study aimed to investigate new mothers' self-rated and perceived health problems and complications; their reasons for, and the frequency of, emergency department visits; how emergency department visits were associated with sociodemographic and obstetric factors; and new mothers' experiences of received support from the midwifery clinic.

DESIGN

A cross-sectional survey.

SETTING AND PARTICIPANTS

The study was conducted at 35 of 64 midwifery clinics in Stockholm, Sweden. The study population consisted of 580 new mothers.

MEASUREMENT AND FINDINGS

Descriptive statistics and logistic regression were used. New mothers experience a range of different health problems and complications during the first four weeks after giving birth. Sixteen percent sought emergency care. The odds of seeking emergency care increased for women with higher age and poorer self-rated health. Sixty-three percent of the new mothers received support from a midwife in primary care within the first four weeks after childbirth. Mothers who did not receive the support they wanted, expressed a wish for earlier contact and better accessibility.

CONCLUSION AND IMPLICATION FOR PRACTICE

It is notable that 16 % of new mothers seek emergency care in the first weeks after childbirth. This study has practical implications for midwifery practice and policy. There is a need for tailored postnatal support strategies so that midwives potentially are able to mitigate emergency department visits. Further studies should look at whether the high number of emergency visits among new mothers varies throughout Sweden, and whether this may be a result of reduced time of hospital stay after childbirth or other factors.

Early Postpartum Hospital Encounters among Patients with Genitourinary and Wound Infections during Hospitalization for Birth

OBJECTIVES

This study aimed to assess the associations between genitourinary and wound infections during the birth hospitalization and early postpartum hospital encounters, and to evaluate clinical risk factors for early postpartum hospital encounters among patients with genitourinary and wound infections during the birth hospitalization.

STUDY DESIGN

We conducted a population-based cohort study of births in California during 2016 to 2018 and postpartum hospital encounters. We identified genitourinary and wound infections using diagnosis codes. Our main outcome was early postpartum hospital encounter, defined as a readmission or emergency department (ED) visit within 3 days after discharge from the birth hospitalization. We evaluated the association of genitourinary and wound infections (overall and subtypes) with early postpartum hospital encounter using logistic regression, adjusting for sociodemographic factors and comorbidities and stratified by mode of birth. We then evaluated factors associated with early postpartum hospital encounter among patients with genitourinary and wound infections.

RESULTS

Among 1,217,803 birth hospitalizations, 5.5% were complicated by genitourinary and wound infections. Genitourinary or wound infection was associated with an early postpartum hospital encounter among patients with both vaginal births (2.2%; adjusted risk ratio [aRR[: 1.26; 95% confidence interval [CI]: 1.17-1.36) and cesarean births (3.2%; aRR: 1.23; 95% CI: 1.15-1.32). Patients with a cesarean birth and a major puerperal infection or wound infection had the highest risk of an early postpartum hospital encounter (6.4 and 4.3%, respectively). Among patients with genitourinary and wound infections during the birth hospitalization, factors associated with an early postpartum hospital encounter included severe maternal morbidity, major mental health condition, prolonged postpartum hospital stay, and, among cesarean births, postpartum hemorrhage (p-value < 0.05).

CONCLUSION

Genitourinary and wound infections during hospitalization for birth may increase risk of a readmission or ED visit within the first few days after discharge, particularly among patients who have a cesarean birth and a major puerperal infection or wound infection.

KEY POINTS

· In all, 5.5% of patients giving birth had a genitourinary or wound infection (GWI).. · A total of 2.7% of GWI patients had a hospital encounter within 3 days of discharge after birth.. · Major puerperal infection and wound infection had the highest risk of an early hospital encounter.. · Among GWI patients, several birth complications were associated with an early hospital encounter..

Multivariable risk model for postpartum re-presentation with hypertension: development phase

OBJECTIVES

Postpartum hypertension is one of the leading causes of re-presentation to hospital postpartum and is associated with adverse long-term cardiovascular risk. Postpartum blood pressure monitoring and management interventions have been shown to reduce hospital re-presentation, complications and long-term blood pressure control. Identifying patients at risk can be difficult as 40%-50% present with de novo postpartum hypertension. We aim to develop a risk model for postpartum re-presentation with hypertension using data readily available at the point of discharge.

