Comparison of placenta consumers' and non-consumers' postpartum depression screening results using EPDS in US community birth settings (n=6038): a propensity score analysis.

BACKGROUND: Preventing postpartum depression (PPD) is the most common self-reported motivation for human maternal placentophagy, yet very little systematic research has assessed mental health following placenta consumption. Our aim was to compare PPD screening scores of placenta consumers and non-consumers in a community birth setting, using propensity score matching to address anticipated extensive confounding. METHODS: We used a medical records-based data set (n = 6038) containing pregnancy, birth, and postpartum information for US women who planned and completed community births. We first compared PPD screening scores as measured by the Edinburgh Postpartum Depression Scale (EPDS) of individuals who consumed their placenta to those who did not, with regard to demographics, pregnancy characteristics, and history of mental health challenges. Matching placentophagic (n = 1876) and non-placentophagic (n = 1876) groups were then created using propensity scores. The propensity score model included more than 90 variables describing medical and obstetric history, demographics, pregnancy characteristics, and intrapartum and postpartum complications, thus addressing confounding by all of these variables. We then used logistic regression to compare placentophagic to non-placentophagic groups based on commonly-cited EPDS cutoff values (≥ 11; ≥ 13) for likely PPD. RESULTS: In the unmatched and unadjusted analysis, placentophagy was associated with an increased risk of PPD. In the matched sample, 9.9% of women who ate their placentas reported EPDS ≥ 11, compared to 8.4% of women who did not (5.5% and 4.8%, respectively, EPDS ≥ 13 or greater). After controlling for over 90 variables (including prior mental health challenges) in the matched and adjusted analysis, placentophagy was associated with an increased risk of PPD between 15 and 20%, depending on the published EPDS cutoff point used. Numerous sensitivity analyses did not alter this general finding. CONCLUSIONS: Placentophagic individuals in our study scored higher on an EPDS screening than carefully matched non-placentophagic controls. Why placentophagic women score higher on the EPDS remains unclear, but we suspect reverse causality plays an important role. Future research could assess psychosocial factors that may motivate some individuals to engage in placentophagy, and that may also indicate greater risk of PPD.

Prevalence and Predictors of Postpartum Cosleeping Practices after Midwife-Led Births in the US.

OBJECTIVE: To evaluate patterns of mother-infant sleeping behaviors among US-based mothers who received care from midwives and breastfed their infants the majority of time at 6 weeks postpartum. STUDY DESIGN: Infant sleep locations were reported for 24 915 mother-infant dyads followed through 6 weeks postpartum, following midwife-led singleton births. Using data derived from medical records, we used multinomial logistic regression to identify predictors of sleep location. RESULTS: The median maternal age was 31 years (IQR, 27-34 years). The majority were White (84.5%), reported having a partner or spouse (95%), had a community birth (87%), and reported bedsharing with their infant for part (13.2%) or most of the night (43.8%). In the adjusted analysis, positive predictors of always bedsharing included increasing maternal age (OR, 1.17; 95% CI, 1.13-1.21; per 5 years), cesarean birth (OR, 1.49; 95% CI, 1.18-1.86), Medicaid eligibility (OR, 1.76; 95% CI, 1.62-1.91), and maternal race/ethnicity (Black OR, 1.40 [95% CI, 1.09-1.79]; Latinx OR, 1.53 [95% CI, 1.35-1.74]; multiracial OR, 1.69 [95% CI, 1.39-2.07]). Negative predictors of bedsharing included having a partner/spouse (OR, 0.66; 95% CI, 0.56-0.77) and birth location in hospitals (OR, 0.56; 95% CI, 0.49-0.64) or birthing centers (OR, 0.48; 95% CI, 0.44-0.51). Partial breastfeeding dyads were less likely to bedshare than those who were exclusively breastfeeding (always bedsharing OR, 0.48 [95% CI, 0.41-0.56]; sometimes bedsharing OR 0.69 [95% CI, 0.56-0.83]). CONCLUSIONS: These data suggest that cosleeping is common among US families who choose community births, most of whom exclusively breastfeed through at least 6 weeks.

Meal patterning and the onset of spontaneous labor.

