Dataset Information

Variation in severe maternal morbidity according to socioeconomic position: a UK national case-control study.

ABSTRACT:

Objectives

This study aimed to explore the independent association between socioeconomic position, defined by occupation, and severe maternal morbidity among women in the UK.

Design

Case-control study.

Setting

The analysis was conducted as a case-control analysis, using data from a series of studies of direct causes of severe maternal morbidity undertaken through the UK Obstetric Surveillance System (UKOSS), with data collected throughout all consultant-let obstetric units in the UK.

Participants

The analysis included 1144 cases and 2256 comparison women (controls). UKOSS studies from which data on case women were obtained included amniotic fluid embolism, acute fatty liver of pregnancy, eclampsia, peripartum hysterectomy, therapies for peripartum haemorrhage and uterine rupture.

Primary outcome measure

Odds of severe maternal morbidity by socioeconomic group, independent of ethnicity, maternal age, smoking, pre-existing medical condition, body mass index (BMI), multiple pregnancy and past pregnancy complications. Occupation was used to classify different socioeconomic groups.

Secondary outcome measure

Odds of morbidity related to ethnic group, maternal age, smoking, pre-existing medical condition, BMI, multiple pregnancy and past pregnancy complications.

Results

Across the socioeconomic groups, compared with the 'managerial/professional' group, adjusted ORs were 1.17 (95% CI 0.94 to 1.45) for the 'intermediate group', 1.16 (95% CI 0.93 to 1.45) for 'routine/manual', 1.22 (95% CI 0.92 to 1.61) for 'unemployed' women and 1.51 (95% CI 1.18 to 1.94) for women with missing socioeconomic information. Women of non-white ethnicity, older maternal age (?35 years), BMI ?25 kg/m(2) and those with pre-existing medical condition/s, multiple pregnancy or past pregnancy complications were shown to have a significantly increased odds of severe maternal morbidity.

Conclusions

This study suggests that socioeconomic position may be independently associated with an increased risk of severe maternal morbidity, although the observed association was not statistically significant. Further research is warranted to confirm this and investigate why this association might exist in a country where healthcare is universal and free at the point of access.

SUBMITTER: Lindquist A

PROVIDER: S-EPMC3686175 | biostudies-literature | 2013 Jun

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Variation in severe maternal morbidity according to socioeconomic position: a UK national case-control study.

Lindquist Anthea A Knight Marian M Kurinczuk Jennifer J JJ

BMJ open 20130620 6

<h4>Objectives</h4>This study aimed to explore the independent association between socioeconomic position, defined by occupation, and severe maternal morbidity among women in the UK.<h4>Design</h4>Case-control study.<h4>Setting</h4>The analysis was conducted as a case-control analysis, using data from a series of studies of direct causes of severe maternal morbidity undertaken through the UK Obstetric Surveillance System (UKOSS), with data collected throughout all consultant-let obstetric units ...[more]

PMID: 23794588

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Project description:In light of increasing rates and severity of sepsis worldwide, this study aimed to estimate the incidence of, and describe the causative organisms, sources of infection, and risk factors for, severe maternal sepsis in the UK.A prospective case-control study included 365 confirmed cases of severe maternal sepsis and 757 controls from all UK obstetrician-led maternity units from June 1, 2011, to May 31, 2012. Incidence of severe sepsis was 4.7 (95% CI 4.2-5.2) per 10,000 maternities; 71 (19.5%) women developed septic shock; and five (1.4%) women died. Genital tract infection (31.0%) and the organism Escherichia coli (21.1%) were most common. Women had significantly increased adjusted odds ratios (aORs) of severe sepsis if they were black or other ethnic minority (aOR?=?1.82; 95% CI 1.82-2.51), were primiparous (aOR?=?1.60; 95% CI 1.17-2.20), had a pre-existing medical problem (aOR?=?1.40; 95% CI 1.01-1.94), had febrile illness or were taking antibiotics in the 2 wk prior to presentation (aOR?=?12.07; 95% CI 8.11-17.97), or had an operative vaginal delivery (aOR?=?2.49; 95% CI 1.32-4.70), pre-labour cesarean (aOR?=?3.83; 95% CI 2.24-6.56), or cesarean after labour onset (aOR?=?8.06; 95% CI 4.65-13.97). Median time between delivery and sepsis was 3 d (interquartile range?=?1-7 d). Multiple pregnancy (aOR?=?5.75; 95% CI 1.54-21.45) and infection with group A streptococcus (aOR?=?4.84; 2.17-10.78) were associated with progression to septic shock; for 16 (50%) women with a group A streptococcal infection there was <2 h-and for 24 (75%) women, <9 h-between the first sign of systemic inflammatory response syndrome and a diagnosis of severe sepsis. A limitation of this study was the proportion of women with sepsis without an identified organism or infection source (16.4%).For each maternal sepsis death, approximately 50 women have life-threatening morbidity from sepsis. Follow-up to ensure infection is eradicated is important. The rapid progression to severe sepsis highlights the importance of following the international Surviving Sepsis Campaign guideline of early administration of high-dose intravenous antibiotics within 1 h of admission to hospital for anyone with suspected sepsis. Signs of severe sepsis in peripartum women, particularly with confirmed or suspected group A streptococcal infection, should be regarded as an obstetric emergency. Please see later in the article for the Editors' Summary.

