Association of in vitro fertilization with severe maternal morbidity in low-risk patients without comorbidities.

OBJECTIVE: To determine whether an association exists between in vitro fertility (IVF) and severe maternal morbidity among low-risk pregnant patients. DESIGN: Retrospective cohort study SUBJECTS: Low-risk pregnant patients who delivered between 1/2019 and 12/2022. Low-risk was defined as having an Obstetric Comorbidity Index (OB-CMI) score of 0. EXPOSURE: IVF MAIN OUTCOME MEASURES: The primary outcome (dependent variable) was any severe maternal morbidity. The secondary outcome was the need for a cesarean delivery. A modified Poisson regression with robust error variance was used to model the probability of severe maternal morbidity as a function of IVF. Risk ratios (RR) and their associated 95% confidence intervals (CI) were computed. An alpha value of 0.05 was considered statistically significant. RESULTS: A total of 39,668 pregnancies were included for analysis, and 454 (1.1%) were conceived by IVF. The overall severe maternal morbidity rate was 2.4% (n=949), with the most common indicator being blood transfusion. Overall cesarean delivery rate was 18.8% (n=7,459). On modified Poisson regression, IVF-conceived pregnancies were associated with 2.56 times the risk of severe maternal morbidity (95% CI 1.73 - 3.79) and 1.54 times the risk of having a cesarean delivery (95% CI, 1.37-1.74) compared to non-IVF pregnancies. CONCLUSION: IVF is associated with higher rates of severe maternal morbidity, primarily the need for a blood transfusion, and cesarean delivery in low-risk pregnancies without major comorbidities. Recognizing this association allows healthcare providers to implement proactive measures for better monitoring and tailored postpartum care.

Women's experiences of maternal near miss: Qualitative findings from Malawi.

OBJECTIVE: This study explored the experiences of women with maternal near miss and their perceptions of the quality of care they received in three facilities in Malawi. METHODS: This study employed a qualitative phenomenological approach. Data were collected using in depth interviews and analysed using thematic content analysis. The data were collected in three hospitals between September and November 2020. The purposively selected participants were 18 women meeting criteria for maternal near miss related to obstetric haemorrhage (6), hypertensive disorders (7), sepsis (2) and ruptured ectopic pregnancy (3). RESULTS: Women's experiences of maternal near miss fell under four broad themes; (a) realisation of the near miss; (b) religious beliefs and interpretation of near miss; (c) social and economic aspects of maternal near miss; and d) perceptions of quality of care. Women's initial emotional responses were fear and anxiety but were soon overshadowed by the fear for their babies' wellbeing. Most women perceived the care they received as timely, adequate, and respectful, yet many women also expressed that their service providers did not provide an opportunity to openly discuss their condition. CONCLUSIONS: The experience of near miss goes beyond the immediate physical discomforts and has psychological, economic, and social consequences for women and their families. Despite women's perception of care as respectful, there are still communication gaps with their service providers. Campaigns to improve the communication between providers and patients and their families in situation of severe morbidity warrant consideration.

Implementation Strategies for Maternal Near-Miss Case Reviews in LICs and LMICs: A scoping review protocol.

Background: Maternal mortality remains a persistent public health concern despite significant strides in reduction over the past few decades, with a global maternal mortality ratio (MMR) of 223 deaths per 100,000 live births in 2020, indicating a 34.3% decline over 20 years, with Low income countries (LICs) and Lower Middle-Income Countries (LMICs) bearing the major burden. Effective implementation of facility-based near-miss case reviews (NMCR), endorsed by the World Health Organization (WHO), faces challenges hindering progress, making exploring implementation strategies through a scoping review essential. This scoping review aims to identify and characterize implementation strategies employed in Low and Lower Middle- Income Countries to facilitate the implementation of facility-based NMCR. Methods: The scoping review will follow Arksey and O'Malley's methodological framework, involving five stages: identifying the research question, selecting relevant studies, selecting data, charting, and summarizing the results. Electronic databases like PubMed, Embase, Web of Science, EBSCOhost - CINAHL Ultimate, and Ovid MEDLINE will be searched, supplemented by citation tracking. Rayyan will be used to screen and remove duplicates, with data charting conducted using Google Sheets. Two independent reviewers will conduct blinded screening, eligibility assessment, and inclusion phases. Reviewers will conduct Systematic data extraction independently using piloted forms, with discrepancies resolved through team discussion and consensus. Results: The review will identify and characterize implementation strategies employed to facilitate the implementation of facility-based near-miss case reviews in LICs and LMICs. Conclusions: The findings of this review will contribute to the understanding of implementing strategies for facility-based NMCR in LICs and LMICs. The review can help in designing interventions/programs to reduce maternal mortality and knowledge products.

