Occurrence and determinants of postpartum maternal morbidities and disabilities among women in Matlab, Bangladesh

The burden of maternal ill-health includes not only the levels of maternal mortality and complications during pregnancy and around the time of delivery but also extends to the standard postpartum period of 42 days with consequences of obstetric complications and poor management at delivery. There is a dearth of reliable data on these postpartum maternal morbidities and disabilities in developing countries, and more research is warranted to investigate these and further strengthen the existing safe motherhood programmes to respond to these conditions. This study aims at identifying the consequences of pregnancy and delivery in the postpartum period, their association with acute obstetric complications, the sociodemographic characteristics of women, mode and place of delivery, nutritional status of the mother, and outcomes of birth. From among women who delivered between 2007 and 2008 in the icddr,b service area in Matlab, we prospectively recruited all women identified with complicated births (n=295); a perinatal mortality (n=182); and caesarean-section delivery without any maternal indication (n=147). A random sample of 538 women with uncomplicated births, who delivered at home or in a facility, was taken as the control. All subjects were clinically examined at 6-9 weeks for postpartum morbidities and disabilities. Postpartum women who had suffered obstetric complications during birth and delivered in a hospital were more likely to suffer from hypertension [adjusted odds ratio (AOR)=3.44; 95% confidence interval (CI)=1.14-10.36], haemorrhoids (AOR=1.73; 95% CI=1.11-3.09), and moderate to severe anaemia (AOR=7.11; 95% CI=2.03-4.88) than women with uncomplicated normal deliveries. Yet, women who had complicated births were less likely to have perineal tears (AOR=0.05; 95% CI=0.02-0.14) and genital prolapse (AOR=0.22; 95% CI=0.06-0.76) than those with uncomplicated normal deliveries. Genital infections were more common amongst women experiencing a perinatal death than those with uncomplicated normal births (AOR=1.92; 95% CI=1.18-3.14). Perineal tears were significantly higher (AOR=3.53; 95% CI=2.32-5.37) among those who had delivery at home than those giving birth in a hospital. Any woman may suffer a postpartum morbidity or disability. The increased likelihood of having hypertension, haemorrhoids, or anaemia among women with obstetric complications at birth needs specific intervention. A higher quality of maternal healthcare services generally might alleviate the suffering from perineal tears and prolapse amongst those with a normal uncomplicated delivery.     

Health Status and Health Insurance Coverage of Women with Live-Born Infants: An Opportunity for Preventive Services After Pregnancy

Most women in the US have access to health care and insurance during pregnancy; however women with Medicaid-paid deliveries lose Medicaid eligibility in the early postpartum period. This study examined the association between health insurance coverage at the time of delivery and health conditions that may require preventive or treatment services extending beyond pregnancy into the postpartum period. We used 2008 Pregnancy Risk Assessment Monitoring System data from 27 states (n = 35,980). We calculated the prevalence of maternal health conditions, including emotional and behavioral risks, by health insurance status at the time of delivery. We used multivariable logistic regression to assess the association between health insurance coverage, whether Medicaid or private, and maternal health status. As compared to women with private health insurance, women with Medicaid-paid deliveries had higher odds of reporting smoking during pregnancy (adjusted odds ratio [AOR]: 1.85, 95 % confidence interval [CI]: 1.56–2.18), physical abuse during pregnancy (AOR: 1.73, 95 % CI: 1.24–2.40), having six or more stressors during pregnancy (AOR: 2.48, 95 % CI: 1.93–3.18), and experiencing postpartum depressive symptoms (AOR: 1.24, 95 % CI: 1.04–1.48). There were no significant differences by insurance status at delivery in pre-pregnancy overweight/obesity, pre-pregnancy physical activity, weight gain during pregnancy, alcohol consumption during pregnancy, or postpartum contraceptive use. Compared to women with private insurance, women with Medicaid-paid deliveries were more likely to experience risk factors during pregnancy such as physical abuse, stress, and smoking, and postpartum depressive symptoms for which continued screening, counseling, or treatment in the postpartum period could be beneficial.     

