Hospital Readmission Following Delivery With and Without Severe Maternal Morbidity

MOMs Chat & Care Study: Rationale and design of a pragmatic randomized clinical trial to prevent severe maternal morbidity among Black birthing people

BACKGROUND

Black birthing people are disproportionately affected by severe maternal morbidity (SMM). The MOMs Chat & Care Study (R01NR021134) is a pragmatic, randomized clinical trial designed to test the effectiveness of an integrated care model to facilitate timely, appropriate care for high-risk Black birthing people and reduce the risk for SMM.

METHODS

We will recruit 674 adult, English and Spanish-speaking Black birthing people who are less than 17 weeks gestational age, considered high risk based on the Obstetrics-Comorbidity Index and/or history of preeclampsia, and receive care at a Northwell Health obstetric practice. Participants will be randomized to either MOMs High Touch or Low Touch. In both intervention arms participants will receive close monitoring via chatbot technology and navigation to timely care and services by the MOMs team throughout the prenatal and postpartum periods, Fitbit to track physical activity, and bi-weekly postpartum telehealth visits up to 6-weeks postpartum. MOMs High Touch will also receive 12 bi-weekly self-management support telehealth visits during pregnancy and a home blood pressure monitor. The two arms will be compared on incidence of SMM at labor and delivery (Aim 1), SMM-related hospitalizations at 1-month and 1-year postpartum (Aim 1a), time to preeclampsia diagnosis and treatment (Aim 2), perceived social support (Aim 3), and physical activity trajectories (exploratory Aim 4). Mixed methods will be used to examine facilitators and barriers to intervention implementation (Aim 5).

CONCLUSION

Findings from this study will inform how to feasibly implement an effective and sustainable integrated care approach to address SMM disparities.

REGISTRATION OF CLINICAL TRIALS

This trial is registered on www.

CLINICALTRIALS

gov (NCT06335381).

PROTOCOL VERSION

07/22/2024, 24-0131-NH.

Severe Maternal Morbidity and Postpartum Care: An Investigation Among a Privately Insured Population in the United States, 2008-2019

Objective: This study examines postpartum health care utilization among women with severe maternal morbidity (SMM) subtypes (e.g., blood transfusion, renal), focusing on both early (within 7 days) and late (8-42 days) postpartum periods. By including outpatient visits alongside inpatient and emergency department (ED) visits, the study offers a comprehensive view of postpartum health care needs among women with SMM. Methods: This retrospective cohort study used data from Optum's de-identified Clinformatics® Data Mart Database from 2008 to 2019. The primary outcomes were early and late postpartum inpatient readmissions, early and late ED visits, and outpatient care within 42 days after delivery. Multilevel logistic regression models were used to estimate the association between SMM subtypes and postpartum readmission, ED, and outpatient care. Results: Except for hemorrhage, most SMM subtypes increased the postpartum odds of health care utilization. Women with other medical SMM (e.g., puerperal cerebrovascular disorders or sickle cell disease with crisis) had 2.9 times the odds (odds ratio [OR]: 2.87, 95% confidence interval [CI]: 1.30-6.34) of experiencing early readmissions compared with those without other medical SMM. Women with sepsis had 4.5-fold elevated odds (OR: 4.53, 95% CI: 2.48-8.28) of late readmission, a 1.9-fold increased odds (OR: 1.85, 95% CI: 1.12-3.04) of early ED visits, and over a 2-fold increased odds (OR: 2.27, 95% CI: 1.67-3.08) of postpartum outpatient visits compared with those without sepsis. Conclusion: This study reveals that certain SMM subtypes significantly increase postpartum health care utilization, emphasizing the need for further research and interventions to improve outcomes for affected women.

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.

Severe maternal morbidity from pregnancy through 1 year postpartum

BACKGROUND

Few recent studies have examined the rate of severe maternal morbidity occurring during the antenatal and/or postpartum period to 42 days after delivery. However, little is known about the rate of severe maternal morbidity occurring beyond 42 days after delivery.