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.

External validation and comparison of four prediction scores for severe maternal morbidity.

BACKGROUND: Severe maternal morbidity is increasing in the United States. Several tools and scores exist to stratify an individual's risk of severe maternal morbidity. OBJECTIVE: We sought to examine and compare the validity of four scoring systems for predicting severe maternal morbidity. STUDY DESIGN: This was a retrospective cohort study of all individuals in the Consortium on Safe Labor dataset, which was conducted from 2002 to 2008. Individuals were excluded if they had missing information on risk factors. Severe maternal morbidity was defined based on the Centers for Disease Control and Prevention excluding blood transfusion. Blood transfusion was excluded due to concerns regarding the specificity of ICD codes for this indicator and its variable clinical significance. Risk scores were calculated for each participant using the Assessment of Perinatal Excellence, California Maternal Quality Care Collaborative, Obstetric Comorbidity Index, and Modified Obstetric Comorbidity Index. We calculated the probability of severe maternal morbidity according to the risk scores. The discriminative performance of the prediction score was examined by the areas under receiver operating characteristic curves and their 95% confidence intervals. The area under the curve for each score was compared using the bootstrap resampling. Calibration plots were developed for each score to examine the goodness-of-fit. The concordance probability method was used to define an optimal cutoff point for the best-performing score. RESULTS: Of 153, 463 individuals, 1,115 (0.7%) had severe maternal morbidity. The California Maternal Quality Care Collaborative scoring system had a significantly higher area under the curve [95% confidence interval] (0.78 [0.77-0.80]) compared to the Assessment of Perinatal Excellence scoring system, Obstetric Comorbidity Index and Modified Obstetric Comorbidity Index scoring systems 0.75 [0.73-0.76],. 0.67 [0.65-0.68], 0.66 [0.70-0.73]; P < 0.001). Calibration plots showed excellent concordance between the predicted and actual severe maternal morbidity for the Assessment of Perinatal Excellence scoring system and Obstetric Comorbidity Index (both Hosmer-Lemeshow test P-values = 1.00, suggesting goodness-of-fit). CONCLUSION: This study validated four risk-scoring systems to predict severe maternal morbidity. Both California Maternal Quality Care Collaborative and Assessment of Perinatal Excellence scoring systems had good discrimination to predict severe maternal morbidity. The Assessment of Perinatal Excellence score and the Obstetric Comorbidity Index had goodness-of-fit. At ideal calculated cut-off points, the Assessment of Perinatal Excellence score had the highest sensitivity of the four scores at 71%, indicating that better scoring systems are still needed for predicting severe maternal morbidity.

Racial/ethnic disparity in severe maternal morbidity among women who conceived by in vitro fertilization.