Project description:ImportanceSevere maternal morbidity (SMM) is a major risk factor for maternal mortality, yet little is known about geographic variation in SMM or factors associated with geographical variation at the local level. Municipal governments incur substantial expenditures providing services that are an essential part of residents' lives, but associations between municipal expenditures and SMM have not been previously examined.ObjectiveTo investigate variation in rates of SMM across municipalities in New Jersey, the contributions of individual-level characteristics and municipal expenditures to that variation, and associations between municipal expenditures and SMM.Design, setting, and participantsThis cross-sectional study analyzed 2008 to 2018 New Jersey birth files linked to maternal hospital discharge records and US Census municipal expenditures data. The birth files contain all birth records for New Jersey, and hospital discharge records contain information from all in-patient hospitalizations in New Jersey over the study period. Birth records were matched to maternal discharge records and expenditures data. Data were analyzed from August 2020 to August 2021.ExposuresIndividual-level characteristics and per capita municipal expenditures on education; public health; fire and ambulance; parks, recreation, and natural resources; housing and community development; public welfare; police; transportation; and libraries.Main outcomes and measuresSMM was identified using diagnosis and procedure codes developed by the Centers for Disease Control and Prevention to measure SMM.ResultsOf 1 001 410 individuals (mean [SD] age, 29.8 [5.9] years; 108 665 Asian individuals [10.9%]; 147 910 Black individuals [14.8%]; 280 697 Hispanic individuals [28.0%]; 447 442 White individuals [44.7%]) who gave birth in New Jersey hospitals from 2008 to 2018, 19 962 individuals (2.0%) had SMM. There was substantial municipality-level variation in SMM that was not fully explained by demographic characteristics. Municipal expenditures on fire and ambulance, transportation, health, housing, and libraries were negatively associated with SMM; $1000 higher annual expenditures per capita in these categories were associated with 35.4% to 67.3% lower odds of SMM (odds ratios, 0.33 [95% CI, 0.15-0.72] to 0.65 [95% CI, 0.46-0.91]). Expenditures on police were positively associated with SMM (odds ratio, 1.15 [95% CI, 1.04-1.28]).Conclusions and relevanceThe findings in this study regarding associations between spending on various types of services at the municipal level and SMM, holding constant overall spending, population size, and socioeconomic status at the municipal level, indicate that municipal budget allocation decisions were associated with SMM rates and point to the importance of future research investigating potential causal connections.

Project description:ImportancePregnancy outcomes are historically poor among people with sickle cell disease (SCD) in the US, most of whom have Black race. Whether outcomes have improved is unknown.ObjectiveTo tabulate adverse pregnancy outcomes among patients with SCD, comparing outcomes of deliveries among Black people with SCD with those of Black people without SCD and a control non-Black population, and to measure the association of racial disparities with adverse outcomes in SCD pregnancies.Design, setting, and participantsThis cross-sectional study was a secondary analysis involving data from National Inpatient Sample, a nationally representative sample of 20% of acute hospital admissions in the US, between 2012 and 2018. The data set included all admissions with codes for delivery of a pregnancy among people aged 11 to 55 years. Data were analyzed from September 2021 to August 2022.ExposuresSCD, racial disparities.Main outcomes and measuresSevere maternal morbidity (SMM) as measured by the US Centers for Disease Control and Prevention's index alongside other outcomes; multiple logistic regression was used to compare the odds for adverse pregnancy outcomes.ResultsThe sample included 5 401 899 deliveries, including 3901 deliveries among people with SCD and 742 164 deliveries among people with Black race. Compared with the non-Black control group, patients with SCD and Black patients were younger (mean [SD] age: SCD, 27.2 [5.9] years; Black, 27.1 [6.1] years vs 28.7 [5.9] years) and more likely to have public insurance (SCD, 2609 deliveries [67.3%]; Black, 496 828 deliveries [65.4%] vs 1 880 198 deliveries [40.8%]). The maternal mortality rate in deliveries among people with SCD was 26 times greater than in the non-Black control group and more than 10 times greater than among Black pregnant people without SCD (Per 10 000 deliveries: SCD 13.3; 95% CI, 5.7-31.2; Black race, 1.2; 95% CI, 1.0-1.5; non-Black control 0.5; 95% CI, 0.5-0.6). Compared with the control group, SCD deliveries had higher odds of SMM (adjusted odds ratio [aOR], 7.22; 95% CI, 6.25-8.34; P < .001), especially cerebrovascular events (aOR, 22.00; 95% CI, 15.25-31.72; P < .001) and thromboembolism (aOR, 17.34; 95% CI, 11.55-26.03; P < .001). Racial disparities explained a median (IQR) 28.9% (21.2%-33.1%) of the increased risk in deliveries to people with SCD and between 40% and 50% of the increased risk for acute kidney failure (excess risk [ER], 56.9%; 95% CI, 54.3%-59.3%), intrauterine fetal demise (ER, 47.8%; 95% CI, 46.6%-49.1%), and eclampsia (ER, 42.1%; 95% CI, 37.9%-46.1%).Conclusions and relevanceIn this large cross-sectional study of pregnancy outcomes in people with SCD, the risk for SMM was higher compared with deliveries among people without SCD, especially for thrombotic events, organ failure, and death. Racial disparities were associated with adverse outcomes. Our findings compel scientific, clinical, and political effort to improve outcomes for pregnant people with SCD.