OBJECTIVE

This study aimed to examine the distribution of severe maternal morbidity and its indicators during antenatal, delivery, and postpartum hospitalizations to 365 days after delivery and to estimate the increase in severe maternal morbidity rate and its indicators after accounting for antenatal and postpartum severe maternal morbidity to 365 days after delivery.

STUDY DESIGN

This was a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from Michigan, Oregon, and South Carolina from 2008 to 2020. This study examined the distribution of severe maternal morbidity, nontransfusion severe maternal morbidity, and severe maternal morbidity indicators during antenatal, delivery, and postpartum hospitalizations to 365 days after delivery. Subsequently, this study examined "severe maternal morbidity cases added," which represent cases among unique individuals that are included by considering the antenatal and postpartum periods but that would be missed if only the delivery hospitalization cases were included.

RESULTS

A total of 64,661 (2.5%) individuals experienced severe maternal morbidity, whereas 37,112 (1.4%) individuals experienced nontransfusion severe maternal morbidity during antenatal, delivery, and/or postpartum hospitalization. A total of 31% of severe maternal morbidity cases were added after accounting for severe maternal morbidity occurring during the antenatal or postpartum hospitalization to 365 days after delivery, whereas 49% of nontransfusion severe maternal morbidity cases were added after accounting for nontransfusion severe maternal morbidity occurring during the antenatal or postpartum periods. Severe maternal morbidity occurring between 43 and 365 days after delivery contributed to 12% of all severe maternal morbidity cases, whereas nontransfusion severe maternal morbidity occurring between 43 and 365 days after delivery contributed to 19% of all nontransfusion severe maternal morbidity cases.

CONCLUSION

Our study showed that a total of 31% of severe maternal morbidity and 49% of nontransfusion severe maternal morbidity cases were added after accounting for severe maternal morbidity occurring during the antenatal or postpartum hospitalization to 365 days after delivery. Our findings highlight the importance of expanding the severe maternal morbidity definition beyond the delivery hospitalization to better capture the full period of increased risk, identify contributing factors, and design strategies to mitigate this risk. Only then can we improve outcomes for mothers and subsequently the quality of life of their infants.

Postpartum Psychiatric Outcomes following Severe Maternal Morbidity in an Urban Safety-Net Hospital

OBJECTIVE

Severe maternal morbidity (SMM) may be associated with postpartum psychiatric morbidity. However, the direction and strength of this relationship remain unclear. Our goal was to estimate the association between SMM and postpartum inpatient mental health care utilization.

STUDY DESIGN

We examined all liveborn deliveries at a large, safety-net hospital in Atlanta, Georgia, from 2013 to 2021. SMM at or within 42 days of delivery was identified using International Classification of Disease codes. The primary outcome of interest was hospitalization with a psychiatric diagnosis in the year following the delivery. We used inverse probability of treatment weighting based on propensity scores to adjust for demographics, index delivery characteristics, and medical, psychiatric, and obstetric history. We fit log-binomial models with generalized estimating equations to calculate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs).

RESULTS

Among 22,233 deliveries, the rates of SMM and postpartum hospitalization with a psychiatric diagnosis, respectively, were 6.8% (n = 1,149) and 0.8% (n = 169). The most common psychiatric diagnosis was nonpsychotic mood disorders (without SMM 0.4%, n = 79; with SMM 1.7% n = 24). After weighting, 2.2% of deliveries with SMM had a postpartum readmission with a psychiatric diagnosis, compared with 0.7% of deliveries without SMM (aRR: 3.2, 95% CI: [2.0, 5.2]). Associations were stronger among individuals without previous psychiatric hospitalization.

CONCLUSION

Experiencing SMM was associated with an elevated risk of postpartum psychiatric morbidity. These findings support screening and treatment for mild and moderate postpartum psychiatric disorders in the antenatal period.

KEY POINTS

· Experiencing SMM was associated with three-fold excess risk of postpartum psychiatric admission.. · Experiencing SMM was not associated with an elevated risk of outpatient psychiatric care use.. · Experience SMM was not associated with outpatient psychiatric morbidity diagnoses..