Background: In vitro fertilization (IVF) as a fertility treatment is associated with adverse perinatal outcomes. Racial/ethnic disparity in severe maternal morbidity (SMM) in women who conceived by IVF is understudied. Objective: To examine differences in the association between race/ethnicity and SMM between women who conceived spontaneously and those who conceived using IVF. Methods: We included all singleton live births and stillbirths in the United States, 2016-2021; data were obtained from the National Center for Health Statistics. Maternal race/ethnicity included non-Hispanic White (NHW), non-Hispanic Black (NHB), American Indian and Alaska Native (AIAN), Asian, Pacific Islander (PI), Hispanic, and mixed-race categories. The SMM composite outcome included eclampsia, uterine rupture, peripartum hysterectomy, blood transfusion, and intensive care unit (ICU) admission. We used logistic regression to adjust for potential confounders (such as age, education, parity, prepregnancy body mass index, smoking during pregnancy, chronic hypertension, and preexisting diabetes) and to assess modification of the association between race/ethnicity and SMM by IVF. Results: The study population included 21,585,015 women: 52% were NHW, 15% NHB, 0.8% AIAN, 6% Asian, 0.2% PI, 24% Hispanic, and 2% were of mixed race. IVF was used by 183,662 (0.85%) women; the rate of the SMM composite outcome was 18.5 per 1000 deliveries and 7.9 per 1000 deliveries in the IVF and spontaneous conception groups, respectively (unadjusted rate ratio 2.34, 95% confidence interval [CI] 2.26-2.43). In women with spontaneous conception, NHB, Asian and mixed-race women had elevated odds of SMM compared with NHW women (adjusted odds ratio [aOR]=1.39, 95% CI 1.37-1.41; aOR=1.04, 95% CI 1.02-1.07; and aOR=1.42, 95% CI 1.38-1.46, respectively). Racial/ethnic disparities in SMM and its components were not different between the IVF and spontaneous conception groups for the mixed-race category. NHB and Hispanic women had significantly higher aORs for uterine rupture/intrapartum hysterectomy compared with NHW women in the IVF group, while Asian women had a higher aOR for ICU admission compared with NHW women in the IVF group. Conclusion: Women who conceived by IVF have a greater than two-fold higher risk of SMM and this higher risk is evident across all racial/ethnic groups. However, NHB and Hispanic women who conceived by IVF had a higher risk of uterine rupture/hysterectomy, and Asian women who conceived by IVF had a higher risk of ICU admission. Our results warrant further investigation examining pregnancy and postpartum care issues among racial/ethnic minority women who conceive using IVF.

Development of a new definition of maternal near miss based on organ dysfunction in Latin America and the Caribbean: A prospective multicenter cohort study.

BACKGROUND: There has been debate over whether the existing World Health Organization (WHO) criteria accurately represent the severity of maternal near misses. OBJECTIVE: This study assessed the diagnostic accuracy of two WHO clinical and laboratory organ dysfunction markers for determining the best cutoff values in a Latin American setting. METHODS: A prospective multicenter cohort study was conducted in five Latin American countries. Patients with severe maternal complications were followed up from admission to discharge. Organ dysfunction was determined using clinical and laboratory data, and participants were classified according to severe maternal outcomes. This study compares the diagnostic criteria of Latin American Centre for Perinatology, Network for Adverse Maternal Outcomes (CLAP/NAMO) to WHO standards. RESULTS: Of the 698 women studied, 15.2% had severe maternal outcomes. Most measured variables showed significant differences between individuals with and without severe outcomes (all P-values <0.05). Alternative cutoff values suggested by CLAP/NAMOs include pH ≤7.40, lactate ≥2.3 mmol/L, respiratory rate ≥ 24 bpm, oxygen saturation ≤ 96%, PaO2/FiO2 ≤ 342 mmHg, platelet count ≤189 × 109 × mm3, serum creatinine ≥0.8 mg/dL, and total bilirubin ≥0.67 mg/dL. No significant differences were found when comparing the diagnostic performance of the CLAP/NAMO criteria to that of the WHO standards. CONCLUSION: The CLAP/NAMO values were comparable to the WHO maternal near-miss criteria, indicating that the WHO standards might not be superior in this population. These findings suggest that maternal near-miss thresholds can be adapted regionally, improving the identification and management of severe maternal complications in Latin America.

Can Obstetrics and Gynecology Hospitalists Reduce Severe Maternal Morbidity?

Maternal mortality in the United States has risen steadily over the past 20 years. Several interventions including maternal mortality committees and safety bundles have been introduced to decrease the trend. Severe maternal morbidity is a more frequent occurrence related to maternal mortality and can be used to track interventions. Within safety bundles, the presence of well-trained on-site staff such as obstetrics and gynecology (OB/GYN) hospitalists is key to correct implementation. In this article, the authors review the role of OB/GYN hospitalists in specific diagnoses and the evidence present to date on OB/GYN hospitalists' role in decreasing severe 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 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.

Immediate Postpartum Long-Acting Reversible Contraception for Preventing Severe Maternal Morbidity: A Cost-Effectiveness Analysis.