BACKGROUND: There is a lack of consensus in the literature about the association between meal patterning during pregnancy and birth outcomes. This study examined whether maternal meal patterning in the week before birth was associated with an increased likelihood of imminent spontaneous labor. METHODS: Data came from 607 participants in the third phase of the Pregnancy, Infection, and Nutrition Study (PIN3). Data were collected through an interviewer-administered questionnaire after birth, before hospital discharge. Questions included the typical number of meals and snacks consumed daily, during both the week before labor onset and the 24-hour period before labor onset. A self-matched, case-crossover study design examined the association between skipping one or more meals and the likelihood of spontaneous labor onset within the subsequent 24 hours. RESULTS: Among women who experienced spontaneous labor, 87.0% reported routinely eating three daily meals (breakfast, lunch, and dinner) during the week before their labor began, but only 71.2% reported eating three meals during the 24-hour period before their labor began. Compared with the week before their labor, the odds of imminent spontaneous labor were 5.43 times as high (95% CI: 3.41-8.65) within 24 hours of skipping 1 or more meals. The association between skipping 1 or more meals and the onset of spontaneous labor remained elevated for both pregnant individuals who birthed early (37-<39 weeks) and full-term (≥39 weeks). CONCLUSIONS: Skipping meals later in pregnancy was associated with an increased likelihood of imminent spontaneous labor, though we are unable to rule out reverse causality.

Two-Year Test-Retest Reliability of the Breastfeeding Duration Question Used By the Pregnancy Risk Assessment Monitoring System (PRAMS): Implications for Research.

INTRODUCTION: A large literature exists on positive sequelae of breastfeeding, relying heavily on maternal self-reported infant feeding behaviors. Many such studies use PRAMS data, though estimates of reliability for the breastfeeding duration question on PRAMS have not been published. METHODS: We used data from Oregon PRAMS (respondents are a median 3.5 months postpartum) and PRAMS-2 (median 25 months) to assess test-retest reliability of maternal self-reported breastfeeding duration, among women who had weaned prior to completing the PRAMS survey. RESULTS: The sample-wide kappa for the paired, self-reported breastfeeding duration was 0.014, and the intraclass correlation coefficient was 0.17, both of which indicate poor agreement. More than 80% of women reported a longer duration on PRAMS-2; the median (interquartile range) difference was +1.0 (0.31 - 2.1) months. DISCUSSION: Recent literature on this topic from high-income countries falls into two categories: entirely retrospective versus "prospective" reliability assessments. Entirely retrospective assessments (both inquiries occur well after weaning) universally report exceedingly high reliability, whereas "prospective" assessments (women report infant feeding behavior during infancy, immediately after weaning, and some years later are asked to replicate their original answer) universally report poorer reliability. Interestingly, all "prospective" reliability studies, including ours, found that women over-report past breastfeeding durations by about 1 month upon the second inquiry. Researchers need not refrain from using maternal self-reported breastfeeding durations, because participants are largely still ranked correctly, relative to each other. However, such research efforts must avoid attempting to determine any optimal threshold duration.

You're From Where, Again? A Critical Assessment of Institutional Diversity in the Society for Epidemiologic Research.

The Society for Epidemiologic Research (SER) has recently taken laudable steps toward increasing diversity, equity, and inclusion within the society, including participation in the annual meeting. In this essay, we argue that there is one critical piece of the diversity and inclusion equation that is, however, overlooked: institution. At the 2019 Annual Meeting, a mere 8 institutions accounted for a disproportionate number of both oral concurrent sessions and symposium speakers. This lack of institutional diversity, unless addressed, will hinder SER's ability to address other aspects of diversity, equity, and inclusion.

Fetal macrosomia in home and birth center births in the United States: Maternal, fetal, and newborn outcomes.

