Effect of Maternal Body Mass Index on Postpartum Hemorrhage.

BACKGROUND: It is unclear whether obesity is a risk factor for postpartum hemorrhage. The authors hypothesized that obese women are at greater risk of hemorrhage than women with a normal body mass index. METHODS: The authors conducted a cohort study of women who underwent delivery hospitalization in California between 2008 and 2012. Using multilevel regression, the authors examined the relationships between body mass index with hemorrhage (primary outcome), atonic hemorrhage, and severe hemorrhage (secondary outcomes). Stratified analyses were performed according to delivery mode. RESULTS: The absolute event rate for hemorrhage was 60,604/2,176,673 (2.8%). In this cohort, 4% of women were underweight, 49.1% of women were normal body mass index, 25.9% of women were overweight, and 12.7%, 5.2%, and 3.1% of women were in obesity class I, II, and III, respectively. Compared to normal body mass index women, the odds of hemorrhage and atonic hemorrhage were modestly increased for overweight women (hemorrhage: adjusted odds ratio [aOR], 1.06; 99% CI, 1.04 to 1.08; atonic hemorrhage: aOR, 1.07; 99% CI, 1.05 to 1.09) and obesity class I (hemorrhage: aOR, 1.08; 99% CI, 1.05 to 1.11; atonic hemorrhage; aOR, 1.11; 99% CI, 1.08 to 1.15). After vaginal delivery, overweight and obese women had up to 19% increased odds of hemorrhage or atonic hemorrhage; whereas, after cesarean delivery, women in any obesity class had up to 14% decreased odds of severe hemorrhage. CONCLUSIONS: The authors' findings suggest that, at most, maternal obesity has a modest effect on hemorrhage risk. The direction of the association between hemorrhage and body mass index may differ by delivery mode.

Improving Maternal Safety at Scale with the Mentor Model of Collaborative Improvement.

BACKGROUND: Obstetric safety bundles, consisting of action steps shown to improve outcomes, have been developed to address the most common and preventable causes of maternal morbidity and mortality. Implementing these best practices across all birthing facilities remains an important and challenging clinical and public health priority. METHODS: The California Maternal Quality Care Collaborative (CMQCC) developed an innovative external mentor model for large-scale collaborative improvement in which participating organizations were subdivided into small teams of six to eight hospitals, led by a paired dyad of physician and nurse leaders. The mentor model preserves the active sharing that enhances improvement across a large group of facilities working on the same project while enabling individualized attention to teams. The mentor model was tested by implementing the obstetric hemorrhage safety bundle (which consists of 17 key practices in four domains) in multiple California hospitals. RESULTS: A total of 126 hospitals were engaged to simultaneously implement the safety bundle. The adoption rates for the recommended practices in the four action domains were (1) Readiness, 78.9%; (2) Recognition and Prevention, 76.5%; (3) Response, 63.1%; and (4) Reporting and Systems Learning, 58.7%. Mentors (31/40) and participating teams (48 responses from 39/126 hospitals) provided feedback in an exit survey. Among the respondents, 64.5% of mentors and 72.9% of participants agreed that compared to a traditional collaborative structure, the mentor model was better suited for quality improvement at scale. CONCLUSION: The mentor model was successful in providing individualized support to teams and enabled implementation of the hemorrhage safety bundle across a diverse group of 126 hospitals.

Mothers at Risk: Factors Affecting Maternal Postpartum Length of Stay.

Perinatal complications linked to maternal comorbidities contribute to increased healthcare utilization through an extended postpartum length of stay (LOS). Understanding factors influencing postpartum LOS may minimize the adverse effects associated with comorbidities and complications. The purpose of this study was to identify risk factors with the greatest odds of increasing postpartum LOS. Linked 2008-2009 hospital discharge and birth certificate data were used to examine comorbidities and complication codes in 1 015 424 births. The overall rate for an extended LOS (vaginal: >5 days/cesarean: >6 days) was 3.63 per 1000 live births. Complications were present in 17% of pregnancies; multiple complications were seen in 1%. Chronic hypertension was associated with an extended stay for both vaginal and cesarean births (odds ratio [OR] = 5.89 [95% CI, 4.39-7.88]; OR = 3.57 [95% CI, 3.05-4.17], respectively). Puerperal infections (OR = 6.86 [95% CI, 5.73-8.21]), eclampsia (OR = 17.07 [95% CI, 13.76-21.17]), and transfusions (OR = 11.66 [95% CI, 9.20-14.75]) occurred most frequently and conferred the highest odds of an extended stay for vaginal births. Cerebrovascular conditions (OR = 15.32 [95% CI, 11.90-19.60]) and infection (OR = 15.35 [95% CI, 10.11-23.32]) conferred the highest odds of an extended LOS for cesarean births. The earlier risk factors are recognized, the sooner processes can be initiated to optimize organizational preparation, thus decreasing adverse maternal outcomes and extended hospital stays.

Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative.

BACKGROUND: Obstetric hemorrhage is the leading cause of severe maternal morbidity and of preventable maternal mortality in the United States. The California Maternal Quality Care Collaborative developed a comprehensive quality improvement tool kit for hemorrhage based on the national patient safety bundle for obstetric hemorrhage and noted promising results in pilot implementation projects. OBJECTIVE: We sought to determine whether these safety tools can be scaled up to reduce severe maternal morbidity in women with obstetric hemorrhage using a large maternal quality collaborative. STUDY DESIGN: We report on 99 collaborative hospitals (256,541 annual births) using a before-and-after model with 48 noncollaborative comparison hospitals (81,089 annual births) used to detect any systemic trends. Both groups participated in the California Maternal Data Center providing baseline and rapid-cycle data. Baseline period was the 48 months from January 2011 through December 2014. The collaborative started in January 2015 and the postintervention period was the 6 months from October 2015 through March 2016. We modified the Institute for Healthcare Improvement collaborative model for achieving breakthrough improvement to include the mentor model whereby 20 pairs of nurse and physician mentors experienced in quality improvement gave additional support to small groups of 6-8 hospitals. The national hemorrhage safety bundle served as the template for quality improvement action. The main outcome measurement was the composite Centers for Disease Control and Prevention severe maternal morbidity measure, for both the target population of women with hemorrhage and the overall delivery population. The rate of adoption of bundle elements was used as an indicator of hospital engagement and intensity. RESULTS: Compared to baseline period, women with hemorrhage in collaborative hospitals experienced a 20.8% reduction in severe maternal morbidity while women in comparison hospitals had a 1.2% reduction (P < .0001). Women in hospitals with prior hemorrhage collaborative experience experienced an even larger 28.6% reduction. Fewer mothers with transfusions accounted for two thirds of the reduction in collaborative hospitals and fewer procedures and medical complications, the remainder. The rate of severe maternal morbidity among all women in collaborative hospitals was 11.7% lower and women in hospitals with prior hemorrhage collaborative experience had a 17.5% reduction. Improved outcomes for women were noted in all hospital types (regional, medium, small, health maintenance organization, and nonhealth maintenance organization). Overall, 54% of hospitals completed 14 of 17 bundle elements, 76% reported regular unit-based drills, and 65% reported regular posthemorrhage debriefs. Higher rate of bundle adoption was associated with improvement of maternal morbidity only in hospitals with high initial rates of severe maternal morbidity. CONCLUSION: We used an innovative collaborative quality improvement approach (mentor model) to scale up implementation of the national hemorrhage bundle. Participation in the collaborative was strongly associated with reductions in severe maternal morbidity among hemorrhage patients. Women in hospitals in their second collaborative had an even greater reduction in morbidity than those approaching the bundle for the first time, reinforcing the concept that quality improvement is a long-term and cumulative process.

Confirmed severe maternal morbidity is associated with high rate of preterm delivery.