Consequences of maternal complications in women's lives in the first postpartum year: a prospective cohort study

Maternal complications are common during and following childbirth. However, little information is available on the psychological, social and economic consequences of maternal complications on women's lives, especially in a rural setting. A prospective cohort study was conducted in southern Rajasthan, India, among rural women who had a severe or less-severe, or no complication at the time of delivery or in the immediate postpartum period. In total, 1,542 women, representing 93% of all women who delivered in the field area over a 15-month period and were examined in the first week postpartum by nurse-midwives, were followed up to 12 months to record maternal and child survival. Of them, a subset of 430 women was followed up at 6-8 weeks and 12 months to capture data on the physical, psychological, social, or economic consequences. Women with severe maternal complications around the time of delivery and in the immediate postpartum period experienced an increased risk of mortality and morbidity in the first postpartum year: 2.8% of the women with severe complications died within one year compared to none with uncomplicated delivery. Women with severe complications also had higher rates of perinatal mortality [adjusted odds ratio (AOR)=3.98, confidence interval (CI) 1.96-8.1, p=0.000] and mortality of babies aged eight days to 12 months (AOR=3.14, CI 1.4-7.06, p=0.004). Compared to women in the uncomplicated group, women with severe complications were at a higher risk of depression at eight weeks and 12 months with perceived physical symptoms, had a greater difficulty in completing daily household work, and had important financial repercussions. The results suggest that women with severe complications at the time of delivery need to be provided regular follow-up services for their physical and psychological problems till about 12 months after childbirth. They also might benefit from financial support during several months in the postpartum period to prevent severe economic consequences. Further research is needed to identify an effective package of services for women in the first year after delivery.     

Extent of Maternal Morbidity in a Managed Care Population in Georgia

Background: Although maternal deaths are among the most tragic events related to pregnancy, they are uncommon in the US and, therefore, inadequate indicators of a woman's pregnancy‐related health. Maternal morbidity has become a more useful measure for surveillance and research. Traditional attempts to monitor maternal morbidity have used hospital discharge data, which include data only on complications that resulted in hospitalisation, underestimating the frequency and scope of complications. Methods: To obtain a more accurate assessment of morbidity, we applied a validated computerised algorithm to identify pregnancies and pregnancy‐related complications in a defined population enrolled in a health maintenance organisation in the south‐eastern US. We examined the most common morbidities by pregnancy outcome and maternal characteristics. Results: We identified 37 741 pregnancies; in half (50.7%), at least one complication occurred. The five most common were urinary tract infections, anaemia, mental health conditions, pelvic and perineal complications, and obstetrical infections. Complications were more likely in women with low socio‐economic status (SES), and among non‐Hispanic Black women compared with non‐Hispanic White women. Multivariable models stratified by race/ethnicity indicated that in pregnancies among non‐Hispanic White women, low SES had a modest effect on the odds of having preexisting medical conditions [adjusted odd ratio (AOR) 1.3 [95% confidence interval (CI) 1.2, 1.5]] or having any morbidity (AOR 1.3 [95% CI 1.2, 1.4]). Low SES had little effect on complications among non‐Hispanic Black women. Conclusion: Our findings suggest that comprehensive health insurance coverage may lessen the unfavourable impact of socio‐economic disadvantage on the risk of maternal morbidity.     

Obstetric complications during labor and delivery: assessing ethnic differences in California.

PURPOSE: We sought to compare obstetric complications during labor and delivery among white non-Latina (white), black, Asian, and Latina women who delivered in California hospitals. Many intrapartum complications are preventable. METHODS: We used linked 1996-1998 state hospital discharge and birth certificate data to examine obstetric complications International Classification of Diseases, 9th Revision, Clinical Modification codes considered relevant for population surveillance. We compared the observed and adjusted odds of experiencing a complication among women of color, using white women as the reference group. FINDINGS: One out of 5 deliveries had >or=1 complication. White (21.3%) and Asian women (21.1%) had similar prevalence rates, whereas black women (24.2%) had higher and Latina women (19.6%) had lower rates. After adjusting for covariates, the odds of experiencing >or=1 complication was lower for Asians (odds ratio [OR] = 0.95; 95% confidence interval [CI] = 0.93, 0.96) and Latinas (OR = 0.97; 95% CI = 0.96, 0.98) than whites; the odds for black women remained elevated (OR = 1.25; 95% CI = 1.23, 1.27). Asian women stood a higher risk of deliveries with major lacerations, postpartum hemorrhage, and major puerperal infections. Rates for the latter complication were higher among all women of color. CONCLUSIONS: The burden of morbidity is high for all women, regardless of ethnicity. Yet, compared to white women, blacks suffer more aggregate morbidities, and Asians stand a high risk of all 3 intrapartum care-sensitive conditions. Furthermore, all women of color experience disproportionate rates of puerperal infections. Collective action is needed to reduce these disparities and improve maternal health.     