BACKGROUND: Fetal macrosomia is associated with negative outcomes, although less is known about how severities of macrosomia influence these outcomes. Planned community births in the United States have higher rates of gestational age-adjusted macrosomia than planned hospital births, providing a novel population to examine macrosomia morbidity. METHODS: Maternal and neonatal outcomes associated with grade 1 (4000-4499 g), grade 2 (4500-4999 g), and grade 3 (≥5000 g) macrosomia were compared to normal birthweight newborns (2500-3999 g), using data from the MANA Statistics Project-a registry of planned community births, 2012-2018 (n = 68 966). Outcomes included perineal trauma, postpartum hemorrhage, cesarean birth, neonatal birth injury, shoulder dystocia, neonatal respiratory distress, neonatal intensive care unit (NICU) stay >24 hours, and perinatal death. Logistic regressions controlled for parity and mode of birth, obesity, gestational diabetes, and preeclampsia. RESULTS: Sixteen percent of the sample were grade 1 macrosomic, 3.3% were grade 2 macrosomic, and 0.4% were grade 3 macrosomic. Macrosomia grades 1-3 were associated in a dose-response fashion with higher odds of all outcomes, compared to non-macrosomia. The adjusted odds ratios and 95% confidence intervals for postpartum hemorrhage for grade 1, grade 2, and grade 3 macrosomia vs normal birthweight were 1.75 (1.56-1.96), 2.12 (1.70-2.63), and 5.18 (3.47-7.74), respectively. Other outcomes had similar patterns. DISCUSSION: The adjusted odds of negative outcomes increase as grade of macrosomia increases in planned community births; results are comparable with the published literature. Pre-birth fetal weight estimation is imprecise; prenatal supports and shared decision-making processes should reflect these complexities.

Factors affecting third-stage management and postpartum hemorrhage in planned midwife-led home and birth center births in the United States.

BACKGROUND: Postpartum hemorrhage (PPH) is a potential childbirth complication. Little is known about how third-stage labor is managed by midwives in the United States, including use of uterotonic medication during community birth. Access to uterotonic medication may vary based on credentials of the midwife or state regulations governing midwifery. METHODS: Using data from the Midwives of North America 2.0 database (2004-2009), we describe the PPH incidence for women giving birth in the community, their demographic and clinical characteristics, and methods used by midwives to address PPH. We also examined PPH rates by midwifery credentials and by the presence of regulations for legal midwifery practice. RESULTS: Of the 17 836 vaginal births, 15.9% had blood loss of over 500 mL and 3.3% had 1000 mL or greater blood loss. Midwives used pharmaceuticals to prevent or treat postpartum bleeding in 6.3% and 13.9% of births, respectively, and the rate of hospital transfer after birth was 1.4% (n = 247). In adjusted analyses, PPH was less likely when births occurred at home vs a birth center, if the midwife had a CNM/CM credential vs a CPM/LM/LDM credential, or if the woman was multiparous without a history of PPH or prior cesarean birth. PPH was more likely in states with barriers to midwifery practice compared with regulated states (OR: 1.26; 95% CI, 1.16-1.38). CONCLUSIONS: Women giving birth in the community experienced low overall incidence of PPH-related hospital transfer. However, the occurrence of PPH itself would likely be reduced with improved legal access to uterotonic medication.

Utility of the 5-Minute Apgar Score as a Research Endpoint.

Although Apgar scores are commonly used as proxy outcomes, little evidence exists in support of the most common cutpoints (<7, <4). We used 2 data sets to explore this issue: one contained planned community births from across the United States (n = 52,877; 2012-2016), and the other contained hospital births from California (n = 428,877; 2010). We treated 5-minute Apgars as clinical "tests," compared against 18 known outcomes; we calculated sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic curve for each. We used 3 different criteria to determine optimal cutpoints. Results were very consistent across data sets, outcomes, and all subgroups: The cutpoint that maximizes the trade-off between sensitivity and specificity is universally <9. However, extremely low positive predictive values for all outcomes at <9 indicate more misclassification than is acceptable for research. The areas under the receiver operating characteristic curves (which treat Apgars as quasicontinuous) were generally indicative of adequate discrimination between infants destined to experience poor outcomes and those not; comparing median Apgars between groups might be an analytical alternative to dichotomizing. Nonetheless, because Apgar scores are not clearly on any causal pathway of interest, we discourage researchers from using them unless the motivation for doing so is clear.

Rural community birth: Maternal and neonatal outcomes for planned community births among rural women in the United States, 2004-2009.