DESIGN

A case-control study comparing all patients who re-presented to hospital with hypertension within 28 days post partum to a random sample of all deliveries who did not re-present with hypertension. Multivariable analysis identified risk factors and bootstrapping selected variables for inclusion in the model. The area under the receiver operator characteristic curve or C-statistic was used to test the model's discriminative ability.

SETTING

A retrospective review of all deliveries at a tertiary metropolitan hospital in Melbourne, Australia from 1 January 2016 to 30 December 2020.

RESULTS

There were 17 746 deliveries, 72 hypertension re-presentations of which 51.4% presented with de novo postpartum hypertension. 15 variables were considered for the multivariable model. We estimated a maximum of seven factors could be included to avoid overfitting. Bootstrapping selected six factors including pre-eclampsia, gestational hypertension, peak systolic blood pressure in the delivery admission, aspirin prescription and elective caesarean delivery with a C-statistic of 0.90 in a training cohort.

CONCLUSION

The development phase of this risk model builds on the three previously published models and uses factors readily available at the point of delivery admission discharge. Once tested in a validation cohort, this model could be used to identify at risk women for interventions to help prevent hypertension re-presentation and the short-term and long-term complications of postpartum hypertension.

Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care

Sepsis in obstetric care is one of the leading causes of maternal death in the United States, with Black, Asian/Pacific Islander, and American Indian/Alaska Native obstetric patients experiencing sepsis at disproportionately higher rates. State maternal mortality review committees have determined that deaths are preventable much of the time and are caused by delays in recognition, treatment, and escalation of care. The "Sepsis in Obstetric Care" patient safety bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people by preventing infection and recognizing and treating infection early to prevent progression to sepsis. This is one of several core patient safety bundles developed by AIM (the Alliance for Innovation on Maternal Health) to provide condition- or event-specific clinical practices that should be implemented in all appropriate care settings. As with other bundles developed by AIM, the "Sepsis in Obstetric Care" patient safety bundle is organized into five domains: Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, and Respectful, Equitable, and Supportive Care. The Respectful, Equitable, and Supportive Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into the elements of each domain.

Understanding categories of postpartum care use among privately insured patients in the United States: a cluster-analytic approach

The postpartum period is critical for the health and well-being of birthing people, yet little is known about the range of health care services and supports needed during this time. Maternity care patients are often targeted for clinical interventions based on "low risk" or "high risk" designations, but dichotomized measures can be imprecise and may not reflect meaningful groups for understanding needed postpartum care. Using claims data from privately insured patients with childbirths between 2016 and 2018, this study identifies categories and predictors of postpartum care utilization, including the use of maternal care and other, nonmaternal, care (eg, respiratory, digestive). We then compare identified utilization-based categories with typical high- and low-risk designations. Among 269 992 patients, 5 categories were identified: (1) low use (55% of births); (2) moderate maternal care use, low other care use (25%); (3) moderate maternal, high other (8%); (4) high maternal, moderate other (7%); and (5) high maternal, high other (5%). Utilization-based categories were better at differentiating postpartum care use and were more consistent across patient profiles, compared with high- and low-risk dichotomies. Identifying categories of postpartum care need beyond a simple risk dichotomy is warranted and can assist in maternal health services research, policymaking, and clinical practice.

