Last data update: Apr 22, 2024. (Total: 46599 publications since 2009)
Records 1-30 (of 88 Records) |
Query Trace: Callaghan WM [original query] |
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Ranked severe maternal morbidity index for population-level surveillance at delivery hospitalization based on hospital discharge data
Kuklina EV , Ewing AC , Satten GA , Callaghan WM , Goodman DA , Ferre CD , Ko JY , Womack LS , Galang RR , Kroelinger CD . PLoS One 2023 18 (11) e0294140 BACKGROUND: Severe maternal morbidity (SMM) is broadly defined as an unexpected and potentially life-threatening event associated with labor and delivery. The Centers for Disease Control and Prevention (CDC) produced 21 different indicators based on International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) hospital diagnostic and procedure codes to identify cases of SMM. OBJECTIVES: To examine existing SMM indicators and determine which indicators identified the most in-hospital mortality at delivery hospitalization. METHODS: Data from the 1993-2015 and 2017-2019 Healthcare Cost and Utilization Project's National Inpatient Sample were used to report SMM indicator-specific prevalences, in-hospital mortality rates, and population attributable fractions (PAF) of mortality. We hierarchically ranked indicators by their overall PAF of in-hospital mortality. Predictive modeling determined if SMM prevalence remained comparable after transition to ICD-10-CM coding. RESULTS: The study population consisted of 18,198,934 hospitalizations representing 87,864,173 US delivery hospitalizations. The 15 top ranked indicators identified 80% of in-hospital mortality; the proportion identified by the remaining indicators was negligible (2%). The top 15 indicators were: restoration of cardiac rhythm; cardiac arrest; mechanical ventilation; tracheostomy; amniotic fluid embolism; aneurysm; acute respiratory distress syndrome; acute myocardial infarction; shock; thromboembolism, pulmonary embolism; cerebrovascular disorders; sepsis; both DIC and blood transfusion; acute renal failure; and hysterectomy. The overall prevalence of the top 15 ranked SMM indicators (~22,000 SMM cases per year) was comparable after transition to ICD-10-CM coding. CONCLUSIONS: We determined the 15 indicators that identified the most in-hospital mortality at delivery hospitalization in the US. Continued testing of SMM indicators can improve measurement and surveillance of the most severe maternal complications at the population level. |
Prenatal ultrasound use and risk of autism spectrum disorder: Findings from the case-control Study to Explore Early Development
Christensen D , Pazol K , Overwyk KJ , England LJ , Alexander AA , Croen LA , Dowling NF , Schieve LA , Tian LH , Tinker SC , Windham GC , Callaghan WM , Shapira SK . Paediatr Perinat Epidemiol 2023 37 (6) 527-535 BACKGROUND: Studies evaluating the association between prenatal ultrasounds and autism spectrum disorder (ASD) have largely produced negative results. Concern remains due to the rising identification of children with ASD and ultrasound use. OBJECTIVE: To evaluate the association between prenatal ultrasound use and ASD. METHODS: We used data from the Study to Explore Early Development, a multisite case-control study of preschool-aged children with ASD implemented during 2007-2012. We recruited cases from children receiving developmental disability services and randomly selected population controls from birth records. ASD case status was based on in-person standardised assessments. We stratified analyses by pre-existing maternal medical conditions and pregnancy complications associated with increased ultrasound use (ultrasound indications) and used logistic regression to model case status by increasing ultrasound counts. For pregnancies with medical record data on ultrasound timing, we conducted supplementary tests to model associations by trimester of exposure. RESULTS: Among 1524 singleton pregnancies, ultrasound indications were more common for ASD cases than controls; respectively, for each group, no indications were reported for 45.1% and 54.2% of pregnancies, while ≥2 indications were reported for 26.1% and 18.4% of pregnancies. The percentage of pregnancies with multiple ultrasounds varied by case status and the presence of ultrasound indications. However, stratified regression models showed no association between increasing ultrasound counts and case status, either for pregnancies without (aOR 1.01, 95% CI 0.92, 1.11) or with ultrasound indications (aOR 1.01, 95% CI 0.95, 1.08). Trimester-specific analyses using medical record data showed no association in any individual trimester. CONCLUSIONS: We found no evidence that prenatal ultrasound use increases ASD risk. Study strengths included gold-standard assessments for ASD case classification, comparison of cases with controls, and a stratified sample to account for conditions associated both with increased prenatal ultrasound use and ASD. |
Bias in Self-reported Prepregnancy Weight Across Maternal and Clinical Characteristics
Sharma AJ , Bulkley JE , Stoneburner AB , Dandamudi P , Leo M , Callaghan WM , Vesco KK . Matern Child Health J 2021 25 (8) 1242-1253 OBJECTIVES: Prepregnancy body mass index (BMI) and gestational weight gain (GWG) are known determinants of maternal and child health; calculating both requires an accurate measure of prepregnancy weight. We compared self-reported prepregnancy weight to measured weights to assess reporting bias by maternal and clinical characteristics. METHODS: We conducted a retrospective cohort study among pregnant women using electronic health records (EHR) data from Kaiser Permanente Northwest, a non-profit integrated health care system in Oregon and southwest Washington State. We identified women age ≥ 18 years who were pregnant between 2000 and 2010 with self-reported prepregnancy weight, ≥ 2 measured weights between ≤ 365-days-prior-to and ≤ 42-days-after conception, and measured height in their EHR. We compared absolute and relative difference between self-reported weight and two "gold-standards": (1) weight measured closest to conception, and (2) usual weight (mean of weights measured 6-months-prior-to and ≤ 42-days-after conception). Generalized-estimating equations were used to assess predictors of misreport controlling for covariates, which were obtained from the EHR or linkage to birth certificate. RESULTS: Among the 16,227 included pregnancies, close agreement (± 1 kg or ≤ 2%) between self-reported and closest-measured weight was 44% and 59%, respectively. Overall, self-reported weight averaged 1.3 kg (SD 3.8) less than measured weight. Underreporting was higher among women with elevated BMI category, late prenatal care entry, and pregnancy outcome other than live/stillbirth (p < .05). Using self-reported weight, BMI was correctly classified for 91% of pregnancies, but ranged from 70 to 98% among those with underweight or obesity, respectively. Results were similar using usual weight as gold standard. CONCLUSIONS FOR PRACTICE: Accurate measure of prepregnancy weight is essential for clinical guidance and surveillance efforts that monitor maternal health and evaluate public-health programs. Identification of characteristics associated with misreport of self-reported weight can inform understanding of bias when assessing the influence of prepregnancy BMI or GWG on health outcomes. |
Pregnant Validity of the pregnancy checkbox on death certificates in four states, and characteristics associated with pregnancy checkbox errors