OBJECTIVE: To estimate the cost effectiveness of Medicaid covering immediate postpartum long-acting reversible contraception (LARC) as a strategy to reduce future short interpregnancy interval (IPI), severe maternal morbidity (SMM), and preterm birth. METHODS: We built a decision analytic model using TreeAge software to compare maternal health and cost outcomes in two settings, one in which immediate postpartum LARC is a covered option and the other where it is not, among a theoretical cohort of 100,000 people with Medicaid insurance who were immediately postpartum and did not have permanent contraception. The primary outcome was the incremental cost-effectiveness ratio (ICER), which represents the incremental cost increase per an incremental quality-adjusted life-years (QALY) gained from one health intervention compared with another. Secondary outcomes included subsequent short IPI , defined as time between last delivery and conception of less than 18 months, as well as SMM, preterm birth, overall costs, and QALYs. We performed sensitivity analyses on all costs, probabilities, and utilities. RESULTS: Use of immediate postpartum LARC was the cost-effective strategy, with an ICER of -11,880,220,102. Use of immediate postpartum LARC resulted in 299 fewer repeat births overall, 178 fewer births with short IPI, two fewer cases of SMM, and 34 fewer preterm births. Coverage of immediate postpartum LARC resulted in 25 additional QALYs and saved $2,968,796. CONCLUSION: Coverage of immediate postpartum LARC at the time of index delivery can improve quality of life and reduce health care costs for Medicaid programs. Expanding coverage to include immediate postpartum LARC can help to achieve optimal IPI and decrease SMM and preterm birth.

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 (2007-19) from California for NTSV births with a second birth (N = 779,382). The exposure was cesarean delivery in 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 second birth. RESULTS: The adjusted risk ratio for SMM in the second birth given a prior cesarean birth was 1.7 (95% CI 1.5-1.9); 15.5% (95% CI 15.3%-15.7%) of this SMM may be attributable to prior cesarean birth. In a counterfactual analysis where 12% of the California population 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 a subsequent birth. CONCLUSIONS: In our counterfactual analysis, lowering primary cesarean birth among a 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.

Leveraging a Longitudinally Linked Dataset to Assess Recurrence of Severe Maternal Morbidity.

OBJECTIVES: Among those with a severe maternal morbidity (SMM) event and a subsequent birth, we examined how the risk of a second SMM event varied by patient characteristics and intrapartum hospital utilization. METHODS: We used a Massachusetts population-based dataset that longitudinally linked in-state births, hospital discharge records, prior and subsequent births, and non-birth-related hospital utilizations for birthing individuals and their children from January 1, 1999, to December 31, 2018, representing 1,460,514 births by 907,530 birthing people. We restricted our study sample to 2,814 people who had their first SMM event associated with a singleton birth and gave birth a second time within the study period. Our outcome measure was recurrence of SMM in the second birth. We calculated the prevalence of SMM at second birth, compared SMM conditions between births, and estimated the adjusted risk ratios and 95% confidence intervals for having an SMM event at second birth among those who had an SMM at the first birth. We also examined overall hospital utilization including inpatient admissions, emergency room visits, and observational stays, and hospital utilization by interpregnancy intervals (IPIs) between the first and second birth. RESULTS: There were 2,814 birthing people with at least one birth after the first SMM singleton birth. Among those, 198 (7.0%) had a subsequent SMM. The percentage of people with a second SMM event varied by age, race/ethnicity, insurance, IPI, and history of hypertension at first case of SMM (all p < .05). Between births, people with a second SMM event had significantly higher proportions of inpatient admissions (60.1% vs. 33.2.0%; p < .001), emergency room visits (71.7% vs. 57.7%; p < .001), and observational stays (35.4% vs. 19.5%; p < .001) compared with those who did not experience a second SMM event. CONCLUSION: Hospital utilization after a birth with SMM might indicate an elevated risk of a second SMM event. Providers should counsel their patients about prevention and warning signs.

Prediction model for severe maternal morbidity in pregnant women with hypertensive disorders of pregnancy.