Optimal management of post-discharge postpartum hypertensive disorders of pregnancy: a quality improvement initiative

Introduction: Postpartum hypertensive disorders of pregnancy occur in 2-5% of pregnancies. It is a major cause of urgent postpartum consultation and is associated with life-threatening complications. Our objective was to evaluate if local management of postpartum hypertensive disorders of pregnancy was congruent with expert recommendations. Methods: We conducted a quality improvement initiative through a retrospective single-centre cross-sectional study. All women over 18-year-old consulting emergently for hypertensive disorders of pregnancy in the first six weeks postpartum, from 2015 to 2020, were eligible. Results: We included 224 women. Optimal management of postpartum hypertensive disorders of pregnancy was observed in 65.0%. While diagnosis and laboratory work-up were excellent, adequate blood pressure surveillance and recommendations upon discharge of an outpatient postpartum episode (69.7%) did not meet expectations. Conclusion: Efforts should be targeted to improve discharge recommendations on optimal blood pressure surveillance after delivery for women at risk for hypertensive disorders of pregnancy and for postpartum hypertensive disorders of pregnancy in women treated as outpatients.

Extending Maternal Care After Pregnancy: An Initiative to Address Health Care Disparities and Enhance Access to Care After Delivery

PROBLEM DEFINITION

A substantial proportion of maternal morbidity and mortality occurs after birth. However, little is known about the optimal design of programs to improve outcomes and decrease disparities during this period.

CONTEXT

Parkland Health is a tax-supported health system in Dallas that delivers more than 11,000 patients annually. A community needs assessment identified substantial health disparities in this community. The proportion of women in this region with diabetes mellitus (DM) and chronic hypertension (CHTN) during pregnancy is higher than surrounding regions, but access to care in the area is difficult because of the limited availability of ambulatory care.

INITIAL APPROACH

The authors created extending Maternal Care After Pregnancy (eMCAP), a community-based program, to address health care disparities and enhance access to care for the 12 months after birth. The team also evaluated the ability of Z codes (ICD-10 codes for social determinants of health) to identify patients with health-related social needs.

KEY INSIGHTS AND SURPRISES

The eMCAP program demonstrated improvement in attendance and quality of postpartum care for women living in underserved areas with CHTN and DM. For both CHTN and DM, eMCAP patients were matched 1:2 to controls outside of the eMCAP target region with similar comorbidities for maternal age ± 4 years, Black race, and delivery date ± 45 days. Compared to matched controls who were provided standard referrals, follow-up postpartum attendance for eMCAP women with CHTN was significantly better at 2 weeks and 1, 3, 6, 9, and 12 months (all p < 0.001). Similarly, eMCAP women with DM had significantly better follow-up at 2 weeks (p = 0.04), 1 month (p = 0.002), and 3 months (p = 0.049), resulting in HbA1c values for DM being significantly lower (p < 0.05) throughout the postpartum period. Despite the health system leading in reporting of Z codes, nearly 99% of applicable Z codes were not recorded, underscoring a public health opportunity. Through the eMCAP program, this initiative has demonstrated improved clinical performance for health care outcomes relevant to postpartum patients that can be deployed elsewhere to improve maternal health in underserved communities.

Maternal Centric Measurement and Data Gaps in Addressing Maternal Morbidities: A Scoping Review

OBJECTIVE

The objectives of this project were to (1) describe maternal-centric measures and survey data which are publicly available to evaluate the incidence, frequency, and distribution of maternal morbidity in the postpartum period, and (2) to identify postpartum care quality improvement targets and outline the types of measurement and data required to support them.

METHODS

We conducted a scoping review of two types of data sources: maternal health quality measures used by providers and payers and nationally-representative survey data sets administered by federal agencies. Each source was searched for keywords associated with pregnancy and the postpartum period. We included quality measures and survey questions that are maternal-centric and addressed the postpartum period. We excluded infant-centric measures and data. Quality measures were organized according to the Donabedian quality model.

RESULTS

Our analysis demonstrates that existing maternal-centric quality measures and survey data offer limited insight into diagnosis and patient care delivery experiences associated with maternal morbidities during the postpartum period.

CONCLUSION

There is inadequate maternal-centric data on the incidence, frequency, and distribution of postpartum maternal morbidities and associated care use. This gap reduces the ability of research to estimate the incidence of illness and injury among postpartum women and create targeted quality improvement efforts. Our findings highlight the need for quality measure stewards and data sponsors to enhance data collection and methods to become more inclusive of maternal-centric outcomes during the postpartum period.