Postpartum navigation decreases severe maternal morbidity most among Black women

BACKGROUND

Postpartum care is crucial for addressing conditions associated with severe maternal morbidity and mortality. Examination of programs that affect these outcomes for women at high risk, including disparate populations, is needed.

OBJECTIVE

This study aimed to examine whether a postpartum navigation program decreases all-cause 30-day postpartum hospitalizations and hospitalizations because of severe maternal morbidity identified using the US Centers for Disease Control and Prevention guidelines. The effect of this program was explored across patient demographics, including race and ethnicity.

STUDY DESIGN

This was a retrospective cohort study that used health records of women who delivered at 3 large hospitals in the New York metropolitan area (Queens and Long Island) between April 2020 and November 2021 and who were at high risk of severe maternal morbidity. The incidence rates of 30-day postpartum all-cause hospitalization and hospitalization because of severe maternal morbidity were compared between women who were and were not enrolled in a novel postpartum transitional care management program. Navigation included standardized assessments, development of care plans, clinical management, and connection to clinical and social services that would extend beyond the postpartum period. Because the program prioritized enrolling women of the greatest risk, the risk-adjusted incidence was estimated using multivariate Poisson regression and stratified across patient demographics.

RESULTS

Patient health records of 5819 women were included for analysis. Of note, 5819 of 19,258 deliveries (30.2%) during the study period were identified as having a higher risk of severe maternal morbidity. This was consistent with the incidence of high-risk pregnancies for tertiary hospitals in the New York metropolitan area. The condition most identified for risk of severe maternal morbidity at the time of delivery was hypertension (3171/5819 [54.5%]). The adjusted incidence of all-cause rehospitalization was 20% lower in enrollees than in nonenrollees (incident rate ratio, 0.80; 95% confidence interval, 0.67-0.95). Rehospitalization was decreased the most among Black women (incident rate ratio, 0.57; 95% confidence interval, 0.42-0.80). The adjusted incidence of rehospitalization because of indicators of severe maternal morbidity was 56% lower in enrollees than in nonenrollees (incident rate ratio, 0.44; 95% confidence interval, 0.24-0.77). Furthermore, it decreased most among Black women (incident rate ratio, 0.23; 95% confidence interval, 0.07-0.73).

CONCLUSION

High-risk medical conditions at the time of delivery increased the risk of postpartum hospitalization, including hospitalizations because of severe maternal morbidity. A postpartum navigation program designed to identify and resolve clinical and social needs reduced postpartum hospitalizations and racial disparities with hospitalizations. Hospitals and healthcare systems should adopt this type of care model for women at high risk of severe maternal morbidity. Cost analyses are needed to evaluate the financial effect of postpartum navigation programs for women at high risk of severe maternal morbidity or mortality, which could influence reimbursement for these types of services. Further evidence and details of novel postpartum interventional models are needed for future studies.

Severe Maternal Morbidity and Postpartum Readmission Through 1 Year

OBJECTIVE

To conduct a cohort study to estimate risk for readmission through 1 year postpartum and the most common readmission diagnoses for individuals with and without severe maternal morbidity (SMM) at delivery.

METHODS

Using national health care claims data from IBM MarketScan Commercial Research Databases (now known as Merative), we identified all delivery hospitalizations for continuously enrolled individuals 15-49 years of age that occurred between January 1, 2016, and December 31, 2018. Severe maternal morbidity at delivery was identified using diagnosis and procedure codes. Individuals were followed for 365 days after delivery discharge, and cumulative readmission rates were calculated for up to 42 days, up to 90 days, up to 180 days, and up to 365 days. We used multivariable generalized linear models to estimate adjusted relative risks (aRR), adjusted risk differences, and 95% CIs for the association between readmission and SMM at each of the timepoints.

RESULTS

The study population included 459,872 deliveries; 5,146 (1.1%) individuals had SMM during the delivery hospitalization, and 11,603 (2.5%) were readmitted within 365 days. The cumulative incidence of readmission was higher in individuals with SMM than those without at all timepoints (within 42 days: 3.5% vs 1.2%, aRR 1.44, 95% CI 1.23-1.68; within 90 days: 4.1% vs 1.4%, aRR 1.46, 95% CI 1.26-1.69); within 180 days: 5.0% vs 1.8%, aRR 1.48, 95% CI 1.30-1.69; within 365 days: 6.4% vs 2.5%, aRR 1.44, 95% CI 1.28-1.61). Sepsis and hypertensive disorders were the most common reason for readmission within 42 and 365 days for individuals with SMM (35.2% and 25.8%, respectively).