Risk factors for neonatal mortality in rural areas of Bangladesh served by a large NGO programme

Neonatal deaths account for about half of all deaths among children under 5 years of age in Bangladesh, making prevention a major priority. This paper reports on a study of neonatal deaths in 12 areas of Bangladesh served by a large NGO programme, which had high coverage of reproductive health outreach services and relatively low neonatal mortality in recent years. The study aimed to identify the main factors associated with neonatal mortality in these areas, with a view to developing appropriate strategies for prevention. A case-control design was adopted for collection of data from mothers whose children, born alive in 2003, died within 28 days postpartum (142 cases), or did not (617 controls). Crude and adjusted odds ratios (AOR) were calculated as estimates of relative risk for neonatal death, using 'neighbourhood' controls (241) and 'non-neighbourhood' controls (376). A similar proportion of case and control mothers had received NGO health education and maternal health services. The main risk factors for neonatal death among 122 singleton babies, based on the two sets of controls, were: complications during delivery [AOR, 2.6 (95% CI: 1.5-4.5) and 3.1 (95% CI: 1.8-5.3)], prematurity [AOR, 7.2 (95% CI: 3.6-14.4) and 8.3 (95% CI: 4.2-16.5)], care for a sick neonate from an unlicensed 'traditional healer' [AOR, 2.9 (95% CI 0.9-9.5 and 5.9 (95% CI: 1.3-26.3)], or care not sought at all [AOR, 23.3 (95% CI: 3.9-137.4)]. The strongest predictor of neonatal death was having a previous sibling not vaccinated against measles [AOR, 5.9 (95% CI: 2.2-15.5) and 12.0 (95% CI: 4.5-31.7)]. The findings of this study indicate the need for identification of babies at high risk and early postpartum interventions (40.2% of the deaths occurred within 24 hours of delivery). Relevant strategies include special counselling during pregnancy for mothers with risk characteristics, training birth attendants in resuscitation, immediate postnatal check-up in the home for high-risk babies identified at delivery, advice for mothers on appropriate care-seeking for sick babies, improving the capacity of sub-district hospitals for emergency obstetric and newborn care, and promotion of institutional deliveries.     

Adverse birth outcomes in a malarious area

To determine factors associated with fetal growth, preterm delivery and stillbirth in an area of high malaria transmission in Southern Malawi, a cross-sectional study of pregnant women attending and delivering at two study hospitals was undertaken. A total of 243 (17.3%) babies were preterm and 54 (3.7%) stillborn. Intra-uterine growth retardation (IUGR) occurred in 285 (20.3%), of whom 109 (38.2%) were low birthweight and 26 (9.1%) preterm. Factors associated with IUGR were maternal short stature [adjusted odds ratio (AOR) 1.6, 95% confidence interval (CI) 1.0-2.5]; primigravidae (AOR 1.9, 95% CI 1.4-2.7); placental or peripheral malaria at delivery (AOR 1.4, 95% CI 1.0-1.9) and maternal anaemia at recruitment (Hb<8 g/dl) (AOR 1.9, 95% CI 1.3-2.7). Increasing parasite density in the placenta was associated with both IUGR (P=0.008) and prematurity (P=0.02). Factors associated with disproportionate fetal growth were maternal malnutrition [mid-upper arm circumference (MUAC)<23 cm, AOR 1.9, 95% CI 1.0-3.7] and primigravidae (AOR 1.8, 95% CI 1.0-3.1). Preterm delivery and stillbirth were associated with <5 antenatal care visits (AOR 2.2, 95% CI 1.3-3.7 and AOR 3.1, 95% CI 1.4-7.0 respectively) and stillbirth with a positive Venereal Disease Research Laboratory (VDRL) test (AOR 4.7, 95% CI 1.5-14.8). Interventions to reduce poor pregnancy outcomes must reduce the burden of malaria in pregnancy, improve antenatal care and maternal malnutrition.     