Catalano A , Davis NL , Petersen EE , Harrison C , Kieltyka L , You M , Conrey EJ , Ewing AC , Callaghan WM , Goodman D . Am J Obstet Gynecol 2019 222 (3) 269 e1-269 e8 BACKGROUND: Maternal mortality rates in the United States appear to be increasing. One potential reason may be increased identification of maternal deaths after the addition of a pregnancy checkbox to the death certificate. In 2016, four state health departments (Georgia, Louisiana, Michigan, Ohio) implemented a pregnancy checkbox quality assurance pilot, with technical assistance provided by the Centers for Disease Control and Prevention. The pilot aimed to improve accuracy of the pregnancy checkbox on death certificates and resultant state maternal mortality estimates. OBJECTIVE(S): To estimate the validity of the pregnancy checkbox on the death certificate and describe characteristics associated with errors using 2016 data from a four state quality assurance pilot. STUDY DESIGN: Potential pregnancy-associated deaths were identified by linking death certificates with birth or fetal death certificates from within a year preceding death or by pregnancy checkbox status. Death certificates which indicated the decedent was pregnant within a year of death via the pregnancy checkbox, but that did not link to a birth or fetal death certificate, were referred for active follow-up to confirm pregnancy status by either death certifier confirmation or medical record review. Descriptive statistics and 95% confidence intervals were used to examine the distributions of demographic characteristics by pregnancy confirmation category (i.e., confirmed pregnant, confirmed not pregnant, and unable to confirm). We compared the proportion confirmed pregnant and confirmed not pregnant within age, race/ethnicity, pregnancy checkbox category, and certifier type categories using a Wald test of proportions. Binomial and Poisson regression models were used to estimate prevalence ratios for having an incorrect pregnancy checkbox (false positive, false negative) by age group, race/ethnicity, pregnancy checkbox category, and certifier type. RESULTS: Among 467 potential pregnancy-associated deaths, 335 (72%) were confirmed pregnant either via linkage to a birth or fetal death certificate, certifier confirmation, or review of medical records. Ninety-seven (21%) women were confirmed not pregnant (false positives) and 35 (7%) were unable to be confirmed. Women confirmed pregnant were significantly younger than women confirmed not pregnant (p<.001). Deaths certified by coroners and medical examiners were more likely to be confirmed pregnant than confirmed not pregnant (p=0.04). The association between decedent age category and false positive status followed a dose-response relationship (p<0.001), with increasing prevalence ratios for each increase in age category. Death certificates of non-Hispanic black women were more likely to be false positives, compared with non-Hispanic white women [prevalence ratio (PR) 1.41, 95% confidence interval (CI) 1.01, 1.96]. The sensitivity of the pregnancy checkbox among these four states in 2016 was 62% and the positive predictive value was 68%. CONCLUSION(S): We provide a multi-state analysis of the validity of the pregnancy checkbox and highlight a need for more accurate reporting of pregnancy status on death certificates. States and other jurisdictions may increase the accuracy of their data used to calculate maternal mortality rates by implementing quality assurance processes. |
Racial/ethnic disparities in pregnancy-related deaths - United States, 2007-2016
Petersen EE , Davis NL , Goodman D , Cox S , Syverson C , Seed K , Shapiro-Mendoza C , Callaghan WM , Barfield W . MMWR Morb Mortal Wkly Rep 2019 68 (35) 762-765 Approximately 700 women die in the United States each year as a result of pregnancy or its complications, and significant racial/ethnic disparities in pregnancy-related mortality exist (1). Data from CDC's Pregnancy Mortality Surveillance System (PMSS) for 2007-2016 were analyzed. Pregnancy-related mortality ratios (PRMRs) (i.e., pregnancy-related deaths per 100,000 live births) were analyzed by demographic characteristics and state PRMR tertiles (i.e., states with lowest, middle, and highest PRMR); cause-specific proportionate mortality by race/ethnicity also was calculated. Over the period analyzed, the U.S. overall PRMR was 16.7 pregnancy-related deaths per 100,000 births. Non-Hispanic black (black) and non-Hispanic American Indian/Alaska Native (AI/AN) women experienced higher PRMRs (40.8 and 29.7, respectively) than did all other racial/ethnic groups. This disparity persisted over time and across age groups. The PRMR for black and AI/AN women aged >/=30 years was approximately four to five times that for their white counterparts. PRMRs for black and AI/AN women with at least some college education were higher than those for all other racial/ethnic groups with less than a high school diploma. Among state PRMR tertiles, the PRMRs for black and AI/AN women were 2.8-3.3 and 1.7-3.3 times as high, respectively, as those for non-Hispanic white (white) women. Significant differences in cause-specific proportionate mortality were observed among racial/ethnic populations. Strategies to address racial/ethnic disparities in pregnancy-related deaths, including improving women's health and access to quality care in the preconception, pregnancy, and postpartum periods, can be implemented through coordination at the community, health facility, patient, provider, and system levels. |
Vital Signs: Pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017
Petersen EE , Davis NL , Goodman D , Cox S , Mayes N , Johnston E , Syverson C , Seed K , Shapiro-Mendoza CK , Callaghan WM , Barfield W . MMWR Morb Mortal Wkly Rep 2019 68 (18) 423-429 BACKGROUND: Approximately 700 women die from pregnancy-related complications in the United States every year. METHODS: Data from CDC's national Pregnancy Mortality Surveillance System (PMSS) for 2011-2015 were analyzed. Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births; PRMRs) were calculated overall and by sociodemographic characteristics. The distribution of pregnancy-related deaths by timing relative to the end of pregnancy and leading causes of death were calculated. Detailed data on pregnancy-related deaths during 2013-2017 from 13 state maternal mortality review committees (MMRCs) were analyzed for preventability, factors that contributed to pregnancy-related deaths, and MMRC-identified prevention strategies to address contributing factors. RESULTS: For 2011-2015, the national PRMR was 17.2 per 100,000 live births. Non-Hispanic black (black) women and American Indian/Alaska Native women had the highest PRMRs (42.8 and 32.5, respectively), 3.3 and 2.5 times as high, respectively, as the PRMR for non-Hispanic white (white) women (13.0). Timing of death was known for 87.7% (2,990) of pregnancy-related deaths. Among these deaths, 31.3% occurred during pregnancy, 16.9% on the day of delivery, 18.6% 1-6 days postpartum, 21.4% 7-42 days postpartum, and 11.7% 43-365 days postpartum. Leading causes of death included cardiovascular conditions, infection, and hemorrhage, and varied by timing. Approximately sixty percent of pregnancy-related deaths from state MMRCs were determined to be preventable and did not differ significantly by race/ethnicity or timing of death. MMRC data indicated that multiple factors contributed to pregnancy-related deaths. Contributing factors and prevention strategies can be categorized at the community, health facility, patient, provider, and system levels and include improving access to, and coordination and delivery of, quality care. CONCLUSIONS: Pregnancy-related deaths occurred during pregnancy, around the time of delivery, and up to 1 year postpartum; leading causes varied by timing of death. Approximately three in five pregnancy-related deaths were preventable. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Strategies to address contributing factors to pregnancy-related deaths can be enacted at the community, health facility, patient, provider, and system levels. |
Association of glucose levels in pregnancy with use of health care services
Vesco KK , Sharma AJ , Bulkley J , Terry Kimes M , Callaghan WM , England FLJ , Hornbrook MC . Diabetes Res Clin Pract 2019 152 146-155 AIMS: To determine whether women with abnormal gestational diabetes (GDM) screening test results short of frank GDM have increased health-services utilization compared to women with normal results. METHODS: We conducted a retrospective-cohort study among 29,999 women enrolled in Kaiser Permanente Northwest who completed GDM screening (two-step method:1-hour, 50-gram glucose-challenge test (GCT); 3-hour, 100-gram oral-glucose-tolerance test (OGTT)). Test results were categorized as normal GCT (referent, n=25,535), normal OGTT (n=2,246), abnormal OGTT but not GDM (n=1477), and GDM (n=741). Rate ratios (RRs) were calculated for utilization measures and analyses were age- and BMI-adjusted. RESULTS: Compared to women with normal GCT, rates for obstetrical ultrasound, noninvasive and invasive antenatal testing, and ambulatory visits to the obstetrics department were significantly greater among women with abnormal OGTT (RRs 1.2 [95%CI 1.1, 1.4], 1.3 [1.1, 1.4], 1.7 [1.3, 2.3], and 1.1 [1.1, 1.1], respectively) and GDM (RRs 1.8, 1.8, 2.0, and 1.3, respectively). Women with abnormal OGTT results were more likely to visit a dietician than women with normal GCT; RRs ranged from 4.0 [3.3, 4.9] for women with abnormal GCT but normal OGTT to 72.1 [64, 81] for women with GDM. CONCLUSIONS: Health-services utilization increased with severity of glucose result, even among women without GDM. |