BACKGROUND: Approximately 22% of women in the United States live in rural areas with limited access to obstetric care. Despite declines in hospital-based obstetric services in many rural communities, midwifery care at home and in free standing birth centers is available in many rural communities. This study examines maternal and neonatal outcomes among planned home and birth center births attended by midwives, comparing outcomes for rural and nonrural women. METHODS: Using the Midwives Alliance of North America Statistics Project 2.0 dataset of 18 723 low-risk, planned home, and birth center births, rural women (n = 3737) were compared to nonrural women. Maternal outcomes included mode of delivery (cesarean and instrumental delivery), blood transfusions, severe events, perineal lacerations, or transfer to hospital and a composite (any of the above). The primary neonatal outcome was a composite of early neonatal intensive care unit or hospital admissions (longer than 1 day), and intrapartum or neonatal deaths. Analysis involved multivariable logistic regression, controlling for sociodemographics, antepartum, and intrapartum risk factors. RESULTS: Rural women had different risk profiles relative to nonrural women and reduced risk of adverse maternal and neonatal outcomes in bivariable analyses. However, after adjusting for risk factors and confounders, there were no significant differences for a composite of maternal (adjusted odds ratio [aOR] 1.05 [95% confidence interval {CI} 0.93-1.19]) or neonatal (aOR 1.13 [95% CI 0.87-1.46]) outcomes between rural and nonrural pregnancies. CONCLUSION: Among this sample of low-risk women who planned midwife-led community births, no increased risk was detected by rural vs nonrural status.

Placentophagy among women planning community births in the United States: Frequency, rationale, and associated neonatal outcomes.

BACKGROUND: Limited systematic research on maternal placentophagy is available to maternity care providers whose clients/patients may be considering this increasingly popular practice. Our purpose was to characterize the practice of placentophagy and its attendant neonatal outcomes among a large sample of women in the United States. METHODS: We used a medical records-based data set (n = 23 242) containing pregnancy, birth, and postpartum information for women who planned community births. We used logistic regression to determine demographic and clinical predictors of placentophagy. Finally, we compared neonatal outcomes (hospitalization, neonatal intensive unit admission, or neonatal death in the first 6 weeks) between placenta consumers and nonconsumers, and participants who consumed placenta raw vs cooked. RESULTS: Nearly one-third (30.8%) of women consumed their placenta. Consumers were more likely to have reported pregravid anxiety or depression compared with nonconsumers. Most (85.3%) placentophagic mothers consumed their placentas in encapsulated form, and nearly half (48.4%) consumed capsules containing dehydrated, uncooked placenta. Placentophagy was not associated with any adverse neonatal outcomes. Women with home births were more likely to engage in placentophagy than women with birth center births. The most common reason given (73.1%) for engaging in placentophagy was to prevent postpartum depression. [Corrections added on 16 May 2018, after first online publication: The percentage values in the Results sections were updated.] CONCLUSIONS: The majority of women consumed their placentas in uncooked/encapsulated form and hoping to avoid postpartum depression, although no evidence currently exists to support this strategy. Preparation technique (cooked vs uncooked) did not influence adverse neonatal outcomes. Maternity care providers should discuss the range of options available to prevent/treat postpartum depression, in addition to current evidence with respect to the safety of placentophagy.

Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States.

BACKGROUND: There is little agreement on who is a good candidate for community (home or birth center) birth in the United States. METHODS: Data on n=47 394 midwife-attended, planned community births come from the Midwives Alliance of North America Statistics Project. Logistic regression quantified the independent contribution of 10 risk factors to maternal and neonatal outcomes. Risk factors included: primiparity, advanced maternal age, obesity, gestational diabetes, preeclampsia, postterm pregnancy, twins, breech presentation, history of cesarean and vaginal birth, and history of cesarean without history of vaginal birth. Models controlled additionally for Medicaid, race/ethnicity, and education. RESULTS: The independent contributions of maternal age and obesity were quite modest, with adjusted odds ratios (AOR) less than 2.0 for all outcomes: hospital transfer, cesarean, perineal trauma, postpartum hemorrhage, low/very-low Apgar, maternal or neonatal hospitalization, NICU admission, and fetal/neonatal death. Breech was strongly associated with morbidity and fetal/neonatal mortality (AOR 8.2, 95% CI, 3.7-18.4). Women with a history of both cesarean and vaginal birth fared better than primiparas across all outcomes; however, women with a history of cesarean but no prior vaginal births had poor outcomes, most notably fetal/neonatal demise (AOR 10.4, 95% CI, 4.8-22.6). Cesarean births were most common in the breech (44.7%), preeclampsia (30.6%), history of cesarean without vaginal birth (22.1%), and primipara (11.0%) groups. DISCUSSION: The outcomes of labor after cesarean in women with previous vaginal deliveries indicates that guidelines uniformly prohibiting labor after cesarean should be reconsidered for this subgroup. Breech presentation has the highest rate of adverse outcomes supporting management of vaginal breech labor in a hospital setting.

