Societal cost of nine selected maternal morbidities in the United States

Adverse maternal outcomes among women who gave birth at public hospitals in eastern Ethiopia: a cross-sectional study

Background

An adverse maternal outcome, such as anemia, postpartum hemorrhage, and postpartum eclampsia, poses a significant risk to women. While studies on the burden of adverse maternal outcomes have been conducted in various countries, including Ethiopia, many predictors beyond obstetric factors have not been fully explored. This study aimed to determine the magnitude and factors associated with adverse maternal outcomes among women who gave birth at selected public hospitals in eastern Ethiopia.

Methods

A hospital-based cross-sectional study was conducted among 2,608 randomly selected women who gave birth in six public hospitals in eastern Ethiopia from November 2023 to March 2024. Data were collected through face-to-face interviews and clinical chart reviews. Factors associated with adverse maternal outcomes were identified using bivariable and multivariable robust Poisson regression analyses. Adjusted relative risk (ARR) with a 95% confidence interval (CI) was used to report the strength of the association. The variables with a p-value of <0.05 were considered statistically significant.

Results

The magnitude of adverse maternal outcomes was 15.68% (95% CI: 14.70%-16.66%). A poor wealth index (ARR = 4.41; 95% CI: 3.46-5.62), having danger signs at admission (ARR = 1.86; 95% CI: 1.18-2.91), alcohol use during pregnancy (ARR = 1.86; 95% CI: 1.32-2.62), duration of labor ≥24 h (ARR = 1.69; 95% CI: 1.00-2.85), and maternal age greater than 35 years (ARR = 1.39; 95% CI: 1.03-1.86) increased the risk of adverse maternal outcomes. In contrast, folic acid intake during pregnancy (ARR = 0.47; 95% CI: 0.38-0.57), having partner support (ARR = 0.70; 95% CI: 0.59-0.83), and spontaneous vaginal delivery (ARR = 0.58; 95% CI: 0.49-0.68) reduced the risk of adverse maternal outcomes.

Conclusion

One in six women who gave birth in eastern Ethiopia experienced adverse maternal outcomes. This rate was determined to be moderate when compared to the WHO projections for lower- and middle-income countries and better than the higher averages reported by the WHO. Targeted intervention programs, such as targeted education and empowerment programs, and the strengthening of the community health worker program would help address socioeconomic disparities and improve early detection and management of danger signs during pregnancy, which would aid in averting the occurrence of adverse outcomes.

How much can we reduce delivery-related medical costs associated with maternal mortality? A nationwide cohort study from 2003 to 2021

Objective

This study aims to examine the association between maternal mortality and childbirth-related medical costs using both unadjusted and adjusted models and to assess the potential reduction in delivery-related medical costs associated with maternal mortality in South Korea.

Methods

This retrospective cohort study used data from the National Health Insurance Service Delivery Cohort Database of South Korea. A total of 7,171,578 participants were included. The outcome measured was delivery-related medical costs associated with maternal mortality. A Generalized Estimating Equation model with a log link and gamma distribution was used to estimate delivery-related medical costs.

Results

The maternal death rates were 9.7 per 100,000 births. The adjusted mean delivery-related medical costs were approximately six times higher in cases with maternal death than in those without ($2,802 vs. $480, p < 0.0001). The total delivery-related medical costs for all women with maternal mortality were approximately $2 million, accounting for 0.06% of total delivery-related medical costs. Although this proportion is relatively small, 83% of the direct medical costs associated with maternal mortality among South Korean women were potentially reducible.

Conclusion

This study found that maternal mortality is associated with significantly higher delivery-related medical costs, nearly six times those of non-maternal mortality cases. Therefore, policymakers should consider reducing costs and improving maternal health outcomes, expanding access to prenatal care for early risk detection and strengthen nationwide maternal health monitoring systems.