Mexican women in California: differentials in maternal morbidity between foreign and US-born populations

In the US, the majority of deaths and serious complications of pregnancy occur during childbirth and are largely preventable. We conducted a population-based study to assess disparities in maternal health between Mexican-born and Mexican-American women residing in California and to evaluate the extent to which immigrants have better outcomes. Mothers in these two populations deliver 40% of infants in the state. We compared maternal mortality ratios and maternal morbidities during labour and delivery in the two populations using linked 1996-98 hospital discharge and birth certificate data files. For maternal morbidities, we calculated frequencies and observed and adjusted odds (OR) ratios using pre-existing maternal health, sociodemographic characteristics and quality of health care as covariates. Approximately 19% of Mexican-born women suffered a maternal disorder compared with 21% of Mexican-American women (Observed OR = 0.89, [95% CI 0.88, 0.90]). Despite their lower education and relative poverty, Mexican-born women still experienced a lower odds of any maternal morbidity than Mexican-American women, after adjusting for covariates (OR = 0.92, [95% CI 0.90, 0.93]). These findings suggest a paradox of more favourable outcomes among Mexican immigrants similar to that found with birth outcomes. Nevertheless, the positive aggregate outcome of Mexican-born women did not extend to maternal mortality, nor to certain conditions associated with suboptimal intrapartum obstetric care.     

Risk Factors for Non-use of Skilled Birth Attendants: Analysis of South Sudan Household Survey, 2010

Objectives South Sudan has the lowest percentage of births attended by skilled health personnel in the world. This paper aims to identify potential risk factors associated with non-use of skilled birth attendants at delivery in South Sudan. Methods Secondary data analyses of the 2010 South Sudan Household Health Survey second round were conducted with data for 3504 women aged 15–49 years who gave birth in the 2 years prior to the survey. The risk of non-use of skilled birth attendants was examined using simple and multiple logistic regression analyses. Results The prevalence rates for skilled, unskilled and no birth attendants at delivery were 41 [95 % confidence interval (CI) 38.2, 43.0], 36 [95 % CI 33.9, 38.8], and 23 % [95 % CI 20.6, 24.9] respectively. Multivariable analyses indicated that educated mothers [adjusted odds ratio (AOR) 0.70; 95 % CI 0.57, 0.86], mothers who had three and more complications during pregnancy [AOR 0.77; 95 % CI 0.65, 0.90], mothers who had at least 1–3 ANC visits [AOR 0.38; 95 % CI 0.30, 0.49] and mothers from rich households [AOR 0.52; 95 % CI 0.42, 0.65] were significantly more likely to use skilled birth attendants (SBAs) at delivery. Mothers who lived in rural areas [AOR 1.44; 95 % CI 1.06, 1.96] were less likely to deliver with SBAs. Conclusion Intensive investments to recruit and train more skilled birth attendants’ on appropriate delivery care are needed, as well as building a community-based skilled birth attendants’ program to reduce avoidable maternal mortality in South Sudan.     

Obstetric Complications in Women with Diagnosed Mental Illness: The Relative Success of California's County Mental Health System

Objective. To examine disparities in serious obstetric complications and quality of obstetric care during labor and delivery for women with and without mental illness.
Data Source. Linked California hospital discharge (2000–2001), birth, fetal death, and county mental health system (CMHS) records.
Study Design. This population-based, cross-sectional study of 915,568 deliveries in California, calculated adjusted odds ratios (AORs) for obstetric complication rates for women with a mental illness diagnosis (treated and not treated in the CMHS) compared with women with no mental illness diagnosis, controlling for sociodemographic, delivery hospital type, and clinical factors.
Results. Compared with deliveries in the general non–mentally ill population, deliveries to women with mental illness stand a higher adjusted risk of obstetric complication: AOR=1.32 (95 percent confidence interval [CI]=1.25, 1.39) for women treated in the CMHS and AOR=1.72 (95 percent CI=1.66, 1.79) for women not treated in the CMHS. Mentally ill women treated in the CMHS are at lower risk than non-CMHS mentally ill women of experiencing conditions associated with suboptimal intrapartum care (postpartum hemorrhage, major puerperal infections) and inadequate prenatal care (acute pyelonephritis).
Conclusion. Since mental disorders during pregnancy adversely affect mothers and their infants, care of the mentally ill pregnant woman by mental health and primary care providers warrants special attention.     

