Assessment of Incidence and Factors Associated With Severe Maternal Morbidity After Delivery Discharge Among Women in the US | Health Disparities | JAMA Network Open | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 18.207.129.82. Please contact the publisher to request reinstatement.
1.
Centers for Disease Control and Prevention. Pregnancy mortality surveillance system. Centers for Disease Control and Prevention, US Department of Health and Human Services; 2020. Accessed March 4, 2020. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm
2.
Petersen  EE, Davis  NL, Goodman  D,  et al.  Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017.   MMWR Morb Mortal Wkly Rep. 2019;68(18):423-429. doi:10.15585/mmwr.mm6818e1PubMedGoogle ScholarCrossref
3.
Maternal Mortality Review Committees. Report from Maternal Mortality Review Committees: A View into Their Critical Role. Building US Capacity to Review and Prevent Maternal Deaths Program, CDC Foundation; 2017. Accessed March 4, 2020. https://www.cdcfoundation.org/sites/default/files/files/MMRIAReport.pdf
4.
Maternal Mortality Review Committees. Report From Nine Maternal Mortality Review Committees. Building US Capacity to Review and Prevent Maternal Deaths Program, CDC Foundation; 2018. Accessed March 4, 2020. https://www.cdcfoundation.org/sites/default/files/files/ReportfromNineMMRCs.pdf
5.
Callaghan  WM, Mackay  AP, Berg  CJ.  Identification of severe maternal morbidity during delivery hospitalizations, United States, 1991-2003.   Am J Obstet Gynecol. 2008;199(2):133.e1-133.e8. doi:10.1016/j.ajog.2007.12.020PubMedGoogle ScholarCrossref
6.
Callaghan  WM, Creanga  AA, Kuklina  EV.  Severe maternal morbidity among delivery and postpartum hospitalizations in the United States.   Obstet Gynecol. 2012;120(5):1029-1036. doi:10.1097/AOG.0b013e31826d60c5PubMedGoogle ScholarCrossref
7.
Kilpatrick  SK, Ecker  JL; American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine.  Severe maternal morbidity: screening and review.   Am J Obstet Gynecol. 2016;215(3):B17-B22. doi:10.1016/j.ajog.2016.07.050PubMedGoogle ScholarCrossref
8.
Creanga  AA, Berg  CJ, Ko  JY,  et al.  Maternal mortality and morbidity in the United States: where are we now?   J Womens Health (Larchmt). 2014;23(1):3-9. doi:10.1089/jwh.2013.4617PubMedGoogle ScholarCrossref
9.
Centers for Disease Control and Prevention. Severe maternal morbidity in the United States. Centers for Disease Control and Prevention, US Department of Health and Human Services; 2019. Updated January 31, 2020. Accessed November 26, 2019. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html
10.
Martin  JA, Hamilton  BE, Osterman  MJK, Driscoll  AK, Mathews  TJ.  Births: Final Data for 2015.   Natl Vital Stat Rep. 2017;66(1):1.PubMedGoogle Scholar
11.
Campbell  KH, Savitz  D, Werner  EF,  et al.  Maternal morbidity and risk of death at delivery hospitalization.   Obstet Gynecol. 2013;122(3):627-633. doi:10.1097/AOG.0b013e3182a06f4ePubMedGoogle ScholarCrossref
12.
Main  EK, Markow  C, Gould  J.  Addressing maternal mortality and morbidity in California through public-private partnerships.   Health Aff (Millwood). 2018;37(9):1484-1493. doi:10.1377/hlthaff.2018.0463PubMedGoogle ScholarCrossref
13.