Assisted reproductive technology surveillance - United States, 2016
Sunderam S , Kissin DM , Zhang Y , Folger SG , Boulet SL , Warner L , Callaghan WM , Barfield WD . MMWR Surveill Summ 2019 68 (4) 1-23 PROBLEM/CONDITION: Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks for both mothers and infants, including obstetric complications, preterm delivery (<37 weeks), and low birthweight (<2,500 g). This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2016 and compares birth outcomes that occurred in 2016 (resulting from ART procedures performed in 2015 and 2016) with outcomes for all infants born in the United States in 2016. PERIOD COVERED: 2016. DESCRIPTION OF SYSTEM: In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493 [October 24, 1992]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia, and Puerto Rico). RESULTS: In 2016, a total of 197,706 ART procedures (range: 162 in Wyoming to 24,030 in California) with the intent to transfer at least one embryo were performed in 463 U.S. fertility clinics and reported to CDC. These procedures resulted in 65,964 live-birth deliveries (range: 57 in Puerto Rico to 8,638 in California) and 76,892 infants born (range: 74 in Alaska to 9,885 in California). Nationally, the number of ART procedures performed per 1 million women of reproductive age (15-44 years), a proxy measure of the ART use rate, was 3,075. ART use rates exceeded the national rate in 14 reporting areas (Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Utah, and Virginia). ART use exceeded 1.5 times the national rate in nine states, including three (Illinois, Massachusetts, and New Jersey) that also had comprehensive mandated health insurance coverage for ART procedures (i.e., coverage for at least four oocyte retrievals). Nationally, among ART transfer procedures for patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age (1.5 among women aged <35 years, 1.7 among women aged 35-37 years, and 2.2 among women aged >37 years). Among women aged <35 years, the national elective single-embryo transfer (eSET) rate was 42.7% (range: 8.3% in North Dakota to 83.9% in Delaware). In 2016, ART contributed to 1.8% of all infants born in the United States (range: 0.3% in Puerto Rico to 4.7% in Massachusetts). ART also contributed to 16.4% of all multiple-birth infants, including 16.2% of all twin infants and 19.4% of all triplets and higher-order infants. ART-conceived twins accounted for approximately 96.5% (21,455 of 22,233) of all ART-conceived infants born in multiple deliveries. The percentage of multiple-birth infants was higher among infants conceived with ART (31.5%) than among all infants born in the total birth population (3.4%). Approximately 30.4% of ART-conceived infants were twins and 1.1% were triplets and higher-order infants. Nationally, infants conceived with ART contributed to 5.0% of all low birthweight (<2,500 g) infants. Among ART-conceived infants, 23.6% had low birthweight compared with 8.2% among all infants. ART-conceived infants contributed to 5.3% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (29.9%) than among all infants born in the total birth population (9.9%). The percentage of ART-conceived infants who had low birthweight was 8.7% among singletons, 54.9% among twins, and 94.9% among triplets and higher-order multiples; the corresponding percentages among all infants born were 6.2% among singletons, 55.4% among twins, and 94.6% among triplets and higher-order multiples. The percentage of ART-conceived infants who were born preterm was 13.7% among singletons, 64.2% among twins, and 97.0% among triplets and higher-order infants; the corresponding percentages among all infants were 7.8% for singletons, 59.9% for twins, and 97.7% for triplets and higher-order infants. INTERPRETATION: Multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born in the United States. For women aged <35 years, who typically are considered good candidates for eSET, on average, 1.5 embryos were transferred per ART procedure, resulting in higher multiple birth rates than could be achieved with single-embryo transfers. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive mandated health insurance coverage, three (Illinois, Massachusetts, and New Jersey) had rates of ART use >1.5 times the national average. Although other factors might influence ART use, insurance coverage for infertility treatments accounts for some of the difference in per capita ART use observed among states because most states do not mandate any coverage for ART treatment. PUBLIC HEALTH ACTION: Twins account for almost all of ART-conceived multiple births born in multiple deliveries. Reducing the number of embryos transferred and increasing use of eSET, when clinically appropriate, could help reduce multiple births and related adverse health consequences for both mothers and infants. Because multiple-birth infants are at increased risk for numerous adverse sequelae that cannot be ascertained from the data collected through NASS alone, long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes. |
Venous thromboembolism as a cause of severe maternal morbidity and mortality in the United States
Abe K , Kuklina EV , Hooper WC , Callaghan WM . Semin Perinatol 2019 43 (4) 200-204 In the U.S., deaths due to pulmonary embolism (PE) account for 9.2% of all pregnancy-related deaths or approximately 1.5 deaths per 100,000 live births. Maternal deaths and maternal morbidity due to PE are more common among women who deliver by cesarean section. In the past decade, the clinical community has increasingly adopted venous thromboembolism (VTE) guidelines and thromboprophylaxis recommendations for pregnant women. Although deep vein thrombosis rates have decreased during this time-period, PE rates have remained relatively unchanged in pregnancy hospitalizations and as a cause of maternal mortality. Changes in the health profile of women who become pregnant, particularly due to maternal age and co-morbidities, needs more attention to better understand the impact of VTE risk during pregnancy and the postpartum period. |
Putting the 'M' back in maternal-fetal medicine: A five-year report card on a collaborative effort to address maternal morbidity and mortality in the U.S
D'Alton ME , Friedman AM , Bernstein PS , Brown HL , Callaghan WM , Clark SL , Grobman WA , Kilpatrick SJ , O'Keeffe DF , Montgomery DM , Srinivas SK , Wendel GD , Wenstrom KD , Foley MR . Am J Obstet Gynecol 2019 221 (4) 311-317 e1 The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014 with a mortality rate of 18.0 per 100,000, higher than many other developed countries. In 2012 the first "Putting the 'M' back in Maternal Fetal Medicine" session was held at the Society for Maternal Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified urgent needs to: (i) enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) improve the medical care and management of pregnant women across the country; and (iii) address critical research gaps in maternal medicine. Since that first meeting a broad collaborative effort has made a number of major steps forward including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 "M in MFM" meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next five years given that too many mothers still experience preventable harm and adverse outcomes. |
Opioid use disorder documented at delivery hospitalization - United States, 1999-2014
