Severe maternal morbidity and postpartum mental health-related outcomes in Sweden: a population-based matched-cohort study.
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ABSTRACT:
SUBMITTER: Wall-Wieler E
PROVIDER: S-EPMC6921935 | biostudies-literature | 2019 Aug
REPOSITORIES: biostudies-literature
Publications
Severe maternal morbidity and postpartum mental health-related outcomes in Sweden: a population-based matched-cohort study.
Wall-Wieler Elizabeth E Carmichael Suzan L SL Urquia Marcelo L ML Liu Can C Hjern Anders A
Archives of women's mental health 20181017 4
We examined whether women experiencing severe maternal morbidity (SMM) are more likely to be treated for a psychiatric illness or be prescribed psychotropic medications in the postpartum year than mothers who did not experience SMM. We also examine the relationship between SMM and specific mental health-related outcomes, and the relationship between specific SMM diagnoses/procedures and postpartum mental-health-related outcomes. The national registers in Sweden were used to create a population-b ...[more]
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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.
| S-EPMC5448726 | biostudies-literature
Project description:BACKGROUND:As the rate of cesarean section delivery has increased, the incidence of severe maternal morbidity continues to increase. Severe maternal morbidity is associated with high medical costs, extended length of hospital stay, and long-term rehabilitation. However, there is no evidence whether severe maternal morbidity affects postpartum readmission. Therefore, this study aimed to determine the relationship between severe maternal morbidity and postpartum readmission. METHODS:This nationwide population-based cohort study used the Korean National Health Insurance Service-National Sample cohort of 90,035 delivery cases between January 2003 and November 2013. The outcome variable was postpartum readmission until 6?weeks after the first date of delivery in the hospital. Another variable of interest was the occurrence of severe maternal morbidity, which was determined using the Center for Disease Control and Prevention's algorithm. The Cox proportional hazard model was used to assess the association between postpartum readmission and severe maternal morbidity after all covariates were adjusted. RESULTS:The overall incidence of postpartum readmission was 2041 cases (0.95%) of delivery. Women with severe maternal morbidity had an approximately 2.4 times higher risk of postpartum readmission than those without severe maternal morbidity (hazard ratio 2.36, 95% confidence interval 1.75-3.19). In addition, compared with reference group, women who were aged 20-30?years, nulliparous, and delivered in a tertiary hospital were at high risk of postpartum readmission. CONCLUSIONS:Severe maternal morbidity was related to the risk of postpartum readmission. Policy makers should provide a quality indicator of postpartum maternal health care and improve the quality of intrapartum care.
| S-EPMC7060630 | biostudies-literature
Project description:BackgroundSevere maternal morbidity (SMM) is a key indicator of maternal health. Generally explored without distinction by the timing of the event, it mainly reflects postpartum SMM. Although antepartum (pre-labour) SMM presents specific challenges in its need to optimise the risk-benefit balance for both mother and foetus, its features remain inadequately explored.ObjectivesWe explored risk factors of antepartum SMM and described adverse delivery and neonatal outcomes associated with antepartum SMM.MethodsWe designed a population-based nested case-control study based on data from the EPIMOMS study (119 maternity hospitals of 6 French regions, 2012-2013, N = 182,309 deliveries in the source cohort). This study included all women with antepartum SMM (cases, n = 601) compared to a randomly selected sample of women who gave birth without SMM in the same hospitals (controls, n = 3651). Antepartum SMM risk factors were identified with multivariable logistic regression following imputations for missing data.ResultsAntepartum SMM complicated 0.33% (95% confidence interval [CI] 0.30, 0.36) of pregnancies. Antepartum SMM risk factors were maternal age ≥35 years (adjusted odds ratio [OR] 1.55, 95% CI 1.22, 1.97), increased body mass index (OR for 5 kg/m2 increase, 1.24, 95% CI 1.14, 1.36), maternal birth in sub-Saharan Africa (OR 1.80, 95% CI 1.29, 2.53), pre-existing medical condition (OR 2.56, 95% CI 1.99, 3.30), nulliparity (OR 2.26, 95% CI 1.83, 2.80), previous pregnancy-related hypertensive disorders (OR 4.94, 95% CI 3.36, 7.26), multiple pregnancy (OR 5.79, 95% CI 3.75, 7.26), irregular prenatal care (OR 1.86, 95% CI 1.27, 2.72). For women with antepartum SMM, preterm delivery, neonatal mortality and transfer to the neonatal intensive care unit were 10 times more frequent than for controls. Emergency caesarean and general anaesthesia were more frequent in women with antepartum SMM.ConclusionsAntepartum SMM is rare but associated with increased rates of adverse delivery and neonatal outcomes.