Perinatal outcomes and 2017 ACC/AHA blood pressure categories

OBJECTIVE

To evaluate the association of blood pressure category < 20 weeks according to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) criteria with adverse perinatal outcomes.

STUDY DESIGN

A retrospective cohort study of singleton deliveries between 1/2014 and 10/2017 was undertaken. Blood pressure category assigned by 2017 ACC/AHA criteria applied to blood pressures prior to 20 weeks gestation: normal (systolic < 120 and diastolic < 80), elevated blood pressure (systolic 120-129 and diastolic < 80 mmHg), stage 1 hypertension (systolic 130-139 and/or diastolic 80-89), stage 2 hypertension (prior diagnosis of chronic hypertension or systolic ≥ 140 or diastolic ≥ 90 mmHg).

MAIN OUTCOME MEASURES

The primary outcome was preeclampsia. Secondary outcomes included preterm birth and postpartum readmission. Chi-square, ANOVA and Kruskal-Wallis tests and multivariable Poisson regression were used for analysis.

RESULTS

Of the 6,067 eligible pregnancies, 3,855 (63.5%) had normotensive blood pressure, 1,224 (20.2%) elevated blood pressure, 624 (10.3%) stage 1 hypertension, and 364 (6.0%) stage 2 hypertension. Compared to 4.6% prevalence of preeclampsia among normotensive pregnancies, higher categories were associated with higher preeclampsia prevalence: elevated blood pressure (10.7%, adjusted relative risk (aRR) 2.2, 95% confidence interval (CI) 1.8-2.6), stage 1 hypertension (15.1%, aRR 2.7, 95% CI 2.2-3.4) and stage 2 hypertension (38.7%, aRR 6.2, 95% CI 5.1-7.4). Non-normal categories were also associated with a higher risk of preterm birth and postpartum readmission.

CONCLUSION

Patients with elevated blood pressure and stage 1 and 2 hypertension at < 20 weeks are at increased risk of adverse obstetric perinatal outcomes.

The Risk of Readmission after Early Postpartum Discharge during the COVID-19 Pandemic

OBJECTIVE

To determine whether early postpartum discharge during the coronavirus disease 2019 (COVID-19) pandemic was associated with a change in the odds of maternal postpartum readmissions.

STUDY DESIGN

This is a retrospective analysis of uncomplicated postpartum low-risk women in seven obstetrical units within a large New York health system. We compared the rate of postpartum readmissions within 6 weeks of delivery between two groups: low-risk women who had early postpartum discharge as part of our protocol during the COVID-19 pandemic (April 1-June 15, 2020) and similar low-risk patients with routine postpartum discharge from the same study centers 1 year prior. Statistical analysis included the use of Wilcoxon's rank-sum and chi-squared tests, Nelson-Aalen cumulative hazard curves, and multivariate logistic regression.

RESULTS

Of the 8,206 patients included, 4,038 (49.2%) were patients who had early postpartum discharge during the COVID-19 pandemic and 4,168 (50.8%) were patients with routine postpartum discharge prior to the COVID-19 pandemic. The rates of postpartum readmissions after vaginal delivery (1.0 vs. 0.9%; adjusted odds ratio [OR]: 0.75, 95% confidence interval [CI]: 0.39-1.45) and cesarean delivery (1.5 vs. 1.9%; adjusted OR: 0.65, 95% CI: 0.29-1.45) were similar between the two groups. Demographic risk factors for postpartum readmission included Medicaid insurance and obesity.

CONCLUSION

Early postpartum discharge during the COVID-19 pandemic was associated with no change in the odds of maternal postpartum readmissions after low-risk vaginal or cesarean deliveries. Early postpartum discharge for low-risk patients to shorten hospital length of stay should be considered in the face of public health crises.

KEY POINTS

· Early postpartum discharge was not associated with an increase in odds of hospital readmissions after vaginal delivery.. · Early postpartum discharge was not associated with an increase in odds of hospital readmissions after cesarean delivery.. · Early postpartum discharge for low-risk patients should be considered during a public health crisis..