Prevalence of Anaemia, Deficiencies of Iron and Folic Acid and Their Determinants in Ethiopian Women

A cross-sectional community-based study with analytic component was conducted among Ethiopian women during June-July 2005 to assess the magnitude of anaemia and deficiencies of iron and folic acid and to compare the factors responsible for anaemia among anaemic and non-anaemic cases. In total, 970 women, aged 15-19 years, were selected systematically for haematological and other important parameters. The overall prevalence of anaemia, iron deficiency, iron-deficiency anaemia, deficiency of folic acid, and parasitic infestations was 30.4%, 50.1%, 18.1%, 31.3%, and 13.7% respectively. Women who had more children aged less than five years but above two years, open-field toilet habits, chronic illnesses, and having intestinal parasites were positively associated with anaemia. Women who had no formal education and who did not use contraceptives were negatively associated with anaemia. The major determinants identified for anaemia were chronic illnesses [adjusted odds ratio (AOR)=1.1, 95% confidence interval (CI) 1.15-1.55), deficiency of iron (AOR=0.4, 95% CI 0.35-0.64), and deficiency of folic acid (AOR=0.5, 95% CI 0.50-0.90). The odds for developing anaemia was 1.1 times more likely among women with chronic illnesses, 60% more likely in the iron-deficient and 40% more likely in the folic acid-deficient than their counterparts. One in every three women had anaemia and deficiency of folic acid while one in every two had iron deficiency, suggesting that deficiencies of both folic acid and iron constitute the major micronutrient deficiencies in Ethiopian women. The risk imposed by anaemia to the health of women ranging from impediment of daily activities and poor pregnancy outcome calls for effective public-health measures, such as improved nutrient supplementation, health education, and timely treatment of illnesses.Key words: Anaemia, Anaemia, Iron-deficiency, Community-based studies, Cross-sectional studies, Folic acid, Iron deficiency, Ethiopia     

Determinants of Postnatal Care Check-ups in Ethiopia: A Multi-Level Analysis

BackgroundPostnatal care is provided to women and their babies within 42 days after delivery. Although the first two days after birth was a critical time in maternal health, it was the most neglected period of maternal health services. Therefore, this study aims to determine the maternal and community-level factors of postnatal check-ups in EthiopiaMethodsEthiopian Demographic and Health Survey (EDHS) in 2016 was utilized. A total of 3,948 women aged 15–49 giving birth in the two years before the survey were included. A multi-level mixed-effects logistic regression model was employed.ResultOnly 17% [95% C.I; 16.46%–17.53%] of the women had a postnatal check-up (PNC) within 2 days of giving birth in Ethiopia. Institutional delivery AOR 2.14 [95% C.I 1.70, 2.0] and giving birth by cesarean section AOR 1.66 [95% CI 1.10, 2.50] were found to be maternal factors. Whereas, administrative regions (Oromia 69%, Somali 56%, Benishangul 55%, SNNPR 43%, Gambela 66%, Afar 50% and Dire Dawa 55% which less likely to utilize PNC as compared to Addis Ababa), higher community-level wealth AOR 1.44 [95% C.I 1.08, 1.2], ANC coverage AOR 1.52 [95% C.I 1.19, 1.96] and perceived distance of the health facility as a big problem AOR 0.78 [95% C.I 0.60, 0.99] were the community level factors.ConclusionBoth maternal factors and community factors are found to be a significant association with PNC, however, based on the ICC maternal factors prevail the community-level factors. Therefore, public health interventions to increasing improve postnatal care services should focus on community level determinants.     