| S-EPMC9255856 | biostudies-literature
Project description:BackgroundSevere maternal morbidity is an important proxy for maternal mortality. Population attributable fraction is the proportion of a disease that is attributable to a given risk factor and can be used to estimate the reduction in the disease that would be anticipated if a risk factor was reduced or eliminated.ObjectiveWe sought to determine the population-attributable fraction (PAF) of potentially modifiable risk factors for severe maternal morbidity.Study designWe used a retrospective cohort of 86,260 delivery hospitalizations from Magee-Womens Hospital, Pittsburgh, PA for this analysis (2003-2012). Severe maternal morbidity was defined as any of the following: Centers for Disease Control and Prevention International Classification of Diseases 9th Revision diagnosis and procedure codes for the identification of maternal morbidity; prolonged postpartum length of stay (defined as >3 standard deviations beyond the mean length of stay: >3 days for vaginal deliveries and >5 days for Cesarean deliveries); or maternal intensive care unit admission. We used multivariable logistic regression with generalized estimating equations to estimate the association of prepregnancy overweight or obesity, maternal age ≥35 years, preexisting hypertension, preexisting diabetes, excessive gestational weight gain, smoking, education, and marital status with severe maternal morbidity. We then calculated the PAF for each risk factor. We also examined the impact of modest reductions and elimination of risk factors on the PAF of severe maternal morbidity.ResultsThe overall rate of severe maternal morbidity was 2.0%. Overweight and obesity, maternal age ≥35 years, preexisting hypertension, excessive gestational weight gain, and lack of a college degree had PAF ranging from 4.5% to 13%. If all risk factors were eliminated, 36% of cases could have been prevented. Modest reductions in the prevalence of excessive BMI and advanced maternal age had minimal impact on preventing severe maternal morbidity. Smoking during pregnancy and marital status were not associated with severe maternal morbidity.ConclusionsOur data suggest maternal morbidity can be reduced by modifying common, individual-level risk factors. Nevertheless, the majority of cases were not attributable to the patient level risk factors we examined. These data support the need for large studies of patient-, provider-, system- and population-level factors to identify high-impact interventions to reduce maternal morbidity.
| S-EPMC7450808 | biostudies-literature
Project description:BackgroundPrepregnancy body mass index and gestational weight gain have been linked with severe maternal morbidity, suggesting that weight change between pregnancies may also play a role, as it does for neonatal outcomes.ObjectiveThis study assessed the association of changes in prepregnancy body mass index between 2 consecutive singleton pregnancies with the outcomes of severe maternal morbidity, stillbirth, and small- and large-for-gestational-age infants in the subsequent pregnancy.Study designThis observational study was based on birth records from 1,111,032 consecutive pregnancies linked to hospital discharge records in California (2007-2017). Interpregnancy body mass index change between the beginning of an index pregnancy and the beginning of the subsequent pregnancy was calculated from self-reported weight and height. Severe maternal morbidity was defined based on the Centers for Disease Control and Prevention index, including and excluding transfusion-only cases. We used multivariable log-binomial regression models to estimate adjusted risks, overall and stratified by prepregnancy body mass index at index birth.ResultsSubstantial interpregnancy body mass index gain (≥4 kg/m2) was associated with severe maternal morbidity in crude but not adjusted analyses. Substantial interpregnancy body mass index loss (>2 kg/m2) was associated with increased risk of severe maternal morbidity (adjusted relative risk, 1.13; 95% confidence interval (1.07-1.19), and both substantial loss (adjusted relative risk, 1.11 [1.02-1.19]) and gain (≥4 kg/m2; adjusted relative risk, 1.09 [1.02-1.17]) were associated with nontransfusion severe maternal morbidity. Substantial loss (adjusted relative risk, 1.17 [1.05-1.31]) and gain (1.26 [1.14-1.40]) were associated with stillbirth. Body mass index gain was positively associated with large-for-gestational-age infants and inversely associated with small-for-gestational-age infants.ConclusionSubstantial interpregnancy body mass index changes were associated with modestly increased risk of severe maternal morbidity, stillbirth, and small- and large-for-gestational-age infants.