Project description:ImportanceOver the past 2 decades, there has been a trend toward increasing maternal age in many high-income countries. Maternal age may lead to greater attendant morbidity and mortality for Canadian mothers.ObjectiveTo investigate the association of maternal age, adjusting for patient-level and hospital-level factors, with severe maternal morbidity (SMM) and maternal death in Canada.Design, setting, and participantsA nationwide population-based cohort study of all antepartum, peripartum, and postpartum women and adolescents seen at Canadian acute care hospitals from April 1, 2004, to March 31, 2015. All analyses were completed on September 13, 2018.ExposuresMaternal age at the index delivery.Main outcomes and measuresSevere maternal morbidity and maternal death during pregnancy and within 6 weeks after termination of pregnancy.ResultsDuring the study period, there were 3?162?303 new pregnancies (mean [SD] maternal age, 29.5 [5.6] years) and 3?533?259 related hospital admissions. There were 54?219 episodes of SMM (17.7 cases per 1000 deliveries) in the entire study period, with a 9.8% relative increase from 2004-2005 to 2014-2015, in addition to an increasing proportion of pregnancies to older mothers. Independent patient-level factors associated with SMM included increasing Maternal Comorbidity Index; maternal age 19 years or younger and 30 years or older, with the greatest risk experienced by women 45 years or older (odds ratio [OR], 2.69; 95% CI, 2.34-3.06 compared with maternal age 20-24 years); and lowest income quintile (OR, 1.19; 95% CI, 1.14-1.22 compared with highest income quintile). Hospital-level factors associated with SMM included specific provinces. Independent patient-level factors associated with maternal mortality included increasing Maternal Comorbidity Index, age 40 to 44 years (OR, 3.39; 95% CI, 1.68-6.82 compared with age 20-24 years), age 45 years or older (OR, 4.39; 95% CI, 1.01-19.10 compared with age 20-24 years), and lowest income quintile (OR, 4.14; 95% CI, 2.03-8.50 compared with highest income quintile). Hospital-level factors associated with maternal mortality included lowest hospital pregnancy volume.Conclusions and relevanceIn Canada, maternal age and SMM have increased over the past decade. Results of this study suggest that province of residence, maternal comorbidity, residence income quintile, and extremes of maternal age, especially those 45 years or older, were associated with SMM and mortality. These findings are relevant to prospective parents, their health care team, and public health planning.