Objectives: To investigate risk factors for severe maternal morbidity (SMM) in pregnant women with hypertensive disorders of pregnancy (HDP) and to develop a risk prediction model. Methods: A prospective observational cohort study was conducted among pregnant women who were hospitalized for hypertensive disorders of pregnancy (HDP) between January 2016 and December 2020 in Fujian College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Province, China (a training set), and a risk predictive model was constructed. Pregnant women with HDP who were hospitalized between January 2021 and December 2021 were selected as a validation set. Concordance index (C-index) and calibration curves were used to test predictive model discrimination and calibration. Results: We included 970 pregnant women (790 in the training set and 180 in the validation set). Least absolute shrinkage and selection operator regression was used to screen for nine related variables such as intra-uterine growth retardation (IUGR), diastolic blood pressure (DBP) and systolic blood pressure (SBP) at suspected diagnosis, total bilirubin, albumin (ALB), uric acid, total cholesterol, serum magnesium, and suspected gestational age. SBP at suspected diagnosis (OR =1.22, 95%CI:1.08-1.42) and total cholesterol (OR = 1.78, 95%CI:1.17-2.80) were independent risk factors of severe maternal morbidity in pregnant women with HDP. A nomogram was constructed, and internal validation of the nomogram model was done using the bootstrap self-sampling method. C-index in the training and the validation set was 0.798 and 0.909, respectively. Conclusion: Our prediction model can be used to determine gestational hypertension severity in pregnant women.

Endometriosis, Severe Maternal Morbidity, and the Effect of Infertility: Population-Based Cohort Study.

This population-based cohort evaluated the association between endometriosis and severe maternal morbidity (SMM), and the mediating effect of infertility and fertility treatment. Included were all singleton deliveries in Ontario between 2006 and 2014. Modified Poisson regression generated adjusted relative risks. Mediation analysis estimated the direct effect of endometriosis and indirect effect through infertility and mode of conception. 787 449 deliveries were included (19 099, 2.4% with endometriosis). SMM occurred in 29.0 per 1000 deliveries among women with endometriosis, in contrast to 18.2 per 1000 deliveries among those without endometriosis-corresponding to an adjusted relative risk of SMM of 1.43 (95% CI 1.31-1.56). Mediation analysis demonstrated that the effect of endometriosis on SMM was independent of infertility or fertility treatment. We conclude that SMM in women with endometriosis appears to be due to the disease itself and not to infertility or related treatments.

Interpretable machine learning predicts postpartum hemorrhage with severe maternal morbidity in a lower-risk laboring obstetric population.

BACKGROUND: Early identification of patients at increased risk for postpartum hemorrhage (PPH) associated with severe maternal morbidity (SMM) is critical for preparation and preventative intervention. However, prediction is challenging in patients without obvious risk factors for postpartum hemorrhage with severe maternal morbidity. Current tools for hemorrhage risk assessment use lists of risk factors rather than predictive models. OBJECTIVE: To develop, validate (internally and externally), and compare a machine learning model for predicting PPH associated with SMM against a standard hemorrhage risk assessment tool in a lower risk laboring obstetric population. STUDY DESIGN: This retrospective cross-sectional study included clinical data from singleton, term births (>=37 weeks' gestation) at 19 US hospitals (2016-2021) using data from 58,023 births at 11 hospitals to train a generalized additive model (GAM) and 27,743 births at 8 held-out hospitals to externally validate the model. The outcome of interest was PPH with severe maternal morbidity (blood transfusion, hysterectomy, vascular embolization, intrauterine balloon tamponade, uterine artery ligation suture, uterine compression suture, or admission to intensive care). Cesarean birth without a trial of vaginal birth and patients with a history of cesarean were excluded. We compared the model performance to that of the California Maternal Quality Care Collaborative (CMQCC) Obstetric Hemorrhage Risk Factor Assessment Screen. RESULTS: The GAM predicted PPH with an area under the receiver-operating characteristic curve (AUROC) of 0.67 (95% CI 0.64-0.68) on external validation, significantly outperforming the CMQCC risk screen AUROC of 0.52 (95% CI 0.50-0.53). Additionally, the GAM had better sensitivity of 36.9% (95% CI 33.01-41.02) than the CMQCC screen sensitivity of 20.30% (95% CI 17.40-22.52) at the CMQCC screen positive rate of 16.8%. The GAM identified in-vitro fertilization as a risk factor (adjusted OR 1.5; 95% CI 1.2-1.8) and nulliparous births as the highest PPH risk factor (adjusted OR 1.5; 95% CI 1.4-1.6). CONCLUSION: Our model identified almost twice as many cases of PPH as the CMQCC rules-based approach for the same screen positive rate and identified in-vitro fertilization and first-time births as risk factors for PPH. Adopting predictive models over traditional screens can enhance PPH prediction.