| S-EPMC10960247 | biostudies-literature
Project description:ObjectiveSignificant changes to the delivery of obstetrical care that occurred with the onset of the COVID-19 pandemic may be associated with higher risks of adverse maternal outcomes. We evaluated preeclampsia/HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome and composite severe maternal morbidity (SMM) among pregnant people who gave birth during the COVID-19 pandemic and compared these data with those of people who gave birth before the pandemic in Ontario, Canada.MethodsThis was a population-based, retrospective cohort study using linked administrative data sets from ICES. Data on pregnant people at ≥20 weeks gestation who gave birth between March 15, 2020, and September 30, 2021, were compared with those of pregnant people who gave birth within the same date range for the years 2015-2019. We used multivariable logistic regression to assess the effect of the pandemic period on the odds of preeclampsia/HELLP syndrome and composite SMM, adjusting for maternal baseline characteristics and comorbidities.ResultsThere were no differences between the study periods in the adjusted odds ratios (aORs) for preeclampsia/HELLP syndrome among primiparous (aOR 1.00; 95% CI 0.91-1.11) and multiparous (aOR 0.94; 95% CI 0.81-1.09) patients and no differences for composite SMM (primiparous, aOR 1.00; 95% CI 0.95-1.05; multiparous, aOR 1.01; 95% CI 0.95-1.08).ConclusionAdverse maternal outcomes were not higher among pregnant people who gave birth during the first 18 months of the COVID-19 pandemic in Ontario, Canada, when compared with those who gave birth before the pandemic.
| S-EPMC8979839 | biostudies-literature
Project description:ObjectivesTo perform a multidimensional assessment of women who experienced severe maternal morbidity (SMM) and its short-term and medium-term impact on the lives and health of women and their children.DesignA retrospective cohort study.SettingA tertiary maternity hospital from the southeast region of Brazil.ParticipantsThe exposed population was selected from intensive care unit admissions if presenting any diagnostic criteria for SMM. Controls were randomly selected among women without SMM admitted to the same maternity and same time of childbirth.Primary and secondary outcome variablesValidated tools were applied, addressing post-traumatic stress disorder (PTSD) and quality of life (SF-36) by phone, and then general and reproductive health, functioning (WHO Disability Assessment Schedule), sexual function (Female Sexual Function Index (FSFI)), substance abuse (Alcohol, Smoking and Substance Involvement Screening Test 2.0) and growth/development (Denver Developmental Screening Test) of children born in the index pregnancy in a face-to-face interview.ResultsAll instruments were applied to 638 women (315 had SMM; 323 were controls, with the assessment of 264 and 307 children, respectively). SF-36 score was significantly lower in the SMM group, while PTSD score was similar between groups. Women who had SMM became more frequently sterile, had more abnormal clinical conditions after the index pregnancy and a higher score for altered functioning, while proportions of FSFI score or any drug use were similar between groups. Furthermore, children from the SMM group were more likely to have weight (threefold) and height (1.5 fold) for age deficits and also impaired development (1.5-fold).ConclusionSMM impairs some aspects of the lives of women and their children. The focus should be directed towards monitoring these women and their children after birth, ensuring accessibility to health services and reducing short-term and medium-term repercussions on physical, reproductive and psychosocial health.
| S-EPMC7733206 | biostudies-literature
Project description:BackgroundThe incidence of severe maternal morbidity is increasing in high-income countries. However, little has been known about the impact on postnatal morbidity, particularly on psychological health outcomes. The objective of this study was to assess the relationship between severe maternal morbidity (ie. major obstetric haemorrhage, severe hypertensive disorders or intensive care unit/obstetric high dependency unit admission) and postnatal psychological health symptoms, focusing on post-traumatic stress disorder (PTSD) symptoms at 6-8 weeks postpartum.MethodA prospective cohort study was undertaken of women who gave birth over six months in 2010 in an inner city maternity unit in England. Primary outcomes were prevalence of PTSD symptoms namely: 1) intrusion and 2) avoidance as measured using the Impact of Event Scale at 6 - 8 weeks postpartum via a self-administered postal questionnaire. Secondary outcomes included probable depression. Data on incidence of severe maternal morbidity were extracted from maternity records. Multivariable logistic regression analysis examined the relationship between severe maternal morbidity and PTSD symptoms taking into account factors that might influence the relationship.ResultsOf women eligible to participate (n=3509), 52% responded. Prevalence of a clinically significant level of intrusion and avoidance were 6.4% (n=114) and 8.4% (n=150) respectively. There was a higher risk of PTSD symptoms among women who experienced severe maternal morbidity compared with women who did not (adjusted OR = 2.11, 95%CI = 1.17-3.78 for intrusion; adjusted OR = 3.28, 95%CI = 2.01-5.36 for avoidance). Higher ratings of reported sense of control during labour/birth partially mediated the risk of PTSD symptoms. There were no statistically significant differences in the prevalence or severity of symptoms of depression.ConclusionThis is one of the largest studies to date of PTSD symptoms among women who had recently given birth. Findings showed that an experience of severe maternal morbidity was independently associated with symptoms of PTSD. Individually tailored care that increases women's sense of control during labour may be a protective factor with further work required to promote effective interventions to prevent these symptoms. Findings have important implications for women's health and the content and organisation of maternity services during and after the birth.