Creanga  AA, Bateman  BT, Kuklina  EV, Callaghan  WM.  Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010.   Am J Obstet Gynecol. 2014;210(5):435.e1-435.e8. doi:10.1016/j.ajog.2013.11.039PubMedGoogle ScholarCrossref
14.
Chen  H-Y, Chauhan  SP, Blackwell  SC.  Severe maternal morbidity and hospital cost among hospitalized deliveries in the United States.   Am J Perinatol. 2018;35(13):1287-1296. doi:10.1055/s-0038-1649481PubMedGoogle ScholarCrossref
15.
Howell  EA, Zeitlin  J, Hebert  PL, Balbierz  A, Egorova  N.  Association between hospital-level obstetric quality indicators and maternal and neonatal morbidity.   JAMA. 2014;312(15):1531-1541. doi:10.1001/jama.2014.13381PubMedGoogle ScholarCrossref
16.
Harvey  EM, Ahmed  S, Manning  SE, Diop  H, Argani  C, Strobino  DM.  Severe maternal morbidity at delivery and risk of hospital encounters within 6 weeks and 1 year postpartum.   J Womens Health (Larchmt). 2018;27(2):140-147. doi:10.1089/jwh.2017.6437PubMedGoogle ScholarCrossref
17.
Girsen  AI, Sie  L, Carmichael  SL,  et al.  Rate and causes of severe maternal morbidity at readmission: California births in 2008-2012.   J Perinatol. 2020;40(1):25-29. doi:10.1038/s41372-019-0481-zPubMedGoogle ScholarCrossref
18.
Ailes  EC, Simeone  RM, Dawson  AL, Petersen  EE, Gilboa  SM.  Using insurance claims data to identify and estimate critical periods in pregnancy: An application to antidepressants.   Birth Defects Res A Clin Mol Teratol. 2016;106(11):927-934. doi:10.1002/bdra.23573PubMedGoogle ScholarCrossref
19.
Hoyert  DL.  Maternal mortality and related concepts.   Vital Health Stat 3. 2007;(33):1-13.PubMedGoogle Scholar
20.
Main  EK, Abreo  A, McNulty  J,  et al.  Measuring severe maternal morbidity: validation of potential measures.   Am J Obstet Gynecol. 2016;214(5):643.e1-643.e10. doi:10.1016/j.ajog.2015.11.004PubMedGoogle ScholarCrossref
21.
Stata 14. Version 14. StataCorp; 2015. Accessed January 2020. https://www.stata.com/
22.
Kozhimannil  KB, Interrante  JD, Henning-Smith  C, Admon  LK.  Rural-urban differences in severe maternal morbidity and mortality in the US, 2007–15.   Health Aff (Millwood). 2019;38(12):2077-2085. doi:10.1377/hlthaff.2019.00805PubMedGoogle ScholarCrossref
23.
Wall-Wieler  E, Carmichael  SL, Gibbs  RS,  et al.  Severe maternal morbidity among stillbirth and live birth deliveries in California.   Obstet Gynecol. 2019;134(2):310-317. doi:10.1097/AOG.0000000000003370PubMedGoogle ScholarCrossref
24.
McKinney  J, Keyser  L, Clinton  S, Pagliano  C.  ACOG committee opinion no. 736: optimizing postpartum care.   Obstet Gynecol. 2018;132(3):784-785. doi:10.1097/AOG.0000000000002849PubMedGoogle ScholarCrossref
25.
Guglielminotti  J, Landau  R, Wong  CA, Li  G.  Patient-, hospital-, and neighborhood-level factors associated with severe maternal morbidity during childbirth: a cross-sectional study in New York State 2013–2014.   Matern Child Health J. 2019;23(1):82-91. doi:10.1007/s10995-018-2596-9PubMedGoogle ScholarCrossref
26.
Council on Patient Safety in Women’s Health Care. Postpartum care basics for maternal safety from birth to the comprehensive postpartum visit (+AIM). American College of Obstetricians and Gynecologists; 2017. Accessed May 20, 2020. https://safehealthcareforeverywoman.org/patient-safety-bundles/postpartum-care-basics/
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    Obstetrics and Gynecology
    February 2, 2021