Haight SC , Ko JY , Tong VT , Bohm MK , Callaghan WM . MMWR Morb Mortal Wkly Rep 2018 67 (31) 845-849 Opioid use by pregnant women represents a significant public health concern given the association of opioid exposure and adverse maternal and neonatal outcomes, including preterm labor, stillbirth, neonatal abstinence syndrome, and maternal mortality (1,2). State-level actions are critical to curbing the opioid epidemic through programs and policies to reduce use of prescription opioids and illegal opioids including heroin and illicitly manufactured fentanyl, both of which contribute to the epidemic (3). Hospital discharge data from the 1999-2014 Healthcare Cost and Utilization Project (HCUP) were analyzed to describe U.S. national and state-specific trends in opioid use disorder documented at delivery hospitalization. Nationally, the prevalence of opioid use disorder more than quadrupled during 1999-2014 (from 1.5 per 1,000 delivery hospitalizations to 6.5; p<0.05). Increasing trends over time were observed in all 28 states with available data (p<0.05). In 2014, prevalence ranged from 0.7 in the District of Columbia (DC) to 48.6 in Vermont. Continued national, state, and provider efforts to prevent, monitor, and treat opioid use disorder among reproductive-aged and pregnant women are needed. Efforts might include improved access to data in Prescription Drug Monitoring Programs, increased substance abuse screening, use of medication-assisted therapy, and substance abuse treatment referrals. |
Foreword: Maternal mortality and severe maternal morbidity
Callaghan WM . Clin Obstet Gynecol 2018 61 (2) 294-295 The maternal mortality rate has been and continues to be a key indicator of a nation’s health and health care delivery system. During the 20th century the United States had a dramatic decrease in the risk of death associated with pregnancy and childbirth, largely attributed to improved living standards and the modernization of maternity care. However, as we approached the millennium there was evidence of increasing maternal mortality and that trend continued into the 21st century. Although there remains controversy about how to count maternal deaths and what deaths should be counted, some of which is discussed in this symposium, it is clear that US maternal mortality is not headed in the desired direction; our best estimates indicate that about 700 women die each year during or shortly after the end of pregnancy due to causes specific to or aggravated by the physiology of pregnancy. Moreover, deaths are the tip of an iceberg, with estimates of another 75 to 100 women experiencing severe complications for every woman who dies as a result of being pregnant. As someone who has been studying and thinking about these tragic events at the national level, I am honored to edit this symposium on maternal mortality and severe maternal morbidity. Although it is tempting to focus on the numbers and rates, it is my hope that focusing a lens on maternal morbidity and mortality reminds all of us that behind the numbers are our mothers, sisters and daughters, and the events we count are individual human tragedies we are seeking to prevent. |
Challenges and opportunities in identifying, reviewing, and preventing maternal deaths
St Pierre A , Zaharatos J , Goodman D , Callaghan WM . Obstet Gynecol 2017 131 (1) 138-142 Despite many efforts at the state, city, and national levels over the past 70 years, a nationwide consensus on how best to identify, review, and prevent maternal deaths remains challenging. We present a brief history of maternal death surveillance in the United States and compare the three systems of national surveillance that exist today: the National Vital Statistics System, the Pregnancy Mortality Surveillance System, and maternal mortality review committees. We discuss strategies to address the perennial challenges of shared terminology and accurate, comparable data among maternal mortality review committees. Finally, we propose that with the opportunity presented by a systematized shared data system that can accurately account for all maternal deaths, state and local-level maternal mortality review committees could become the gold standard for understanding the true burden of maternal mortality at the national level. |
Health and economic burden of preeclampsia: no time for complacency
Li R , Tsigas EZ , Callaghan WM . Am J Obstet Gynecol 2017 217 (3) 235-236 Preeclampsia is a common and severe pregnancy complication and a leading cause of maternal and infant illness and death.1–3 The incidence of preeclampsia increased in the United States during the past 3 decades,4,5 and substantial evidence suggests that a history of preeclampsia is a significant risk factor for heart disease in the future years following pregnancy.6 In addition to adverse health consequences, preeclampsia is costly because of the medical services needed to treat pregnant and postpartum women and their infants, who are often born preterm.1,7 | In this issue, Stevens et al8 documented the short-term medical costs associated with preeclampsia. The authors combined state hospital discharge data with birth certificate data, commercial insurance claims data, and nationally representative Healthcare Cost and Utilization Project (HCUP) data to derive nationally representative estimates of the additional cost of medical treatment for women with preeclampsia and their newborns vs women without preeclampsia. This aggregated incremental cost was found to be $2.18 billion to the US health care system, including $1.03 billion in maternal health care costs and $1.15 billion for infants born to mothers with preeclampsia (in 2012 US dollars), which is about one third of the total $6.4 billion short-term estimated health care costs for preeclampsia pregnancies. This study is the first to quantify the medical costs associated with preeclampsia in the United States up to 1-year postdelivery. Previous studies estimated only the cost of hypertension during pregnancy in a Medicaid population in a single state,9 the per-person cost associated with pregnancies complicated by hypertension,10 or the cost of prematurity, regardless of the cause.7 |
Pregnancy-related mortality in the United States, 2011-2013
Creanga AA , Syverson C , Seed K , Callaghan WM . Obstet Gynecol 2017 130 (2) 366-373 OBJECTIVE: To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2011-2013. METHODS: We conducted an observational study using population-based data from the Pregnancy Mortality Surveillance System to calculate pregnancy-related mortality ratios by year, age group, and race-ethnicity groups. We explored 10 cause-of-death categories by pregnancy outcome during 2011-2013 and compared their distribution with those in our earlier reports since 1987. RESULTS: The 2011-2013 pregnancy-related mortality ratio was 17.0 deaths per 100,000 live births. Pregnancy-related mortality ratios increased with maternal age, and racial-ethnic disparities persisted with non-Hispanic black women having a 3.4 times higher mortality ratio than non-Hispanic white women. Among causes of pregnancy-related deaths, the following groups contributed more than 10%: cardiovascular conditions ranked first (15.5%) followed by other medical conditions often reflecting pre-existing illnesses (14.5%), infection (12.7%), hemorrhage (11.4%), and cardiomyopathy (11.0%). Relative to the most recent report of Pregnancy Mortality Surveillance System data for 2006-2010, the distribution of cause-of-death categories did not change considerably. However, compared with serial reports before 2006-2010, the contribution of hemorrhage, hypertensive disorders of pregnancy, and anesthesia complications declined, whereas that of cardiovascular and other medical conditions increased (population-level percentage comparison). CONCLUSION: The pregnancy-related mortality ratio and the distribution of the main causes of pregnancy-related mortality have been relatively stable in recent years. |
Contribution of maternal age and pregnancy checkbox on maternal mortality ratios in the United States, 1978-2012