Racial and ethnic disparities in severe maternal morbidity from pregnancy through 1-year postpartum.

BACKGROUND: Previous studies examining racial and ethnic disparities in severe maternal morbidity (SMM) have mainly focused on intrapartum hospitalization. There is limited information regarding the racial and ethnic distribution of SMM occurring in the antepartum and postpartum periods, including SMM occurring beyond the traditional 6 weeks postpartum period. OBJECTIVE: To examine the racial and ethnic distribution of SMM during antepartum, intrapartum, and postpartum hospitalizations through 1-year postpartum, overall and stratified by maternal sociodemographic factors, and to estimate the percent increase in SMM by race and ethnicity and maternal sociodemographic factors within each racial and ethnic group after accounting for both antepartum and postpartum SMM through 1-year postpartum rather than just SMM occurring during the intrapartum hospitalization. STUDY DESIGN: We conducted a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from Michigan, Oregon, and South Carolina from 2008-2020. We examined the distribution of non-transfusion SMM and total SMM per 10,000 cases during antepartum, intrapartum, and postpartum hospitalizations through 365 days postpartum by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. We subsequently examined "SMM cases added" by race and ethnicity and by maternal education and insurance type within each racial and ethnic group. The "SMM cases added" represent cases among unique individuals that are identified by considering the antepartum and postpartum periods but that would be missed if only the intrapartum hospitalization cases were included. RESULTS: Among 2,584,206 birthing individuals, a total of 37,112 (1.4%) individuals experienced non-transfusion SMM and 64,661 (2.5%) experienced any SMM during antepartum, intrapartum, and/or postpartum hospitalization. Black individuals had the highest rate of antepartum, intrapartum, and postpartum non-transfusion and total SMM followed by American Indian individuals. Asian individuals had the lowest rate of non-transfusion and total SMM during antepartum and postpartum hospitalizations while White individuals had the lowest rate of non-transfusion and total SMM during the intrapartum hospitalization. Black individuals were 1.9 times more likely to experience non-transfusion SMM during the intrapartum hospitalization than White individuals, which increased to 2.8 times during the antepartum period and to 2.5 times during the postpartum period. Asian and Hispanic individuals were less likely to experience SMM in the postpartum period than White individuals. Including antepartum and postpartum hospitalizations resulted in disproportionately more cases among Black and American Indian individuals than among White, Hispanic, and Asian individuals. The additional cases were also more likely to occur among individuals with lower educational levels and individuals on government insurance. CONCLUSION: Racial disparities in SMM are underreported in estimates that focus on the intrapartum hospitalization. Additionally, individuals with low socio-economic status bear the greatest burden of SMM occurring during the antepartum and postpartum periods. Approaches that focus on mitigating SMM during the intrapartum period only do not address the full spectrum of health disparities. El resumen está disponible en Español al final del artículo.

Neighborhood-level Fatal Police Violence and Severe Maternal Morbidity in California.

Police violence is a pervasive issue that may have adverse implications for severe maternal morbidity (SMM). We assessed how the occurrence of fatal police violence (FPV) in one's neighborhood before/during pregnancy may influence SMM risk. Hospital discharge records from California between 2002-2018 were linked with the Fatal Encounters database (N=2,608,682). We identified 2,184 neighborhoods (census-tracts) with at least one FPV incident during the study period and used neighborhood fixed-effects models adjusting for individual sociodemographic characteristics to estimate odds of SMM associated with experiencing FPV in one's neighborhood anytime within the 24-months before childbirth. We did not find conclusive evidence on the link between FPV occurrence before delivery and SMM. However, estimates show that birthing people residing in neighborhoods where one or more FPV events had occurred within the preceding 24-months of giving birth may have a mildly elevated odds of SMM than those residing in the same neighborhoods with no FPV occurrence during the 24-months preceding childbirth (Odds Ratio (OR)=1.02; 95% Confidence Interval (CI): 0.99-1.05), particularly among those living in neighborhoods with fewer (1-2) FPV incidents throughout the study period (OR=1.03; 95% CI:1.00-1.06). Our findings provide evidence for the need to continue to examine the health consequences of police violence.