Remote Lifestyle Intervention to Reduce Postpartum Weight Retention: Protocol for a Community-Engaged Hybrid Type I Effectiveness-Implementation Randomized Controlled Trial

BACKGROUND

Maternal obesity is associated with significant racial disparities. People who identify as non-Hispanic Black and Latinx are at the highest risk related adverse short- and long-term health outcomes (eg, hypertension in pregnancy and postpartum weight retention). Remote lifestyle interventions delivered during and after pregnancy hold promise for supporting healthy weight outcomes; however, few are tested in groups of people who self-identify as non-Hispanic Black and Latinx or address the neighborhood-level and psychosocial factors driving maternal health disparities. Implementing remote lifestyle interventions within community-based programs that serve birthing people may optimize trust and engagement, promote scalability and sustainability, and have the broadest public health impact.

OBJECTIVE

The goal of this trial is to test the effectiveness of a culturally adapted remote lifestyle intervention (Healthy for Two-Home Visiting) implemented within home visiting compared to usual home visiting services on postpartum weight retention among pregnant or postpartum individuals, in particular those who identify as non-Hispanic Black and Latinx. Facilitators and barriers to implementation of the intervention within home visiting will be examined.

METHODS

We describe the rationale and protocol for this hybrid type I effectiveness-implementation randomized controlled trial. In this paper, we highlight the community-engaged approach and trial design features that enable the implementation of the intervention within home visiting and demonstrate its applicability to the target population. Participants will be 360 pregnant individuals with overweight or obesity enrolled between 20 and 33 weeks of gestation and randomized 1:1 to Healthy for Two-Home Visiting or usual home visiting services. The primary outcome is weight retention at 6 months post partum, calculated as 6-month postpartum weight minus earliest pregnancy weight (≤18 wk of gestation). The measures of implementation include intervention feasibility, acceptability, reach, adoption, and fidelity. Throughout the paper, we highlight the community input used to improve intervention effectiveness and study implementation and as a strategy to promote maternal health equity.

RESULTS

This study was funded in June 2021, and recruitment began in April 2023. As of November 2024, we enrolled 90 participants. Data collection to assess the intervention's effectiveness is expected to end in June 2026. Implementation evaluation is expected to conclude in December 2026.

CONCLUSIONS

This hybrid type I effectiveness-implementation randomized controlled trial integrates a culturally adapted remote lifestyle intervention into early home visiting services to examine its effectiveness on postpartum weight retention compared to usual home visiting. We anticipate that the study results will enable an understanding of the drivers of successful implementation within a community-based setting to maximize the future sustainability and dissemination of a strategy for reducing long-term obesity and other maternal health disparities.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05619705; https://clinicaltrials.gov/study/NCT05619705.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/62847.

The Impact of Pregestational Diabetes on Maternal Morbidity and Mortality: Trends, Challenges, and Future Directions

Maternal mortality in the United States is on the rise, demonstrating a concerning trend that stands in stark contrast to the falling rates in other developed countries. A key challenge facing the improvement of maternal care is the mounting prevalence of chronic health conditions such as hypertension and diabetes, which are often linked to poor diet and sedentary lifestyle. Pregestational diabetes now impacts 1 to 2% of pregnancies, while gestational diabetes affects another 7.8%. Both type 1 and type 2 diabetes elevate the risk of severe maternal morbidity and mortality (SMM), including severe cardiac morbidity, hypertensive disorders of pregnancy, hemorrhage, infection, and mental health conditions. The increase in diabetes is thought to account for 17% of the increase in maternal mortality between 1997 and 2012. Another critical issue facing maternal care is the significant disparity in pregnancy outcomes among populations facing greater burdens of adverse social determinants of health, including socioeconomic characteristics, chronic stress, and systemic racism. For example, non-Hispanic Black women are 2.5 times more likely to die during pregnancy and the postpartum period than non-Hispanic White women. Vulnerable populations, often minorities, are also more likely to develop risk factors for SMM, such as type 2 diabetes. As pregestational diabetes is a particularly morbid condition in pregnancy, examining its complications and evidence-based treatments could significantly impact both maternal mortality rates and disparities in pregnancy outcomes in the United States. This review explores the relationship between pregestational diabetes and SMM, how the risk of SMM can be modified by disparities, and avenues for advancing care through future research. KEY POINTS: · Diabetes during pregnancy greatly increases the risk of SMM.. · Comprehensive care can improve outcomes in high-risk pregnancies with diabetes.. · Adverse social determinants of health worsen outcomes in pregnancies affected by diabetes.. · Improving diabetes care in pregnancy offers an opportunity to enhance maternal outcomes..