Pilot Study for Managing Complex Chronic Care Medicaid Patients With Diabetes Using a Mobile Health Application Achieves "Triple Aim" Improvement in a Primary Care Setting.

IN BRIEF Cost-effective innovations to improve health and health care in patients with complex chronic diseases are urgently needed. Mobile health (mHealth) remote monitoring applications (apps) are a promising technology to meet this need. This article reports on a study evaluating patients' use of a tablet device with an mHealth app and a cellular-enabled glucose meter that automatically uploaded blood glucose values to the app. Improvements were observed across all three components of the Patient Protection and Affordable Care Act's "triple aim." Self-rated wellness and numerous quality-of-care metrics improved, billed charges and paid claims decreased, but no changes in clinical endpoints were observed.

Planned Home VBAC in the United States, 2004-2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making.

BACKGROUND: In the United States, the number of planned home vaginal births after cesarean (VBACs) has increased. This study describes the maternal and neonatal outcomes for women who planned a VBAC at home with midwives who were contributing data to the Midwives Alliance of North America Statistics Project 2.0 cohort during the years 2004-2009. METHOD: Two subsamples were created from the parent cohort: 12,092 multiparous women without a prior cesarean and 1,052 women with a prior cesarean. Descriptive statistics were calculated for maternal and neonatal outcomes for both groups. Sensitivity analyses comparing women with a prior vaginal birth and those who were at the lowest risk with various subgroups in the parent cohort were also conducted. RESULTS: Women with a prior cesarean had a VBAC rate of 87 percent, although transfer rates were higher compared with women without a prior cesarean (18% vs 7%, p < 0.001). The most common indication for transfer was failure to progress. Women with a prior cesarean had higher proportions of blood loss, maternal postpartum infections, uterine rupture, and neonatal intensive care unit admissions than those without a prior cesarean. Five neonatal deaths (4.75/1,000) occurred in the prior cesarean group compared with 1.24/1,000 in multiparas without a history of cesarean (p = 0.015). CONCLUSION: Although there is a high likelihood of a vaginal birth at home, women planning a home VBAC should be counseled regarding maternal transfer rates and potential for increased risk to the newborn, particularly if uterine rupture occurs in the home setting.

The Role of Passive Descent and Epidural Analgesia in Outcomes Associated With Prolonged Pushing Among Nulliparous Individuals in Midwifery Care.

INTRODUCTION: Efforts to reduce primary cesarean birth may include supporting longer second stages of labor. Although midwifery-led care is associated with lower cesarean use, little has been published on associated outcomes of prolonged second stage (≥3 hours of pushing) for nulliparous individuals in US hospital-based midwifery care. Epidural analgesia and the role of passive descent in midwifery-led care are also underexplored in relation to the second stage. In this study, we report the incidence of prolonged second stage stratified by epidural analgesia and/or passive descent. Secondary aims included calculating the odds of cesarean birth, obstetric anal sphincter injury (OASI), postpartum hemorrhage (PPH), and neonatal complications. METHODS: Data were collected prospectively from a single academic center in the United States from 2012 through 2019. Our cohort analysis of labors attended by midwives for nulliparous, term, singleton, and vertex pregnancies included both descriptive and inferential statistics comparing outcomes between prolonged versus nonprolonged pushing groups. We stratified the sample and quantified second stage outcomes by epidural analgesia and by use of passive descent. RESULTS: Of the 1465 births, 17% (n = 247) included prolonged pushing. Cesarean ranged from 2.2% without prolonged pushing to 26.7% with prolonged pushing. Fetal malposition, epidural analgesia, and longer passive descent were more common among those with prolonged active pushing. Despite these factors, neither odds for PPH nor poor neonatal outcomes were associated with prolonged pushing. Those with more than one hour of passive descent in the second stage who also had prolonged active pushing had lower odds for cesarean but higher odds for OASI relative to those who had little passive descent before pushing for more than 3 hours. DISCUSSION: Prolonged pushing occurred in nearly 2 of 10 nulliparous labors. Fetal malposition, epidural analgesia, and prolonged pushing were commonly observed with longer passive descent, cesarean, and OASI. Passive descent in these data likely reflects individualized midwifery care strategies when pushing was complicated by fetal malposition or other complexities.