BACKGROUND: Because severe maternal morbidity (SMM) is increasing in the United States, affecting up to 50,000 women per year, there was a recent call to review all mothers with SMM to better understand their morbidity and improve outcomes. Administrative screening methods for SMM have recently been shown to have low positive predictive value for true SMM after chart review. To ultimately reduce maternal morbidity and mortality we must better understand risk factors, and preventability issues about true SMM such that interventions could be designed to improve care. OBJECTIVE: Our objective was to determine risk factors associated with true SMM identified from California delivery admissions, including the relationship between SMM and preterm delivery. STUDY DESIGN: In this retrospective cohort study, SMM cases were screened for using International Classification of Diseases, Ninth Revision codes for severe illness and procedures, prolonged postpartum length of stay, intensive care unit admission, and transfusion from all deliveries in 16 hospitals from July 2012 through June 2013. Charts of screen-positive cases were reviewed and true SMM diagnosed based on expert panel agreement. Underlying disease diagnosis was determined. Women with true-positive SMM were compared to SMM-negative women for the following variables: maternal age, ethnicity, gestational age at delivery, prior cesarean delivery, and multiple gestation. RESULTS: In all, 491 women had true SMM and 66,977 women did not have SMM for a 0.7% rate of true SMM. Compared to SMM-negative women, SMM cases were significantly more likely to be age >35 years (33.6 vs 23.8%; P < .0001), be African American (14.1 vs 7.9%; P < .0001), have had a multiple gestation (9.7 vs 2.1%; P < .0001), and, for the multiparous women, have had a prior cesarean delivery (58 vs 30.2%; P < .0001). Preterm delivery was significantly more common in SMM women compared to SMM-negative women (41 vs 8%; P < .0001), including delivery <32 weeks (18 vs 2%; P < .0001). The most common underlying disease was obstetric hemorrhage (42%) followed by hypertensive disorders (20%) and placental hemorrhage (14%). Only 1.6% of women with SMM had cardiovascular disease as the underlying disease category. CONCLUSION: An extremely high proportion of women with severe morbidity (42.5%) delivered preterm with 17.8% delivering <32 weeks, which underscores the importance of access to appropriate-level care for mothers with SMM and their newborns. Further, the extremely high rate of preterm delivery (75%) in women with placental hemorrhage in combination with their 63% prior cesarean delivery rate highlights another risk of prior cesarean delivery: subsequent preterm delivery. These data provide a reminder that a cesarean delivery could be a contributing factor to not only hemorrhage-related SMM, but also to increased subsequent preterm delivery, more reason to continue national efforts to safely reduce initial cesarean deliveries.

Severe maternal morbidity in a large cohort of women with acute severe intrapartum hypertension.

BACKGROUND: Hypertensive diseases of pregnancy are associated with severe maternal morbidity and remain common causes of maternal death. Recently, national guidelines have become available to aid in recognition and management of hypertension in pregnancy to reduce morbidity and mortality. The increased morbidity related to hypertensive disorders of pregnancy is presumed to be associated with the development of severe hypertension. However, there are few data on specific treatment or severe maternal morbidity in women with acute severe intrapartum hypertension as opposed to severe preeclampsia. OBJECTIVE: The study aimed to characterize maternal morbidity associated with women with acute severe intrapartum hypertension, and to determine whether there was an association between various first-line antihypertensive agents and posttreatment blood pressure. STUDY DESIGN: This retrospective cohort study of women delivering between July 2012 and August 2014 at 15 hospitals participating in the California Maternal Quality Care Collaborative compared women with severe intrapartum hypertension (systolic blood pressure >160 mm Hg or diastolic blood pressure >105 mm Hg) to women without severe hypertension. Hospital Patient Discharge Data and State of California Birth Certificate Data were used. Severe maternal morbidity using the Centers for Disease Control and Prevention criteria based on International Classification of Diseases-9 codes was compared between groups. The efficacy of different antihypertensive medications in meeting the 1-hour posttreatment goal was determined. Statistical methods included distribution appropriate univariate analyses and multivariate logistic regression. RESULTS: There were 2252 women with acute severe intrapartum hypertension and 93,650 women without severe hypertension. Severe maternal morbidity was significantly more frequent in the women with severe hypertension (8.8%) compared to the control women (2.3%) (P < .0001). Severe maternal morbidity rates did not increase with increasing severity of blood pressures (P = .90 for systolic and .42 for diastolic). There was no difference in severe maternal morbidity between women treated (8.6%) and women not treated (9.5%) (P = .56). Antihypertensive treatment rates were significantly higher in hospitals with a level IV neonatal intensive care unit (85.8%) compared to a level III neonatal intensive care unit (80.2%) (P < .001), and in higher-volume hospitals (84.5%) compared to lower-volume hospitals (69.1%) (P < .001). Severe maternal morbidity rates among severely hypertensive women were significantly higher in hospitals with level III neonatal intensive care unit level compared to hospitals with a level IV neonatal intensive care unit (10.6% vs 5.7%, respectively; P < .001), and significantly higher in low-delivery volume hospitals compared to high-delivery volume hospitals (15.5% vs 7.6%, respectively; P < .001). Only 53% of women treated with oral labetalol as first-line medication met the posttreatment goal of nonsevere hypertension, significantly less than those treated with intravenous hydralazine, intravenous labetalol, or oral nifedipine (68%, 71%, and 82%, respectively) (P = .001). Severe intrapartum hypertension remained untreated in 17% of women. CONCLUSION: Women with acute severe intrapartum hypertension had a significantly higher risk of severe maternal morbidity compared to women without severe hypertension. Significantly lower antihypertensive treatment rates and higher severe maternal morbidity rates were seen in lower-delivery volume hospitals.