CONCLUSION

Severe maternal morbidity at delivery was associated with increased risk for readmission throughout the year after delivery, a finding that underscores the need for heightened awareness of risk for complications beyond the traditional 6-week postpartum period.

Postpartum Hospital Readmissions With and Without Severe Maternal Morbidity Within 1 Year of Birth, Oregon, 2012-2017

Postpartum readmissions (PPRs) represent a critical marker of maternal morbidity after hospital childbirth. Most severe maternal morbidity (SMM) events result in a hospital admission, but most PPRs do not have evidence of SMM. Little is known about PPR and SMM beyond the first 6 weeks postpartum. We examined the associations of maternal demographic and clinical factors with PPR within 12 months postpartum. We categorized PPR as being with or without evidence of SMM to assess whether risk factors and timing differed. Using the Oregon All Payer All Claims database, we analyzed hospital births from 2012-2017. We used log-binomial regression to estimate associations between maternal factors and PPR. Our final analytical sample included 158,653 births. Overall, 2.6% (n = 4,141) of births involved at least 1 readmission within 12 months postpartum (808 (19.5% of PPRs) with SMM). SMM at delivery was the strongest risk factor for PPR with SMM (risk ratio (RR) = 5.55, 95% confidence interval (CI): 4.14, 7.44). PPR without SMM had numerous risk factors, including any mental health diagnosis (RR = 2.10, 95% CI: 1.91, 2.30), chronic hypertension (RR = 2.17, 95% CI: 1.85, 2.55), and prepregnancy diabetes (RR = 2.85, 95% CI: 2.47, 3.30), all which were on par with SMM at delivery (RR = 1.89, 95% CI: 1.49, 2.40).

Early postpartum readmissions: identifying risk factors at birth hospitalization

BACKGROUND

The high maternal mortality and severe morbidity rates in the United States compared with other high-income countries have received national attention. Characterization of postpartum hospital readmissions within the first days after delivery hospitalization discharge could help to identify patients who need additional preparedness for discharge.

OBJECTIVE

This study aimed to investigate conditions at birth associated with postpartum readmissions occurring within 0 to 6 days and at 7 to 29 days after discharge from the delivery hospitalization.

STUDY DESIGN

We analyzed linked vital statistics and hospital discharge records of patients who gave birth in California during 2007 to 2018. We investigated hospital readmissions within 30 days after birth hospitalization discharge. We used multivariable logistic regression to investigate factors associated with early readmission (0-6 days) and later readmission (7-29 days) compared with no readmission within 30 days (reference). The risk factors assessed included maternal medical or obstetrical conditions before and at birth, birth hospitalization length of stay, and mode of delivery. Severe maternal morbidity was defined as the presence of any of the 21 indicators recommended by the Centers for Disease Control and Prevention.

RESULTS

Among 5,248,746 pregnant patients, 23,636 (0.45%) had an early postpartum readmission, whereas 24,712 (0.47%) had a later postpartum readmission. After adjustments, early readmission was most strongly associated with sepsis (adjusted odds ratio, 4.63; 95% confidence interval, 3.87-5.53), severe maternal morbidity (adjusted odds ratio, 3.46; 95% confidence interval, 3.28-3.65) at birth hospitalization, or preeclampsia before birth hospitalization (adjusted odds ratio, 3.67; 95% confidence interval, 3.54-3.81). The associations between later readmission and sepsis and severe maternal morbidity were similar, whereas the association between preeclampsia and later readmission was less strong (adjusted odds ratio, 1.65; 95% confidence interval, 1.57-1.73).

CONCLUSION

Pregnant patients with sepsis or severe maternal morbidity during delivery hospitalization or preeclampsia before birth hospitalization were at the highest risk for readmission within 6 days of discharge. These findings may be informative for efforts to improve postpartum care.