Muscle power predicts frailty status over four years: A retrospective cohort study of the National Health and Aging Trends Study.

Objectives: Muscle power is a critical measure of physical capacity in older adults, however the association between muscle power and frailty is not well explored. The purpose of this study is to estimate the association between muscle power and frailty in community-dwelling older adults in the National Health and Aging Trends Study from 2011-2015. Methods: Cross-sectional and prospective analyses were performed on 4,803 community-dwelling older adults. Mean muscle power was calculated using the five-time sit-to-stand test, height, weight, and chair height and dichotomized into high-watt and low-watt groups. Frailty was defined using the five Fried criteria. Results: The low watt-group had higher odds of pre-frailty and frailty at baseline year 2011. In prospective analyses, the low-watt group that was pre-frail at baseline had increased hazards of frailty (AHR 1.62, 95% CI 1.31, 1.99) and decreased hazards of non-frailty (AHR 0.71, 95% CI 0.59, 0.86). The low-watt group that was non-frail at baseline had increased hazards of pre-frailty (1.24, 95% CI 1.04, 1.47) and frailty (1.70, 1.07, 2.70). Conclusions: Lower muscle power is associated with higher odds of pre-frailty and frailty and increased hazards of becoming frail or pre-frail over four years in those who are pre-frail or non-frail at baseline.

Current Resources for Evidence-Based Practice, May 2022.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of the roles of researchers and clinicians in fostering evidence-based practice, diagnostic test accuracy in suspected preeclampsia, and the effectiveness of decision-making tools in patients with pre-pregnancy morbidities.

Current Resources for Evidence-Based Practice, January 2022.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of breastfeeding while employed and commentaries on reviews focused on mammography test characteristics and sexual health for gynecologic cancer survivors. It also includes a quick update on a USPSTF review for aspirin as pre-eclampsia prophylaxis.

Current Resources for Evidence-Based Practice, March 2022.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of systemic racism and its effect on maternal health in the United States and commentaries on reviews focused on barriers and facilitators to HPV vaccination and delayed cord clamping in preterm infants.

Critical care in obstetrics: Clinical audit in the Republic of Ireland, 2014-2016.

INTRODUCTION: Admission to an Intensive Care Unit (ICU) in obstetrics is often used as a proxy for maternal near miss/severe maternal morbidity (MNM/SMM) events. Understanding incidence and management of pregnant or postpartum patients requiring critical care (CC) is thus important for continued improvement of maternity care. This study aims to describe provision of critical care in obstetrics in the Republic of Ireland. MATERIAL AND METHODS: The national clinical audit on critical care included 15 of 19 maternity units in Ireland (2014-2016). 960 pregnant or postpartum (within 42 days) individuals who required CC were included. Data were reported on all cases requiring level 2 or level 3 CC. We calculated basic descriptive statistics for diagnosis and process of care variables, and compared characteristics of women requiring level 2 care to those requiring level 3. Outcomes included diagnoses necessitating critical care; additional complications; level of care required; care process outcomes such as length of stay, consultation with non-obstetric specialties, location of maternal critical care, and neonatal care provision. RESULTS: Overall, the rate of critical care in obstetrics for these hospitals was 1 in 131 live births; 900 of the 960 cases required level 2 care only. Hypertensive disorders contributed to the need for critical care for 1 in 242; hemorrhage, 1 in 422; and infections, 1 in 926. A substantial minority (15.7%) had more than one diagnosis, accounting for 40% of level 3 care. Serious complications were rare (eg, hysterectomy, 1 in 3846). Parity, hospital size, and identification as high-risk antenatally (<50% cases) were associated with requiring level 3 care. Critical care was provided in multiple locations, including ICUs, HDUs, and operating theatres. Only 23.8% of patients received CC in an ICU, suggesting ICU admission is not an ideal method for identifying severe maternal morbidity. CONCLUSIONS: We reported rates of critical care admission and primary diagnoses within the range of other published estimates, but huge variability exists in the literature, and within our data. ICU admission in and of itself iss not a reliable proxy for having received level 2 or 3 obstetric critical care in Ireland.