Training traditional birth attendants in clean delivery does not prevent postpartum infection

OBJECTIVE: To compare the maternal outcome, in terms of postpartum infection, of deliveries conducted by trained traditional birth attendants (TBAs) with those conducted by untrained birth attendants. METHODS: The study took place in a rural area of Bangladesh where a local NGO (BRAC) had previously undertaken TBA training. Demographic surveillance in the study site allowed the systematic identification of pregnant women. Pregnant women were recruited continuously over a period of 18 months. Data on the delivery circumstances were collected shortly after delivery while data on postpartum morbidity were collected prospectively at 2 and 6 weeks. All women with complete records who had delivered at home with a non-formal birth attendant (800) were included in the analysis. The intervention investigated was TBA training in hygienic delivery comprising the 'three cleans' (hand-washing with soap, clean cord care, clean surface). The key outcome measure was maternal postpartum genital tract infection diagnosed by a symptom complex of any two out of three symptoms: foul discharge, fever, lower abdominal pain. RESULTS: Trained TBAs were significantly more likely to practice hygienic delivery than untrained TBAs (45.0 vs. 19.3%, p < 0.0001). However, no significant difference in levels of postpartum infection was found when deliveries by trained TBAs and untrained TBAs were compared. The practice of hygienic delivery itself also had no significant effect on postpartum infection. Logistic regression models confirmed that TBA training and hygienic delivery had no independent effect on postpartum outcome. Other factors, such as pre-existing infection, long labour and insertion of hands into the vagina were found to be highly significant. CONCLUSIONS: Trained TBAs are more likely to practice hygienic delivery than those that are untrained. However, hygienic delivery practices do not prevent postpartum infection in this community. Training TBAs to wash their hands is not an effective strategy to prevent maternal postpartum infection. More rigorous evaluation is needed, not only of TBA training programmes as a whole, but also of the effectiveness of the individual components of the training.     

Relationship of parity and prior cesarean delivery to levonorgestrel 52 mg intrauterine system expulsion over 6 years

ObjectiveAssess the relationship between parity and prior route of delivery to levonorgestrel 52 mg intrauterine system (IUS) expulsion during the first 72 months of use.Study DesignWe evaluated women enrolled in the ACCESS IUS multicenter, Phase 3, open-label clinical trial of the Liletta levonorgestrel 52 mg IUS. Investigators evaluated IUS presence at 3 and 6 months after placement and then every 6 months and during unscheduled visits. We included women with successful placement and at least one follow-up assessment. We evaluated expulsion rates based on obstetric history; for prior delivery method subanalyses, we excluded 12 participants with missing delivery data. We determined predictors of expulsion using multivariable regression analyses.ResultsOf 1714 women with IUS placement, 1710 had at least one follow-up assessment. The total population included 986 (57.7%) nulliparous women. Sixty-five (3.8%) women experienced expulsion within 72 months, 50 (76.9%) within the first 12 months. Expulsion rates among nulliparous women (22/986 [2.2%]) or parous women with any pregnancy ending with a Cesarean delivery (6/195 [3.1%]) differed from parous women who only experienced vaginal deliveries (37/517 [7.2%]) (p < 0.001). In multivariable regression, obesity (adjusted odds ratio [aOR] 2.2, 95% confidence interval [CI] 1.3–3.7), parity (aOR 2.2, 95% CI 1.2–4.1), and non-white race (aOR 1.8, 95% CI 1.1–3.2) predicted expulsion. Among parous women, obesity (aOR 2.2, 95% CI 1.2–4.2) increased the odds and having ever had a cesarean delivery (aOR 0.4, 95% CI 0.1–0.9) decreased the odds of expulsion.ConclusionIUS expulsion occurs in less than 4% of users over the first 6 years of use and occurs mostly during the first year. Expulsion is more likely among obese and parous women.ImplicationsLevonorgestrel 52 mg intrauterine system expulsion occured more commonly in parous than nulliparous women; the increase in parous women is primarily in women who had vaginal deliveries only. The association between obesity, delivery route, and IUS expulsion needs further elucidation.     

Associations Between Mistreatment by a Provider during Childbirth and Maternal Health Complications in Uttar Pradesh,India