Using Longitudinally Linked Data to Measure Severe Maternal Morbidity Beyond the Birth Hospitalization in California

Most studies of severe maternal morbidity (SMM) include only cases that occur during birth hospitalizations. We examined the increase in cases when including SMM during antenatal and postpartum (within 42 days of discharge) hospitalizations, using longitudinally linked data from 1,010,250 births in California from September 1, 2016, to December 31, 2018. For total SMM, expanding the definition resulted in 22.8% more cases; for nontransfusion SMM, 45.1% more cases were added. Sepsis accounted for 55.5% of the additional cases. The increase varied for specific indicators, for example, less than 2% for amniotic fluid embolism, 7.0% for transfusion, 112.9% for sepsis, and 155.6% for acute myocardial infarction. These findings reiterate the importance of considering SMM beyond just the birth hospitalization and facilitating access to longitudinally linked data to facilitate a more complete understanding of SMM.

Postpartum Readmission and Uninsurance at Readmission for Medicaid versus Privately Insured Births

BACKGROUND

Routine postpartum care is essential to managing pregnancy complications, like hypertension and diabetes, or screening for new conditions, such as depression. Insurance coverage can impact women's ability to access these postpartum services, with women who change or lose insurance postpartum having a lower likelihood of receiving recommended postpartum care. Pregnancy-related Medicaid eligibility is only federally guaranteed for a minimum 60 days after birth, creating the potential for publicly insured women to lose their insurance and their access to postpartum care.

OBJECTIVE

The objective of this study was to examine the rates of postpartum readmission and predictors of uninsurance at readmission before and after 60-days postpartum for Medicaid versus privately paid births.

STUDY DESIGN

This is a retrospective cohort study using the 2017 Nationwide Readmissions Database (NRD). Women who delivered with Medicaid or private insurance between January and June 2017 were included. Potential readmissions were observed between 0-180 days after their childbirth hospitalization were included. The primary outcomes of interest were postpartum readmission and delivery payer at postpartum readmission, observed at 30-day intervals through 180 days postpartum. Multivariable logistic regressions were used to determine the association between the risk of readmission and the risk of being uninsured at the time of readmission among those with private insurance and Medicaid at the time of delivery. The analysis was also conducted in a subset of "acute-cause" readmissions, or those not likely to be related to chronic or pre-existing medical conditions.

RESULTS

24,719 (2.7%) were readmitted within 180 days after delivery: 14,179 (54.1%) had Medicaid delivery insurance, 10,540 (40.2%) had private insurance at delivery. Readmission rates decreased over the time intervals after delivery for both delivery payer types, though were consistently higher for those with Medicaid. The rate of uninsurance at readmission increased more each month postpartum for those with Medicaid compared to private insurance at delivery: 0.9% (95% confidence interval (CI) 0.7, 1.1%) at 0-30 days to 9.7% (95% CI 8.1, 11.6%) at 150-180 days postpartum and from 0.2% (95% CI 0.1, 0.4%) at 0-30 days to 2.6% (95% CI 1.6, 4.1%) at 150-180 days postpartum, respectively. Medicaid coverage at the time of delivery was a significant predictor of being readmitted [adjusted odds ratio (aOR) 1.86 (95% confidence interval (CI) 1.75, 1.97) and uninsured at the time of readmission [aOR 3.99 (95% CI 2.88, 5.52)] compared to being privately insured. Findings were similar in the acute-cause readmissions.

CONCLUSIONS

Women with Medicaid at delivery have a higher risk of readmission and uninsurance at readmission compared to privately insured women beyond 60 days postpartum. This analysis provides further evidence of the insurance instability women face in the postpartum period, especially by those insured by Medicaid at the time of delivery, and should promote discussions among policymakers, payers, and providers on strategies to ensure coverage and access to care for women and their families after childbirth. For states considering expanding their eligibility criteria to 1 year postpartum, this study provides evidence on the vulnerabilities and unique risks that women with Medicaid face after 60 days postpartum.