| S-EPMC4021064 | biostudies-literature
Project description:ObjectiveTo investigate associations of morbidity with subsequent sickness absence (SA) and disability pension (DP) among initially nulliparous women with no, one or several childbirths during follow-up.DesignLongitudinal register-based cohort study.SettingSweden.ParticipantsNulliparous women, aged 18 to 39 years and living in Sweden on 31 December 2004 and the three preceding years (n=492 504).Outcome measuresAnnual mean DP and SA days (in SA spells >14 days) in the 3 years before and after inclusion date in 2005.MethodsWomen were categorised into three groups: no childbirth in 2005 nor during the follow-up, first childbirth in 2005 but not during follow-up, and having first childbirth in 2005 and at least one more during follow-up. Microdata were obtained for 3 years before and 3 years after inclusion regarding SA, DP, mortality and morbidity (ie, hospitalisation and specialised outpatient healthcare, also excluding healthcare for pregnancy, childbirth and puerperium). HRs and 95% CIs for SA and DP in year 2 and 3 after childbirth were estimated by Cox regression; excluding those on DP at inclusion.ResultsAfter controlling for study participants' prior morbidity and sociodemographic characteristics, women with one childbirth had a lower risk of SA and DP than those who remained nulliparous, while women with more than one childbirth had the lowest DP risk. Morbidity after inclusion that was not related to pregnancy, childbirth or the puerperium was associated with a higher risk of future SA and DP, regardless of childbirth group. Furthermore, morbidity both before and after childbirth showed a strong association with SA and DP (HR range: 2.54 to 13.12).ConclusionWe found a strong positive association between morbidity and both SA and DP among women, regardless of childbirth status. Those who gave birth had lower future SA and DP risk than those who did not.
| S-EPMC7689079 | biostudies-literature
Project description:BackgroundWomen continue to die unnecessarily during or after pregnancy in the developed world. The aim of this analysis was to compare women with severe maternal morbidities who survived with those who died, to quantify the risk associated with identified factors to inform policy and practice to improve survival.Methods and findingsWe conducted a national cohort analysis using data from two sources obtained between 2003 and 2009: the Centre for Maternal and Child Enquiries maternal deaths database and the United Kingdom Obstetric Surveillance System database. Included women had eclampsia, antenatal pulmonary embolism, amniotic fluid embolism, acute fatty liver of pregnancy or antenatal stroke. These conditions were chosen as major causes of maternal mortality and morbidity about which data were available through both sources, and include 42% of direct maternal deaths over the study period. Rates, risk ratios, crude and adjusted odd ratios were used to investigate risks factors for maternal death. Multiple imputation and sensitivity analysis were used to handle missing data. We identified 476 women who survived and 100 women who died. Maternal death was associated with older age (35+ years aOR 2.36, 95%CI 1.22-4.56), black ethnicity (aOR 2.38, 95%CI 1.15-4.92), and unemployed, routine or manual occupation (aOR 2.19, 95%CI 1.03-4.68). An association was also observed with obesity (BMI?30 kg/m(2) aOR 2.73, 95%CI 1.15-6.46).ConclusionsOngoing high quality national surveillance programmes have an important place in addressing challenges in maternal health and care. There is a place for action to reverse the rising trends in maternal age at childbirth, and to reduce the burden of obesity in pregnancy, as well as ongoing recognition of the impact of older maternal age on the risks of pregnancy. Development and evaluation of services to mitigate the risk of dying associated with black ethnicity and lower socioeconomic status is also essential.
| S-EPMC3247232 | biostudies-literature