Spatial and Racial/Ethnic Variation in the Prevalence of Cesarean Delivery in a South Carolina Medical Center

INTRODUCTION

While racial/ethnic disparities in cesarean delivery have been noted in the literature, less is known about the intersection between individual-level race/ethnicity and community-level social vulnerability as factors in cesarean delivery. The goal was to use medical record data from a large medical center combined with census tract-level data to examine patterns of social vulnerability, racial population distribution, and prevalence of cesarean delivery.

METHODS

Data were obtained from electronic medical records of patients from a large medical center in South Carolina from 2019 to 2020. The outcome variable was cesarean delivery (yes/no), and covariates included the year of delivery; age of patient; race/ethnicity; spoken language; BMI categories; clinical indications of anemia, hypertension, preeclampsia, and diabetes; and census tract Social Vulnerability Index (SVI). Generalized linear mixed models for multilevel binary logistic regression were used to test the main hypothesis that the census tract level Social Vulnerability Index is positively associated with cesarean delivery.

RESULTS

Among a total of 5011 patients, we found that non-Hispanic Black mothers were more likely to have cesarean deliveries compared with non-Hispanic White mothers. After controlling for census tract-level SVI, the individual-level race/ethnicity association was no longer significant. Significant spatial autocorrelation across census tracts was evident for cesarean delivery prevalence, non-Hispanic Black population, and SVI. A high prevalence of cesarean delivery tended to cluster with high SVI and a high non-Hispanic Black population.

CONCLUSIONS

We found that non-Hispanic Black mothers were more likely to have cesarean deliveries, which was explained by census tract differences in the SVI.

Cardiovascular Disease in Pregnancy: Clinical Outcomes and Cost-Associated Burdens From a National Cohort at Delivery

Background

Cardiovascular disease (CVD) in pregnancy is a leading cause of maternal morbidity and mortality in the United States, with an increasing prevalence.

Objectives

This study aimed to examine risk factors for adverse maternal cardiac, maternal obstetric, and neonatal outcomes as well as costs for pregnant people with CVD at delivery.

Methods

Using the National Inpatient Sample 2010-2019 and the Internal Classification of Diseases diagnosis codes, all pregnant people admitted for their delivery hospitalization were included. CVD diagnoses included congenital heart disease, cardiomyopathy, ischemic heart disease, arrhythmias, and valvular disease. Multivariable regressions were used to analyze major adverse cardiovascular events (MACE), maternal and fetal complications, length of stay, and resource utilization.

Results

Of the 33,639,831 birth hospitalizations included, 132,532 (0.39%) had CVD. These patients experienced more frequent MACE (8.5% vs 0.4%, P < 0.001), obstetric (24.1% vs 16.6%, P < 0.001), and neonatal complications (16.1% vs 9.5%, P < 0.001), and maternal mortality (0.16% vs 0.01%, P < 0.001). Factors associated with MACE included cardiomyopathy (adjusted OR [aOR]: 49.9, 95% CI: 45.2-55.1), congenital heart disease (aOR: 13.8, 95% CI: 12.0-15.9), Black race (aOR: 1.04, 95% CI: 1.00-1.08), low income (aOR: 1.06, 95% CI: 1.02-1.11), and governmental insurance (aOR: 1.03, 95% CI: 1.00-1.07). On adjusted analysis, CVD was associated with higher odds of maternal mortality (aOR: 9.28, 95% CI: 6.35-13.56), stillbirth (aOR: 1.66, 95% CI: 1.49-1.85), preterm birth (aOR: 1.33, 1.27-1.39), and congenital anomalies (aOR: 1.84, 95% CI: 1.69-1.99). CVD was also associated with an increase of $2,598 (95% CI: $2,419-2,777) per patient during admission for delivery.

Conclusions

CVD in pregnancy is associated with higher rates of adverse outcomes. Our study highlights the association of key clinical and demographic factors with CVD during pregnancy to emphasize those at highest risk for complications.