Objectives This study assesses associations between mistreatment by a provider during childbirth and maternal complications in Uttar Pradesh, India. Methods Cross-sectional survey data were collected from women (N?=?2639) who had delivered at 68 public health facilities in Uttar Pradesh, participating in a quality of care study. Participants were recruited from April to July 2015 and surveyed on demographics, mistreatment during childbirth (measure developed for this study, Cronbach’s alpha?=?0.70), and maternal health complications. Regression models assessed associations between mistreatment during childbirth and maternal complications, at delivery and postpartum, adjusting for demographics and pregnancy complications. Results Participants were aged 17–48 years, and 30.3% were scheduled caste/scheduled tribe. One in five (20.9%) reported mistreatment by their provider during childbirth, including discrimination and abuse; complications during delivery (e.g., obstructed labor) and postpartum (e.g., excessive bleeding) were reported by 45.8 and 41.5% of women, respectively. Health providers at delivery included staff nurses (81.8%), midwives (14.0%), and physicians (2.2%); Chi square analyses indicate that women were significantly more likely to report mistreatment when their provider was a nurse rather than a physician or midwife. Women reporting mistreatment by a provider during childbirth had higher odds of complications at delivery (AOR?=?1.32; 95% CI 1.05–1.67) and postpartum (AOR?=?2.12; 95% CI 1.67–2.68). Conclusions for Practice Mistreatment of women by their provider during childbirth is a pervasive health and human rights violation, and is associated with increased risk for maternal health complications in Uttar Pradesh. Efforts to improve quality of maternal care should include greater training and monitoring of providers to ensure respectful treatment of patients.     

Racial/Ethnic Disparities in Costs,Length of Stay,and Severity of Severe Maternal Morbidity

Understanding the frequency of and reasons for postpartum revisits, which occur more often for women with delivery complications than for those without, can help identify risk and inform discharge care. The objective of this study was to examine the rate of and reasons for inpatient and emergency department (ED) revisits 7 days and 42 days following deliveries with and without severe maternal morbidity (SMM). Retrospective conveys the intended meaning. cohort study using data from the Agency for Healthcare Research and Quality’s 2016-2017 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases from 14 states with de-identified patient linkage numbers and adequate race/ethnicity coding (AR, FL, GA, IA, MD, MS, MO, NV, OR, SC, SD, TN, VT, and WI). The analysis consisted of delivery hospitalizations and postpartum inpatient and ED revisits for women aged 12-55 years. SMM conditions at delivery were grouped into eight types: severe cardiac conditions, sickle cell disease with crisis, severe hypertensive disorders, severe respiratory conditions, sepsis, severe hemorrhage, other severe obstetric conditions, and other severe medical conditions. Outcomes included 7-day and 42-day inpatient and ED age-adjusted revisit rates and the reason for the revisit. A total of 9164 index deliveries with an SMM condition and 1 406 582 deliveries without an SMM condition at delivery were included. Of those deliveries with an SMM condition, 35.0% were for black women and 23.1% were for women aged 35 years and older compared with 22.4% and 15.2% of deliveries without an SMM condition, respectively. Overall, 73.2 per 1000 deliveries with an SMM condition had an inpatient or ED revisit within 7 days and one in five women returned within 42 days postpartum (207.0 revisits per 1000 deliveries). These rates were more than twice as high as those for deliveries without an SMM condition (32.1 and 87.7 per 1000, respectively). Among women with only one SMM type at delivery, the 42-day revisit rate for inpatient or ED care was as high as 445.5 per 1000 deliveries with sickle cell disease with crisis, followed by 250.9 per 1000 deliveries with severe cardiac conditions. An additional 2400 women without an SMM condition diagnosed at delivery had an inpatient readmission within 7 days for an SMM-related condition. Women with the highest postpartum revisit rates included those with a diagnosis of SMM at delivery overall and specifically those with sickle cell disease with crisis and severe cardiac conditions. A number of women with SMM conditions were diagnosed at a postpartum readmission and not at the delivery. Examining revisits during the postpartum period is an important consideration when studying SMM. This study can help identify women at high risk of postpartum revisits. The data can be used to inform the scheduling and content of coordinated discharge care, assist with resource allocation, and identify research priorities for maternal care. Future research is needed to examine the contributions of clinical factors at delivery, expected payer, and hospital and community characteristics in explaining disparities in the risk of postpartum readmission. Agency for Healthcare Research and Quality.     