Davis NL , Hoyert DL , Goodman DA , Hirai AH , Callaghan WM . Am J Obstet Gynecol 2017 217 (3) 352 e1-352 e7 BACKGROUND: Maternal mortality ratios (MMR) appear to have increased in the United States over the last decade. Three potential contributing factors are: 1) a shifting maternal age distribution, 2) changes in age-specific MMR, and 3) the addition of a checkbox indicating recent pregnancy on the death certificate. OBJECTIVE: Determine the contribution of rising maternal age on changes in MMR from 1978-2012, and estimate the contribution of the pregnancy checkbox on increases in MMR over the last decade. STUDY DESIGN: Kitagawa decomposition analyses were conducted to partition the maternal age contribution to the MMR increase into two components: changes due to a shifting maternal age distribution, and changes due to higher age-specific mortality ratios. We used National Vital Statistics System (NVSS) natality and mortality data. The following five-year groupings were used: 1978-1982, 1988-1992, 1998-2002, and 2008-2012. Changes in age-specific MMRs among states that adopted the standard pregnancy checkbox onto their death certificate before 2008 (n=23) were compared with states that had not adopted the standard pregnancy checkbox on their death certificate by the end of 2012 (n=11) to estimate the percentage increase in the MMR due to the pregnancy checkbox. RESULTS: Overall U.S. MMRs for 1978-1982, 1988-1992, and 1998-2002 were 9.0, 8.1, and 9.1 deaths per 100,000 live births, respectively. There was a modest increase in the MMR between 1998-2002 and 2008-2012 in the 11 states that had not adopted the standard pregnancy checkbox on their death certificate by the end of 2012 (8.6 and 9.9 deaths per 100,000 respectively). However, the MMR more than doubled between 1998-2002 and 2008-2012 in the 23 states that adopted the standard pregnancy checkbox (9.0 to 22.4); this dramatic rise was almost entirely attributable to increases in age-specific MMRs (94.9%) as opposed to increases in maternal age (5.1%), with an estimated 90% of the observed change reflecting the change in maternal death identification rather than a real change in age-specific rates alone. Of all age categories, women ages 40 and older in states that adopted the standard pregnancy checkbox had the largest increase in MMR-from 31.9 to 200.5-a relative increase of 528%, which accounted for nearly one-third of the overall increase. An estimated 28.8% of the observed change was potentially due to maternal death misclassification among women ≥40. CONCLUSION: Increasing age-specific maternal mortality seems to be contributing more heavily than a changing maternal age distribution to recent increases in MMR. In states with the standard pregnancy checkbox, the vast majority of the observed change in MMR over the last decade was estimated to be due to the pregnancy checkbox, with the greatest change in MMR occurring in women ages ≥40 years. The addition of a pregnancy checkbox on state death certificates appears to be increasing case identification, but may also be leading to maternal death misclassification, particularly for women ages ≥40 years. |
Recent increases in the U.S. Maternal mortality rate: Disentangling trends from measurement issues
Creanga AA , Callaghan WM . Obstet Gynecol 2017 129 (1) 206-207 MacDorman et al1 aim to quantify the contribution of a pregnancy checkbox added to the 2003 U.S. standard death certificate to the estimated increase in U.S. maternal mortality during 2000–2014. Given its variable adoption by states, both in terms of format and timing, the authors skillfully employ innovative methods to estimate maternal mortality and are to be congratulated. | As the authors recognize, the analysis relies on the cause-of-death information recorded on death certificates and a statistical definition of maternal deaths—all records of women who died during or within 42 days of pregnancy who receive an International Classification of Diseases (version 10) O chapter code (except O96 and O97) are considered maternal deaths. Of note, using the Centers for Disease Control and Prevention's WONDER mortality data,2 the proportion of females aged 15–54 years with the nonspecific O chapter-coded underlying cause of death O26.8 (other specified pregnancy-related conditions) or O99.8 (other specified diseases and conditions complicating pregnancy, childbirth and the puerperium) increased from less than 10% to more than 40% during 2000–2014 as more states used the pregnancy checkbox (Fig. 1). At first glance, this suggests an increase in maternal deaths that parallels documented increases in chronic medical conditions in pregnant women in the United States.3 However, the incorrect marking of the pregnancy checkbox vis-à-vis pregnant status or timing of death can influence the assignment of cause-of-death International Classification of Diseases codes, especially regarding these nonspecific O codes. |
Vaginal and Rectal Clostridium sordellii and Clostridium perfringens Presence Among Women in the United States
Chong E , Winikoff B , Charles D , Agnew K , Prentice JL , Limbago BM , Platais I , Louie K , Jones HE , Shannon C , NCT01283828 Study Team , Avillan J , Kitchel B , Hubbard A , MacCannell D , Rasheed JK , Callaghan WM , McDonald LC . Obstet Gynecol 2016 127 (2) 360-8 OBJECTIVE: To characterize the presence of Clostridium sordellii and Clostridium perfringens in the vagina and rectum, identify correlates of presence, and describe strain diversity and presence of key toxins. METHODS: We conducted an observational cohort study in which we screened a diverse cohort of reproductive-aged women in the United States up to three times using vaginal and rectal swabs analyzed by molecular and culture methods. We used multivariate regression models to explore predictors of presence. Strains were characterized by pulsed-field gel electrophoresis and tested for known virulence factors by polymerase chain reaction assays. RESULTS: Of 4,152 participants enrolled between 2010 and 2013, 3.4% (95% confidence interval [CI] 2.9-4.0) were positive for C sordellii and 10.4% (95% CI 9.5-11.3) were positive for C perfringens at baseline. Among the 66% with follow-up data, 94.7% (95% CI 88.0-98.3) of those positive for C sordellii and 74.4% (95% CI 69.0-79.3) of those positive for C perfringens at baseline were negative at follow-up. At baseline, recent gynecologic surgery was associated with C sordellii presence, whereas a high body mass index was associated with C perfringens presence in adjusted models. Two of 238 C sordellii isolates contained the lethal toxin gene, and none contained the hemorrhagic toxin gene. Substantial strain diversity was observed in both species with few clusters and no dominant clones identified. CONCLUSION: The relatively rare and transient nature of C sordellii and C perfringens presence in the vagina and rectum makes it inadvisable to use any screening or prophylactic approach to try to prevent clostridial infection. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01283828. |
Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies
Clark SL , Romero R , Dildy GA , Callaghan WM , Smiley RM , Bracey AW , Hankins GD , D'Alton ME , Foley M , Pacheco LD , Vadhera RB , Herlihy JP , Berkowitz RL , Belfort MA . Am J Obstet Gynecol 2016 215 (4) 408-12 Amniotic fluid embolism is a leading cause of maternal mortality in developed countries. Our understanding of risk factors, diagnosis, treatment, and prognosis is hampered by a lack of uniform clinical case definition; neither histologic nor laboratory findings have been identified unique to this condition. Amniotic fluid embolism is often overdiagnosed in critically ill peripartum women, particularly when an element of coagulopathy is involved. Previously proposed case definitions for amniotic fluid embolism are nonspecific, and when viewed through the eyes of individuals with experience in critical care obstetrics, would include women with a number of medical conditions much more common than amniotic fluid embolism. We convened a working group under the auspices of a committee of the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation whose task was to develop uniform diagnostic criteria for the research reporting of amniotic fluid embolism. These criteria rely on the presence of the classic triad of hemodynamic and respiratory compromise accompanied by strictly defined disseminated intravascular coagulopathy. It is anticipated that limiting research reports involving amniotic fluid embolism to women who meet these criteria will enhance the validity of published data and assist in the identification of risk factors, effective treatments, and possibly useful biomarkers for this condition. A registry has been established in conjunction with the Perinatal Research Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development to collect both clinical information and laboratory specimens of women with suspected amniotic fluid embolism in the hopes of identifying unique biomarkers of this condition. |