Phenotypic Environmental Sensitivity and Mental Health During Pregnancy and Post Partum: Protocol for the Experiences of Pregnancy Longitudinal Cohort Study

BACKGROUND

Mental health problems during pregnancy and post partum are common and associated with negative short- and long-term impacts on pregnant individuals, obstetric outcomes, and child socioemotional development. Socio-environmental factors are important predictors of perinatal mental health, but the effects of the environment on mental health are heterogeneous. The differential susceptibility theory and the environmental sensitivity framework suggest that individuals differ in their degree of sensitivity to positive and negative environments, which can be captured by individual phenotypes such as temperament and personality. While there is strong evidence for these models in childhood, few studies examined them in adults, and they were not examined in pregnancy.

OBJECTIVE

The primary objective of the Experiences of Pregnancy study is to explore whether childhood and current environments are associated with mental health and well-being in pregnancy and whether these effects depend on individual sensitivity phenotypes (personality). This study also aims to gather important psychosocial and health data for potential secondary data analyses and integrative data analyses.

METHODS

We will conduct a longitudinal cohort study. The study was not registered elsewhere, other than this protocol. Participants will be recruited through social media advertisements linking to the study website, followed by an eligibility call on Zoom (Zoom Video Communications). Participants must be aged 18 years or older, currently residing in the United States as citizens or permanent residents, and currently planning to continue the pregnancy. A minimum of 512 participants will be recruited based on power analyses for the main objectives. Since the data will also be a resource for secondary analyses, up to 1000 participants will be recruited based on the available budget. Participants will be in their first trimester of pregnancy, and they will be followed at each trimester and once post partum. Data will be obtained through self-reported questionnaires assessing demographic factors; pregnancy-related factors; delivery, labor, and birth outcomes; early infant feeding; individual personality factors; childhood and current environments; mental health and well-being; attachment; and infant temperament. A series of measures were taken to safeguard the study from web robots and fraudulent participants, as well as to reduce legal and social risks for participants following Dobbs v. Jackson.

RESULTS

The study received ethics approval in April 2023 from the University of Oklahoma-Norman Campus Institutional Review Board. Recruitment occurred from May to August 2023, with 3 follow-ups occurring over 10 months.

CONCLUSIONS

The Experiences of Pregnancy study will extend theories of environmental sensitivity, mainly applied in children to the perinatal period. This will help better understand individual sensitivity factors associated with risk, resilience, plasticity, and receptivity to negative and positive environmental influences during pregnancy for pregnant individuals.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/49243.

Contraceptive counseling and choices in pregnancies with maternal cardiac disease

OBJECTIVE

Unplanned pregnancies in women with maternal cardiac disease (MCD) are associated with increased morbidity and mortality, but the majority of these individuals do not use highly reliable contraception on postpartum hospital discharge. Contraceptive counseling in this population outside of pregnancy is incomplete and counseling during pregnancy remains poorly characterized. Our objective was to evaluate the provision and quality of contraceptive counseling for individuals with MCD during pregnancy.

METHODS

All individuals with MCD who delivered between 2008 and 2021 at a tertiary care institution with a multidisciplinary cardio-obstetrics team were sent a 27-question survey. A subset of questions were derived from the validated Interpersonal Quality in Family Planning (IQFP) survey, which emphasizes interpersonal connection, adequate information, and decision support for the individual. Each participant received a $15 gift card for survey completion. We performed chart review for clinical and demographic details, including cardiac risk score.

RESULTS

Of 522 individuals to whom the survey was sent, 133 responded and met inclusion criteria. Overall, 67% discussed contraception with their general obstetrician, 36% with their maternal-fetal medicine (MFM) specialist, and 24% with their cardiologist. Compared to individuals with low cardiac risk scores, those with high cardiac risk scores had a nonsignificant trend toward being more likely to discuss contraception with a MFM provider (52% vs 33%, p = .08). 65% reported that their provider was 'excellent' or 'good' in all IQFP domains. Respondents valued providers who respected their autonomy and offered thorough counseling. Respondents disliked feeling pressured or uninformed about the safety of contraceptive options.

CONCLUSION

Most individuals with MCD reported excellent contraceptive counseling during pregnancy. Additional work is needed to understand barriers to and enablers for effective, patient-centered contraceptive counseling and use in this population.

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.