产科早期预警评分系统应用于产科ICU患者的评估

目的:综合评估英国国家重症监护审计和研究中心(ICNARC)-产科早期预警评分(OEWS)系统对入住重症监护病房(ICU)孕产妇发生产科危重症的预测能力。方法:对2015年1月-2018年5月苏州市立医院本部(我院)入住ICU孕产妇共214例进行回顾性队列研究,采用入ICU 24 h内的数据计算OEWS分值,预测其住院期间发生产科危重症的可能性,综合评估ICNARC-OEWS的性能、区分度和分层能力。结果:研究期间,共有67 148例孕妇在我院分娩,其中214例孕产妇入住ICU,ICU入住率3.19/1 000,其中2例死亡,孕产妇死亡率为2.98/100 000,97例发生危重症,危重症发生率为1.44/1 000。最常见的入住ICU原因为直接产科因素(74.3%,159/214)。发生产科危重症的孕产妇OEWS评分显著高于无危重症孕产妇[7(6,9)vs. 4(1,5),Z=-10.340,P=0.000]。OEWS评分为0分的孕产妇无产科危重症发生,1~3分时阴性预测值(NPV)为94.5%(52/55),≥6分时阳性预测值(PPV)为79.0%(83/105)。OEWS区分产科危重症的受试者工作特征(ROC)曲线下面积(AUC)为0.908(95%CI:0.870~0.946,P<0.001),预测因间接和直接产科因素入住ICU孕产妇发生危重症的AUC分别为0.875(95%CI:0.784~0.966)和0.920(95%CI:0.879~0.961,P<0.001)。结论:ICNARC-OEWS系统对于ICU孕产妇发生产科危重症具有良好的区分能力和分层能力,可以在ICU的围生期妇女中推广。     

Women’s Use of Health Care in the First 2 Years Postpartum: Occurrence and Correlates

Objectives We sought to determine rates and correlates of accessing health care in the 2 years following delivery among women at an urban academic medical center. Methods We used electronic medical records, discharge, and billing data to determine the occurrence of primary care, other non-primary outpatient care, emergency department visits, and inpatient admissions among women delivering at a single medical center who had a known primary care affiliation to that medical center over a 5 year period. We explored sociodemographic, clinical, and health care-related factors as correlates of care, using bivariate and multivariable modeling. Results Of 6216 women studied, most (91 %) had had at least one health care visit in the window between 2 months and 2 years postpartum (the “late postpartum period”). The majority (81 %) had had a primary care visit. Factors associated with use of health care in this period included a chronic medical condition diagnosed prior to pregnancy (adjusted odds ratio (AOR) 1.42, 95 % CI [1.19, 1.71]), prenatal care received in an urban community health center (AOR 1.35 [1.06, 1.73]), having received obstetric (AOR 1.90 [1.51, 2.37]), primary (AOR 2.30 [1.68, 3.23]), or other non-primary outpatient care (AOR 2.35 [1.72, 3.39]) in the first 2 months postpartum, and living closer to the hospital [AOR for residence >17.8 miles from the medical center (AOR 0.74 [0.61, 0.90])]. Having had an obstetrical complication did not increase the likelihood of receipt of care during this window. Conclusions for Practice Among women already enrolled in a primary care practice at our medical center, health care utilization in the late postpartum period is high, but not universal. Understanding the characteristics of women who return for health care during this window, and where they are seen, can improve transitions of care across the life course and can provide opportunities for important and consistent interconception and well-woman messaging.     

Increased risks of circulatory diseases in late pregnancy and puerperium.

We studied a nationwide Swedish cohort with 654,957 women who had 1,003,489 deliveries from 1987 through September 1995 to assess late pregnancy and puerperal risks of circulatory diseases. We used standardized incidence rate ratios to calculate relative risks [with 95% confidence intervals (CIs)]. Compared with unexposed (nonpregnant and early pregnant) women, relative risks of venous thrombosis and pulmonary embolism during the third trimester were 6.7 (95% CI = 5.7--7.8) and 2.7 (95% CI = 1.7--4.2), respectively. Around delivery (from 2 days before to 1 day after delivery), the relative risks of all assessed circulatory diseases were dramatically increased: venous thrombosis, 115.1 (95% CI = 96.4--137.0); pulmonary embolism, 80.7 (95% CI = 53.9--117.9); subarachnoid hemorrhage, 46.9 (95% CI = 19.3--98.4); intracerebral hemorrhage, 95.0 (95% CI = 42.1--194.8); cerebral infarction, 33.8 (95% CI = 10.5--84.0); and myocardial infarction, 27.0 (95% CI = 0.6--180.0). During the rest of the first 6 weeks postpartum, the risks declined but were still substantially increased for all diseases, with the exception of subarachnoid hemorrhage. The results suggest that the increased risk for circulatory diseases related to pregnancy is mainly confined to a few days around delivery.