A, Mean age at cesarean delivery (CD) and proportion in each age subgroup are shown per year. Footnotes indicate inflection points of temporal trend. B, Temporal trends in perioperative mortality, obesity, and comorbidity are shown per year. While the absolute number of annual CDs increased in the first two-thirds of the study period (mean annual cases: 2001 to 2006, 1 163 834; 2007 to 2012, 1 299 774; 2013 to 2017, 1 228 077), the absolute number of annual deaths decreased during the study period (mean annual deaths: 2001 to 2006, 221.5 deaths per 100 000 procedures; 2007 to 2012, 190.5 deaths per 100 000 procedures; 2013 to 2017, 157 deaths per 100 000 procedures). C, Trends of severe maternal morbidity per the US Centers for Disease Control and Prevention (CDC) criteria5 and failure-to-rescue rates are shown over time. Results are shown for patients with severe maternal morbidity without blood product transfusion, which is similar to the CDC analysis.5 Mortality rates for women with severe maternal morbidity and for those without were 1.6% and 0.002%, respectively, in 2001 to 2006; 1.1% and less than 0.001% in 2007 to 2012; and 0.8% and less than 0.001% in 2013 to 2017 (P < .001). Population-attributable risk percentage of severe maternal morbidity for surgical mortality was greater than 99% for these 3 periods. D, Age-specific perioperative mortality is shown. The association between patient age at CD and perioperative mortality was adjusted for patient demographic characteristics (race/ethnicity, obesity, and comorbidity) and facility data (reference, women aged 25 to 29 years). Dots indicate observed values, and error bars indicate SE or 95% CIs, as applicable. Lines represent modeled values (panels B and C). aOR indicates adjusted odds ratio; CCI, Charlson Comorbidity Index.
dP = .003.
eP < .001.
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Matsuo K, Mandelbaum RS, Matsuzaki S, et al. Decreasing Failure-to-Rescue From Severe Maternal Morbidity at Cesarean Delivery: Recent US Trends. JAMA Surg. 2021;156(6):585–587. doi:10.1001/jamasurg.2021.0600
Cesarean delivery is the most common major surgical procedure performed in the US,1 with approximately 1.2 to 1.3 million cases performed annually.2 The rate of cesarean delivery increased significantly from 24.4% to 32.9% between 2001 and 2009 and has recently remained higher than 30% (ranging from 31.9% to 32.0% from 2016 to 2018). Surgical mortality from cesarean delivery is overall low in the US, estimated at 12.7 deaths per 100 000 procedures between 2000 and 2006, which is lower compared with all-cause mortality in women aged 15 to 44 years (ranging from 42 to 136 per 100 000).3,4 Given recent population trends of increasing maternal age, obesity rates, and maternal morbidity,2,5 which may affect obstetric and surgical outcomes, updated mortality trends and statistics are important to monitor. This study examined recent national trends in patient characteristics and perioperative morbidity and mortality at time of cesarean delivery in the US.
This is a population-based retrospective observational study querying the National Inpatient Sample. This database represents hospital discharge data for more than 90% of the US population when weighted. It is publicly available and deidentified, distributed as part of the Healthcare Cost and Utilization Project by the Agency for Healthcare Research and Quality.6 The University of Southern California Institutional Review Board deemed the study exempt due to the use of publicly available deidentified data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Women who underwent cesarean delivery between 2001 and 2017 were included, and patient demographic characteristics, severe maternal morbidity per the US Centers for Disease Control and Prevention criteria,5 and mortality among those experiencing severe maternal morbidity during the index admission (ie, failure to rescue) were assessed. The temporal trends in outcome measures of interest were assessed with linear segmented regression with log transformation using 1-year increments. We used a binary logistic regression model to estimate adjusted odds ratios. Significance was set at a P value less than .05, and all P values were 2-tailed. Analyses were conducted using SPSS Statistics version 27.0 (IBM) and Joinpoint Regression Program version 22.214.171.124 (National Cancer Institute).