Perinatal regionalization: A geospatial view of perinatal critical care, United States, 2010-2013
Brantley MD , Davis NL , Goodman DA , Callaghan WM , Barfield WD . Am J Obstet Gynecol 2016 216 (2) 185 e1-185 e10 BACKGROUND: Perinatal services exist today as a dyad of maternal and neonatal care. When perinatal care is fragmented or unavailable, excess morbidity and mortality may occur in pregnant women and newborns. OBJECTIVE: Describe spatial relationships between women of reproductive age, individual perinatal subspecialists (Maternal Fetal Medicine and Neonatology), and obstetric and neonatal critical care facilities in the United States to identify gaps in health care access. STUDY DESIGN: We used geographic visualization and conducted surface interpolation, nearest neighbor, and proximity analyses. Source data included 2010 United States Census, October 2013 National Provider Index, 2012 American Hospital Association, 2012 National Center for Health Statistics Natality File, and the 2011 American Academy of Pediatrics Directory. RESULTS: In October 2013, there were 2.5 neonatologists for every Maternal Fetal Medicine specialist in the United States. In 2012 there were 1.4 Level III or higher neonatal intensive care units (NICU) for every Level III obstetric unit (hereafter, obstetric critical care unit). Nationally, 87% of women of reproductive age live within 50 miles of both an obstetric critical care unit and NICU. However, 18% of obstetric critical care units had no NICU and 20% of NICUs had no obstetric critical care unit within a 10 mile radius. Additionally, 26% of obstetric critical care units had no Maternal Fetal Medicine specialist practicing within 10 miles of the facility and 4% of NICUs had no neonatologist practicing within 10 miles. CONCLUSION: Gaps in access and discordance between the availability of Level III or higher obstetric and neonatal care may affect delivery of risk appropriate care for high risk maternal fetal dyads. Further study is needed to understand the importance of these gaps and discordance on maternal and neonatal outcomes. |
Explaining the recent decrease in US infant mortality rate, 2007-2013
Callaghan WM , Macdorman MF , Shapiro-Mendoza CK , Barfield WD . Am J Obstet Gynecol 2016 216 (1) 73 e1-73 e8 BACKGROUND: The U.S. infant mortality rate has been steadily decreasing in recent years as has the preterm birth rate; preterm birth is a major factor associated with death during the first year of life. The degree to which changes in gestational age-specific mortality and changes in the distribution of births by gestational age have contributed to the decrease in the infant mortality rate requires clarification. OBJECTIVES: To better understand the major contributors to the 2007-2013 infant mortality decline for the total population, and for infants born to non-Hispanic black, non-Hispanic white, and Hispanic women. STUDY DESIGN: We identified births and infant deaths from 2007 and 2013 Centers for Disease Control and Prevention National Vital Statistics System's period linked birth and infant death files. We included all deaths and births for which there was a reported gestational age at birth on the birth certificate of 22 weeks or greater. The decrease in the infant mortality rate was disaggregated such that all of the change could be attributed to improvements in gestational age-specific infant mortality rates and changes in the distribution of gestational age, by week of gestation, using the Kitagawa method. Sensitivity analyses were performed to account for records where obstetric estimate of gestational age was missing and for deaths and births less than 22 weeks gestation. Maternal race and ethnicity information was obtained from the birth certificate. RESULTS: The infant mortality rates after exclusions were 5.72 and 4.92 per 1000 live births for 2007 and 2013 respectively with an absolute difference of -0.80 (14% decrease). Infant mortality rates declined by 11% for non-Hispanic whites, by 19% for non-Hispanic blacks, and by 14% for Hispanics during the period. Compared to 2007, the proportion of births in each gestational age category was lower in 2013 with the exception of 39 weeks where there was an increase in the proportion of births from 30.1 percent in 2007 to 37.5 percent in 2013. Gestational age-specific mortality decreased for each gestational age category between 2007 and 2013 except 33 weeks and >42 weeks. About 31 percent of the decrease in the US infant mortality rate from 2007-2013 was due to changes in the gestational age distribution, and 69 percent was due to improvements in gestational age-specific survival. Improvements in the gestational age distribution from 2007-2013 benefitted infants of non-Hispanic white women (48%) the most, followed by infants of non-Hispanic black (31%) and Hispanic (17%) women. CONCLUSIONS: Infant mortality improved between 2007 and 2013 as a result of both improvements in the distribution of gestational age at birth and improvements in survival after birth. The differential contribution of improvements in the gestational age distribution at birth by race and ethnicity suggests that preconception and antenatal health and health care aimed at preventing or delaying preterm birth may not be reaching all populations. |
Severe maternal morbidity: screening and review
Kilpatrick SK , Ecker JL , Callaghan WM . Am J Obstet Gynecol 2016 215 (3) B17-22 This document builds upon recommendations from peer organizations and outlines a process for identifying maternal cases that should be reviewed. Severe maternal morbidity is associated with a high rate of preventability, similar to that of maternal mortality. It also can be considered a near miss for maternal mortality because without identification and treatment, in some cases, these conditions would lead to maternal death. Identifying severe morbidity is, therefore, important, for preventing such injuries that lead to mortality and for highlighting opportunities to avoid repeat injuries. The two-step screen and review process described in this document is intended to efficiently detect severe maternal morbidity in women and to ensure that each case undergoes a review to determine whether there were opportunities for improvement in care. Like cases of maternal mortality, cases of severe maternal morbidity merit quality review. In the absence of consensus on a comprehensive list of conditions that represent severe maternal morbidity, institutions and systems should either adopt an existing screening criteria, such as having received 4 or more units of blood or having been admitted to an ICU, or create their own list of outcomes that merit review. |
The validity of discharge billing codes reflecting severe maternal morbidity
Sigakis MJ , Leffert LR , Mirzakhani H , Sharawi N , Rajala B , Callaghan WM , Kuklina EV , Creanga AA , Mhyre JM , Bateman BT . Anesth Analg 2016 123 (3) 731-8 BACKGROUND: Discharge diagnoses are used to track national trends and patterns of maternal morbidity. There are few data regarding the validity of the International Classification of Diseases (ICD) codes used for this purpose. The goal of our study was to try to better understand the validity of administrative data being used to monitor and assess trends in morbidity. METHODS: Hospital stay billing records were queried to identify all delivery admissions at the Massachusetts General Hospital for the time period 2001 to 2011 and the University of Michigan Health System for the time period 2005 to 2011. From this, we identified patients with ICD-9-Clinical Modification (CM) diagnosis and procedure codes indicative of severe maternal morbidity. Each patient was classified with 1 of 18 different medical/obstetric categories (conditions or procedures) based on the ICD-9-CM code that was recorded. Within each category, 20 patients from each institution were selected at random, and the corresponding medical charts were reviewed to determine whether the ICD-9-CM code was assigned correctly. The percentage of correct codes for each of 18 preselected clinical categories was calculated yielding a positive predictive value (PPV) and 99% confidence interval (CI). RESULTS: The overall number of correctly assigned ICD-9-CM codes, or PPV, was 218 of 255 (86%; CI, 79%-90%) and 154 of 188 (82%; CI, 74%-88%) at Massachusetts General Hospital and University of Michigan Health System, respectively (combined PPV, 372/443 [84%; CI, 79-88%]). Codes within 4 categories (Hysterectomy, Pulmonary edema, Disorders of fluid, electrolyte and acid-base balance, and Sepsis) had a 99% lower confidence limit ≥75%. Codes within 8 additional categories demonstrated a 99% lower confidence limit between 74% and 50% (Acute respiratory distress, Ventilation, Other complications of obstetric surgery, Disorders of coagulation, Cardiomonitoring, Acute renal failure, Thromboembolism, and Shock). Codes within 6 clinical categories demonstrated a 99% lower confidence limit <50% (Puerperal cerebrovascular disorders, Conversion of cardiac rhythm, Acute heart failure [includes arrest and fibrillation], Eclampsia, Neurotrauma, and Severe anesthesia complications). CONCLUSIONS: ICD-9-CM codes capturing severe maternal morbidity during delivery hospitalization demonstrate a range of PPVs. The PPV was high when objective supportive evidence, such as laboratory values or procedure documentation supported the ICD-9-CM code. The PPV was low when greater judgment, interpretation, and synthesis of the clinical data (signs and symptoms) was required to support a code, such as with the category Severe anesthesia complications. As a result, these codes should be used for administrative research with more caution compared with codes primarily defined by objective data. |
Maternal outcomes of term breech presentation delivery: impact of successful external cephalic version in a nationwide sample of delivery admissions in the United States
Weiniger CF , Lyell DJ , Tsen LC , Butwick AJ , Shachar B , Callaghan WM , Creanga AA , Bateman BT . BMC Pregnancy Childbirth 2016 16 (1) 150 BACKGROUND: We aimed to define the frequency and predictors of successful external cephalic version in a nationally-representative cohort of women with breech presentations and to compare maternal outcomes associated with successful external cephalic version versus persistent breech presentation. METHODS: Using the Nationwide Inpatient Sample, a United States healthcare utilization database, we identified delivery admissions between 1998 and 2011 for women who had successful external cephalic version or persistent breech presentation (including unsuccessful or no external cephalic version attempt) at term. Multivariable logistic regression identified patient and hospital-level factors associated with successful external cephalic version. Maternal outcomes were compared between women who had successful external cephalic version versus persistent breech. RESULTS: Our study cohort comprised 1,079,576 delivery admissions with breech presentation; 56,409 (5.2 %) women underwent successful external cephalic version and 1,023,167 (94.8 %) women had persistent breech presentation at the time of delivery. The rate of cesarean delivery was lower among women who had successful external cephalic version compared to those with persistent breech (20.2 % vs. 94.9 %; p < 0.001). Compared to women with persistent breech at the time of delivery, women with successful external cephalic version were also less likely to experience several measures of significant maternal morbidity including endometritis (adjusted Odds Ratio (aOR) = 0.36, 95 % Confidence Interval (CI) 0.24-0.52), sepsis (aOR = 0.35, 95 % CI 0.24-0.51) and length of stay > 7 days (aOR = 0.53, 95 % CI 0.40-0.70), but had a higher risk of chorioamnionitis (aOR = 1.83, 95 % CI 1.54-2.17). CONCLUSIONS: Overall a low proportion of women with breech presentation undergo successful external cephalic version, and it is associated with significant reduction in the frequency of cesarean delivery and a number of measures of maternal morbidity. Increased external cephalic version use may be an important approach to mitigate the high rate of cesarean delivery observed in the United States. |
Rate of second and third trimester weight gain and preterm delivery among underweight and normal weight women
Sharma AJ , Vesco KK , Bulkley J , Callaghan WM , Bruce FC , Staab J , Hornbrook MC , Berg CJ . Matern Child Health J 2016 20 (10) 2030-6 Objectives Low gestational weight gain (GWG) in the second and third trimesters has been associated with increased risk of preterm delivery (PTD) among women with a body mass index (BMI) < 25 mg/m2. However, few studies have examined whether this association differs by the assumptions made for first trimester gain or by the reason for PTD. Methods We examined singleton pregnancies during 2000-2008 among women with a BMI < 25 kg/m2 who delivered a live-birth ≥28 weeks gestation (n = 12,526). Women received care within one integrated health care delivery system and began prenatal care ≤13 weeks. Using antenatal weights measured during clinic visits, we interpolated GWG at 13 weeks gestation then estimated rate of GWG (GWGrate) during the second and third trimesters of pregnancy. We also estimated GWGrate using the common assumption of a 2-kg gain for all women by 13 weeks. We examined the covariate-adjusted association between quartiles of GWGrate and PTD (28-36 weeks gestation) using logistic regression. We also examined associations by reason for PTD [premature rupture of membranes (PROM), spontaneous labor, or medically indicated]. Results Mean GWGrate did not differ among term and preterm pregnancies regardless of interpolated or assumed GWG at 13 weeks. However, only with GWGrate estimated from interpolated GWG at 13 weeks, we observed a U-shaped relationship where odds of PTD increased with GWGrate in the lowest (OR 1.36, 95 % CI 1.10, 1.69) or highest quartile (OR 1.49, 95 % CI 1.20, 1.85) compared to GWGrate within the second quartile. Further stratifying by reason, GWGrate in the lowest quartile was positively associated with spontaneous PTD while GWGrate in the highest quartile was positively associated with PROM and medically indicated PTD. Conclusions Accurate estimates of first trimester GWG are needed. Common assumptions applied to all pregnancies may obscure the association between GWGrate and PTD. Further research is needed to fully understand whether these associations are causal or related to common antecedents. |
Trends in severe maternal morbidity after assisted reproductive technology in the United States, 2008-2012
Martin AS , Monsour M , Kissin DM , Jamieson DJ , Callaghan WM , Boulet SL . Obstet Gynecol 2016 127 (1) 59-66 OBJECTIVE: To examine trends in severe maternal morbidity from 2008 to 2012 in delivery and postpartum hospitalizations among pregnancies conceived with or without assisted reproductive technology (ART). METHODS: In this retrospective cohort study, deliveries were identified in the 2008-2012 Truven Health MarketScan Commercial Claims and Encounters Databases. Severe maternal morbidity was identified using International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes and Current Procedural Terminology codes. Rate of severe maternal morbidity was calculated for ART and non-ART pregnancies. We performed multivariable logistic regression, controlling for maternal characteristics, and calculated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for severe morbidity. Additionally, a propensity score analysis was performed between ART and non-ART deliveries. RESULTS: Of 1,016,618 deliveries, 14,761 (1.5%) were identified as pregnancies conceived with ART. Blood transfusion was the most common severe morbidity indicator for ART and non-ART pregnancies. For every 10,000 singleton deliveries, there were 273 ART deliveries or postpartum hospitalizations with severe maternal morbidity compared with 126 for non-ART (P<.001). For ART singleton deliveries, the rate of severe morbidity decreased from 369 per 10,000 deliveries in 2008 to 219 per 10,000 deliveries in 2012 (P=.025). Odds of severe morbidity were increased for ART compared with non-ART singletons (adjusted OR 1.84, 95% CI 1.63-2.08). Among multiple gestations, there was no significant difference between ART and non-ART pregnancies (rate of severe morbidity for ART 604/10,000 and non-ART 539/10,000 deliveries, P=.089; adjusted OR 1.04, 95% CI 0.91-1.20). Propensity score matching agreed with these results. CONCLUSION: Singleton pregnancies conceived with ART are at increased risk for severe maternal morbidity; however, the rate has been decreasing since 2008. Multiple gestations have increased risk regardless of ART status. |