Project description:BackgroundOne of the United Nations' Millennium Development Goals of 2000 was to reduce maternal mortality by 75% in 15 y; however, this challenge was not met by many industrialized countries. As average maternal age continues to rise in these countries, associated potentially life-threatening severe maternal morbidity has been understudied. Our primary objective was to examine the associations between maternal age and severe maternal morbidities. The secondary objective was to compare these associations with those for adverse fetal/infant outcomes.Methods and findingsThis was a population-based retrospective cohort study, including all singleton births to women residing in Washington State, US, 1 January 2003-31 December 2013 (n = 828,269). We compared age-specific rates of maternal mortality/severe morbidity (e.g., obstetric shock) and adverse fetal/infant outcomes (e.g., perinatal death). Logistic regression was used to adjust for parity, body mass index, assisted conception, and other potential confounders. We compared crude odds ratios (ORs) and adjusted ORs (AORs) and risk differences and their 95% CIs. Severe maternal morbidity was significantly higher among teenage mothers than among those 25-29 y (crude OR = 1.5, 95% CI 1.5-1.6) and increased exponentially with maternal age over 39 y, from OR = 1.2 (95% CI 1.2-1.3) among women aged 35-39 y to OR = 5.4 (95% CI 2.4-12.5) among women aged ?50 y. The elevated risk of severe morbidity among teen mothers disappeared after adjustment for confounders, except for maternal sepsis (AOR = 1.2, 95% CI 1.1-1.4). Adjusted rates of severe morbidity remained increased among mothers ?35 y, namely, the rates of amniotic fluid embolism (AOR = 8.0, 95% CI 2.7-23.7) and obstetric shock (AOR = 2.9, 95% CI 1.3-6.6) among mothers ?40 y, and renal failure (AOR = 15.9, 95% CI 4.8-52.0), complications of obstetric interventions (AOR = 4.7, 95% CI 2.3-9.5), and intensive care unit (ICU) admission (AOR = 4.8, 95% CI 2.0-11.9) among those 45-49 y. The adjusted risk difference in severe maternal morbidity compared to mothers 25-29 y was 0.9% (95% CI 0.7%-1.2%) for mothers 40-44 y, 1.6% (95% CI 0.7%-2.8%) for mothers 45-49 y, and 6.4% for mothers ?50 y (95% CI 1.7%-18.2%). Similar associations were observed for fetal and infant outcomes; neonatal mortality was elevated in teen mothers (AOR = 1.5, 95% CI 1.2-1.7), while mothers over 29 y had higher risk of stillbirth. The rate of severe maternal morbidity among women over 49 y was higher than the rate of mortality/serious morbidity of their offspring. Despite the large sample size, statistical power was insufficient to examine the association between maternal age and maternal death or very rare severe morbidities.ConclusionsMaternal age-specific incidence of severe morbidity varied by outcome. Older women (?40 y) had significantly elevated rates of some of the most severe, potentially life-threatening morbidities, including renal failure, shock, acute cardiac morbidity, serious complications of obstetric interventions, and ICU admission. These results should improve counselling to women who contemplate delaying childbirth until their forties and provide useful information to their health care providers. This information is also useful for preventive strategies to lower maternal mortality and severe maternal morbidity in developed countries.

Project description:ObjectiveTo investigate the factors associated with maternal death from direct pregnancy complications in the UK.DesignUnmatched case-control analysis.SettingAll hospitals caring for pregnant women in the UK.PopulationA total of 135 women who died (cases) between 2009 and 2012 from eclampsia, pulmonary embolism, severe sepsis, amniotic fluid embolism, and peripartum haemorrhage, using data from the Confidential Enquiry into Maternal Death, and another 1661 women who survived severe complications (controls) caused by these conditions (2005-2013), using data from the UK Obstetric Surveillance System.MethodsMultivariable regression analyses were undertaken to identify the factors that were associated with maternal deaths and to estimate the additive odds associated with the presence of one or more of these factors.Main outcome measuresOdds ratios associated with maternal death and population-attributable fractions, with 95% confidence intervals. Incremental risk of death associated with the factors using a 'risk factors' score.ResultsSix factors were independently associated with maternal death: inadequate use of antenatal care (adjusted odds ratio, aOR 15.87, 95% CI 6.73-37.41); substance misuse (aOR 10.16, 95% CI 1.81-57.04); medical comorbidities (aOR 4.82, 95% CI 3.14-7.40); previous pregnancy problems (aOR 2.21, 95% CI 1.34-3.62); hypertensive disorders of pregnancy (aOR 2.44, 95% CI 1.31-4.52); and Indian ethnicity (aOR 2.70, 95% CI 1.14-6.43). Of the increased risk associated with maternal death, 70% (95% CI 66-73%) could be attributed to these factors. Odds associated with maternal death increased by three and a half times per unit increase in the 'risk factor' score (aOR 3.59, 95% CI 2.83-4.56).ConclusionsThis study shows that medical comorbidities are importantly associated with direct (obstetric) deaths. Further studies are required to understand whether specific aspects of care could be improved to reduce maternal deaths among women with medical comorbidities in the UK.

Dataset Information

Variation in severe maternal morbidity according to socioeconomic position: a UK national case-control study.

Objectives

Design

Setting

Participants

Primary outcome measure

Secondary outcome measure

Results

Conclusions

Publications

Variation in severe maternal morbidity according to socioeconomic position: a UK national case-control study.

Similar Datasets

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