There were 20 922 025 women who underwent cesarean delivery during the study period. The mean (SD) age was 29.0 (6.1) years, which increased from 28.6 to 29.9 years between 2009 and 2017 (P < .001) (Figure, A). Among the age groups, women 45 years and older had the largest interval increase (1.8-fold increase) followed by those aged 40 to 44 years and 35 to 39 years (1.2-fold increase each). During the study period, the number of women with obesity and those with comorbidity increased significantly (obesity: 1.2% to 16.1%; P < .001; comorbidity: 4.1% to 9.4%; P < .001) (Figure, B).
There were 3257 women who died during admission for cesarean delivery (15.6 deaths per 100 000 procedures). Between 2001 and 2017, the estimated perioperative mortality rate decreased by 3.5% (95% CI, 1.4-5.5; P = .003) annually from 20.2 to 11.8 deaths per 100 000 procedures (Figure, B). Overall, the severe maternal morbidity rate was 1.4%. From 2001 to 2017, the number of women with severe maternal morbidity increased by 3.2% (95% CI, 2.6-3.9; P < .001) annually, and the number experiencing multiple severe complications increased by 5.1% (95% CI, 4.4-5.7; P < .001) annually (Figure, C). The failure-to-rescue rate from severe maternal morbidity was 1.1%. The estimated failure-to-rescue rate among those who had severe maternal morbidity decreased by 5.4% (95% CI, 3.2-5.4; P < .001) annually from 1.8% to 0.8% between 2001 and 2017.
The risk of perioperative mortality was significantly increased in older women (Figure, D). Significant disparity for severe maternal morbidity, surgical mortality, and failure to rescue were present across women of different races/ethnicities (Table). Over time, the rate of severe maternal morbidity increased in all examined race/ethnicity groups, but the failure-to-rescue rate improved in the White, Black, and Hispanic groups (Table).
Despite increasing maternal age, degree of maternal comorbidity, and persistent alarming rates of maternal mortality overall in the US, it is reassuring that mortality at cesarean delivery is decreasing in the US. To our knowledge, failure-to-rescue rates in cesarean delivery procedures has not been previously examined, and decreasing failure-to-rescue rates among women experiencing severe life-threatening pregnancy complications may point to improving perioperative care. While improving, high failure-to-rescue rates in Black women need further investigation. Notable limitations of this study include a lack of information on the exact cause of death, mortality following hospital discharge, and indication for cesarean delivery. Restriction of the analysis to short-term perioperative outcomes may have affected the findings.
Accepted for Publication: January 27, 2021.
Published Online: April 21, 2021. doi:10.1001/jamasurg.2021.0600
Corresponding Author: Koji Matsuo, MD, PhD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Ave, IRD 520, Los Angeles, CA 90033 (firstname.lastname@example.org).
Author Contributions: Dr Mandelbaum had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Matsuo and Mandelbaum contributed equally to this work.
Study concept and design: Matsuo, Mandelbaum, Sangara, Klar.
Acquisition, analysis, or interpretation of data: Matsuo, Mandelbaum, Matsuzaki, Lee, Klar, Ouzounian.
Drafting of the manuscript: Matsuo, Mandelbaum, Matsuzaki, Klar.
Critical revision of the manuscript for important intellectual content: Matsuo, Mandelbaum, Sangara, Lee, Klar, Ouzounian.
Statistical analysis: Matsuo, Mandelbaum.
Obtained funding: Matsuo.
Administrative, technical, or material support: Matsuo, Mandelbaum, Matsuzaki, Lee.
Study supervision: Matsuo, Mandelbaum, Klar, Ouzounian.
Conflict of Interest Disclosures: Dr Matsuo has received honorarium from Chugai, textbook editorial expense from Springer, and an investigator meeting attendance fee VBL Therapeutics. Dr Matsuzaki has received grants from Merck Sharp & Dohme. Dr Klar has received consultation fees from Tesaro/GlaxoSmithKline. No other disclosures were reported.
Funding/Support: This work was supported by an Ensign Endowment for Gynecologic Cancer Research (Dr Matsuo).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.