Reply: To PMID 25772211
Ko JY , Tong VT , Callaghan WM . Am J Obstet Gynecol 2015 213 (4) 599 We thank Stadterman et al1 for their interest in our paper, and we would like to provide a few points of clarification. Although there is inconclusive evidence of harm regarding the sole use of marijuana during pregnancy and adverse birth and neonatal outcomes, in utero exposure to marijuana may lead to later learning and developmental impairments.2 Existing research, including our findings, suggests that concurrent use of other substances known to be teratogenic (ie, alcohol, tobacco) is common among marijuana users. | | Guidelines from the American College of Obstetricians and Gynecologists3 recommend universal screening for all maternal substance use, irrespective of whether a substance is legal. Universal screening could be performed by maternal self-report during clinical encounters using validated screening tools as part of a woman's general health history. | | The American College of Obstetricians and Gynecologists guidelines acknowledge the complex legal issues regarding universal screening and that punitive measures resulting from substance use screening are not “applied evenly across sex, race, and socioeconomic status.” However, the guidelines state that “in fulfillment of the therapeutic obligation, physicians must make a substantial effort” to “... practice universal screening questions, brief intervention, and referral to treatment in order to provide benefit and do no harm ...” and “protect confidentiality and the integrity of the physician-patient relationship wherever possible within the requirements of legal obligations, and communicate honestly and directly with patients about what information can and cannot be protected.”3 Thus, effective screening, as well as appropriate provider training and resources for patient education and care, is needed to support pregnant women who may want assistance with cessation. |
Investigating implausible gestational age and high birthweight combinations
England LJ , Bulkley JE , Pazol K , Bruce FC , Kimes T , Berg CJ , Hornbrook MC , Callaghan WM . Paediatr Perinat Epidemiol 2015 29 (6) 562-6 BACKGROUND: Birth certificate data overestimate national preterm births because a high percentage of last menstrual period (LMP) dates have errors. Study goals were to determine: (i) To what extent errors in transfer of birthweight and LMP date from medical records to birth certificates contribute to implausibly high birthweight-for-gestational-age births; (ii) What percentage of implausible births would be resolved if the clinical estimate (CE) from birth certificates were used instead of LMP-based gestational age, and with what degree of certainty; and (iii) Of those not resolved, what percentage had a medical explanation. METHODS: Medical records and birth certificates for all singleton infants with implausibly high birthweight-for-gestational-age based on LMP delivered in the Kaiser Permanente Northwest system in Oregon during 1998-2007 were examined. Percentages of implausible records resolved under various scenarios were calculated. RESULTS: A total of 100 births with implausibly high birthweight-for-gestational age combinations were identified. When LMP date and birthweight from medical records were used instead of from birth certificates, 31% of births with implausible combinations were resolved. Substituting the CE on the birth certificate for the LMP date resolved 92%. Of the latter, the clinician's gestational age estimate in the medical record was obtained in early pregnancy in 72%. Five of the eight births with unresolved implausible combinations were to mothers with diabetes; the remaining three had no documented medical explanation. CONCLUSIONS: In this study, use of the birth certificate CE rather than the LMP resulted in a clinically reliable reclassification for the majority of implausible birthweight-for-gestational age deliveries. |
Abortion-Related Mortality in the United States: 1998-2010
Zane S , Creanga AA , Berg CJ , Pazol K , Suchdev DB , Jamieson DJ , Callaghan WM . Obstet Gynecol 2015 126 (2) 258-65 OBJECTIVE: To examine characteristics and causes of legal induced abortion-related deaths in the United States between 1998 and 2010. METHODS: Abortion-related deaths were identified through the national Pregnancy Mortality Surveillance System with enhanced case-finding. We calculated the abortion mortality rate by race, maternal age, and gestational age and the distribution of causes of death by gestational age and procedure. RESULTS: During the period from 1998-2010, of approximately 16.1 million abortion procedures, 108 women died, for a mortality rate of 0.7 deaths per 100,000 procedures overall, 0.4 deaths for non-Hispanic white women, 0.5 deaths for Hispanic women, and 1.1 deaths for black women. The mortality rate increased with gestational age, from 0.3 to 6.7 deaths for procedures performed at 8 weeks or less and at 18 weeks or greater, respectively. A majority of abortion-related deaths at 13 weeks of gestation or less were associated with anesthesia complications and infection, whereas a majority of abortion-related deaths at more than 13 weeks of gestation were associated with infection and hemorrhage. In 20 of the 108 cases, the abortion was performed as a result of a severe medical condition where continuation of the pregnancy threatened the woman's life. CONCLUSION: Deaths associated with legal induced abortion continue to be rare events-less than 1 per 100,000 procedures. Primary prevention of unintended pregnancy, including those in women with serious pre-existing medical conditions, and increased access to abortion services at early gestational ages may help to further decrease abortion-related mortality in the United States. LEVEL OF EVIDENCE: III. |
Medical and obstetric outcomes among pregnant women with congenital heart disease
Thompson JL , Kuklina EV , Bateman BT , Callaghan WM , James AH , Grotegut CA . Obstet Gynecol 2015 126 (2) 346-54 OBJECTIVE: To estimate nationwide trends in the prevalence of maternal congenital heart disease (CHD) and determine whether women with CHD are more likely than women without maternal CHD to have medical and obstetric complications. METHODS: The 2000-2010 Nationwide Inpatient Sample was queried for International Classification of Diseases, 9th Revision, Clinical Modification codes to identify delivery hospitalizations of women with and without CHD. Trends in the prevalence of CHD were determined and then rates of complications were reported for CHD per 10,000 delivery hospitalizations. For Nationwide Inpatient Sample 2008-2010, logistic regression was used to examine associations between CHD and complications. RESULTS: From 2000 to 2010, there was a significant linear increase in the prevalence of CHD from 6.4 to 9.0 per 10,000 delivery hospitalizations (P<.001). Multivariable logistic regression demonstrated that all selected medical complications, including mortality (17.8 compared with 0.7/10,000 deliveries, adjusted odds ratio [OR] 22.10, 95% confidence interval [CI] 13.96-34.97), mechanical ventilation (91.9 compared with 6.9/10,000, adjusted OR 9.94, 95% CI 7.99-12.37), and a composite cardiovascular outcome (614 compared with 34.3/10,000, adjusted OR 10.54, 95% CI 9.55-11.64) were more likely to occur among delivery hospitalizations with maternal CHD than without. Obstetric complications were also common among women with CHD. Delivery hospitalizations with maternal CHD that also included codes for pulmonary circulatory disorders had higher rates of medical complications compared with hospitalizations with maternal CHD without pulmonary circulatory disorders. CONCLUSION: The number of delivery hospitalizations with maternal CHD in the United States is increasing, and although we were not able to determine whether correction of the cardiac lesion affected outcomes, these hospitalizations have a high burden of medical and obstetric complications. LEVEL OF EVIDENCE: II. |
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