Measuring severe maternal morbidity: validation of potential measures.

BACKGROUND: Both maternal mortality rate and severe maternal morbidity rate have risen significantly in the United Sates. Recently, the Centers for Disease Control and Prevention introduced International Classification of Diseases, 9th revision, criteria for defining severe maternal morbidity with the use of administrative data sources; however, those criteria have not been validated with the use of chart reviews. OBJECTIVE: The primary aim of the current study was to validate the Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria for the identification of severe maternal morbidity. This analysis initially required the development of a reproducible set of clinical conditions that were judged to be consistent with severe maternal morbidity to be used as the clinical gold standard for validation. Alternative criteria for severe maternal morbidity were also examined. STUDY DESIGN: The 67,468 deliveries that occurred during a 12-month period from 16 participating California hospitals were screened initially for severe maternal morbidity with the presence of any of 4 criteria: (1) Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, diagnosis and procedure codes; (2) prolonged postpartum length of stay (>3 standard deviations beyond the mean length of stay for the California population); (3) any maternal intensive care unit admissions (with the use of hospital billing sources); and (4) the administration of any blood product (with the use of transfusion service data). Complete medical records for all screen-positive cases were examined to determine whether they satisfied the criteria for the clinical gold standard (determined by 4 rounds of a modified Delphi technique). Descriptive and statistical analyses that included area under the receiver operating characteristic curve and C-statistic were performed. RESULTS: The Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria had a reasonably high sensitivity of 0.77 and a positive predictive value of 0.44 with a C-statistic of 0.87. The most important source of false-positive cases were mothers whose only criterion was 1-2 units of blood products. The Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria screen rate ranged from 0.51-2.45% among hospitals. True positive severe maternal morbidity ranged from 0.05-1.13%. When hospitals were grouped by their neonatal intensive care unit level of care, severe maternal morbidity rates were statistically lower at facilities with lower level neonatal intensive care units (P < .0001). CONCLUSION: The Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria can serve as a reasonable administrative metric for measuring severe maternal morbidity at population levels. Caution should be used with the use of these criteria for individual hospitals, because case-mix effects appear to be strong.

Time of Birth and the Risk of Severe Unexpected Complications in Term Singleton Neonates.

OBJECTIVE: To assess whether there is a relationship between evening, night, and weekend births and severe unexpected neonatal morbidity in low-risk term singleton births. METHODS: We conducted a population-based, cross-sectional analysis. Severe unexpected neonatal morbidity as defined by the National Quality Forum specification 0716 was derived from linked birth certificate and hospital discharge summaries for 1,048,957 low-risk singleton term Californian births during 2011 through 2013. The association between the nursing shift (7 am-3 pm vs 3-11 pm and 11 pm -7 am) and weekday compared with weekend birth and the risk of severe unexpected neonatal morbidity was estimated using mixed effects logistic regression models. RESULTS: Severe unexpected neonatal morbidity was higher among births during the 3-11 pm evening shift (2.1%) and the 11 pm-7 am night shift (2.1%), compared with those during the 7 am-3 pm day shift (1.8%). The adjusted odds ratios (ORs) were 1.10 (95% CI 1.06-1.13) for the evening shift and 1.15 (1.11-1.19) for the night shift. The adjusted ORs of severe unexpected neonatal morbidity were increased only on Sunday, as compared with other days (adjusted OR 1.08, 95% CI 1.02-1.14). When our analysis was by perinatal region, the increase was seen in four of the nine perinatal regions. CONCLUSION: After risk adjustment, the risk of severe unexpected morbidity in the low-risk singleton California birth cohort was significantly increased on Sundays and births during evening and night shifts. These elevations were detected in only four of California's nine perinatal regions. Further analysis at the individual hospital level is warranted.