    Assessment of Incidence and Factors Associated With Severe Maternal Morbidity After Delivery Discharge Among Women in the US

    Author Affiliations
    • 1Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
    • 2Now with Division of Research, Office of Epidemiology and Research, Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, Maryland
    JAMA Netw Open. 2021;4(2):e2036148. doi:10.1001/jamanetworkopen.2020.36148
    Key Points

    Question  What proportion of de novo severe maternal morbidity is diagnosed after delivery discharge, and what are the most common factors and maternal characteristics associated with severe maternal morbidity among women in the US?

    Findings  In this cohort study of 2 667 325 women in the US with delivery hospitalizations between 2010 and 2014, 14% and 16% of severe maternal morbidity among those with commercial and Medicaid insurance, respectively, developed de novo within 6 weeks after delivery discharge. The most common factors and maternal characteristics associated with severe maternal morbidity after delivery were different than those identified at delivery.

    Meaning  The study’s findings suggest that expanding the focus of severe maternal morbidity assessment to the postdelivery discharge period could improve understanding of severe maternal morbidity and may create opportunities to improve maternity care.

    Abstract

    Importance  Previous efforts to examine severe maternal morbidity (SMM) in the US have focused on delivery hospitalizations. Little is known about de novo SMM that occurs after delivery discharge.

    Objective  To investigate the incidence, timing, factors, and maternal characteristics associated with de novo SMM after delivery discharge among women in the US.

    Design, Setting, and Participants  In this retrospective cohort study, data from the IBM MarketScan Multi-State Medicaid database and the IBM MarketScan Commercial Claims and Encounters database were used to construct a sample of women aged 15 to 44 years who delivered between January 1, 2010, and September 30, 2014. Severe maternal morbidity was reported by the timing of diagnosis, and the associated maternal characteristics were examined. Women in the Medicaid and commercial insurance sample were classified into 3 distinct outcome groups: (1) those without any SMM during the delivery hospitalization and the postdelivery period (reference group), (2) those who exhibited at least 1 factor associated with SMM during the delivery hospitalization, and (3) those who exhibited any factor associated with de novo SMM after delivery discharge (defined as SMM that was first diagnosed in the inpatient setting during the 6 weeks [or 42 days] after discharge from the delivery hospitalization, conditional on no factor associated with SMM being identified during delivery). Data were analyzed from February to July 2020.

    Exposures  Timing of SMM diagnosis.

    Main Outcomes and Measures  Women with SMM were identified using diagnosis and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification for the 21 factors associated with SMM that were developed by the Centers for Disease Control and Prevention.

    Results  A total of 2 667 325 women in the US with delivery hospitalizations between 2010 and 2014 were identified; of those, 809 377 women (30.3%) had Medicaid insurance (30.3%; mean [SD] age, 25.6 [5.5] years; 51.1% White), and 1 857 948 women (69.7%; mean [SD] age, 30.6 [5.4] years; 36.4% from the southern region of the US) had commercial insurance. Among those with Medicaid insurance, 17 584 women (2.2%) experienced SMM during the delivery hospitalization, and 3265 women (0.4%) experienced de novo SMM after delivery discharge. Among those with commercial insurance, 32 079 women (1.7%) experienced SMM during the delivery hospitalization, and 5275 women (0.3%) experienced de novo SMM after hospital discharge. A total of 5275 SMM cases (14.1%) and 3265 SMM cases (15.7%) among women with commercial and Medicaid insurance, respectively, developed de novo within 6 weeks after hospital discharge; of those, 3993 cases (75.7%) in the commercial insurance cohort and 2399 cases (73.5%) in the Medicaid cohort were identified in the first 2 weeks after discharge. The most common factors associated with SMM varied based on the timing of diagnosis. In the Medicaid population, non-Hispanic Black women (adjusted odds ratio [aOR], 1.53; 95% CI, 1.48-1.58), Hispanic women (aOR, 1.46; 95% CI, 1.37-1.57), and women of other races or ethnicities (aOR, 1.40; 95% CI, 1.33-1.47) had higher rates of SMM during delivery hospitalization than non-Hispanic White women; however, only the disparity between Black and White women (aOR, 1.69; 95% CI, 1.57-1.81) persisted into the postdischarge period.

    Conclusions and Relevance  In this study, 15.7% of SMM cases in the Medicaid cohort and 14.1% of SMM cases in the commercial insurance cohort first occurred after the delivery hospitalization, with notable disparities in factors and maternal characteristics associated with the development of SMM. These findings suggest a need to expand the focus of SMM assessment to the postdelivery discharge period.

    ×