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Background: Prehospital obstetric events, including out-of-hospital deliveries and their complications, are a rare but high-risk event encountered by emergency medical services (EMS). Understanding the epidemiology of these encounters would help identify strategies to improve prehospital obstetric care. Our objective was to determine the characteristics of out-of-hospital deliveries and high-risk complications treated by EMS clinicians in the U.S., Methods: We conducted a cross-sectional analysis of EMS patient care records in the 2018 and 2019 National EMS Information System Public Release Version 3.4 datasets. We included EMS activations after a 9-1-1 scene response for patients aged 12-50 years with evidence of an out-of-hospital delivery or delivery complication, or where the patient was a newborn aged 0-<6 h. We examined patient, community, emergency response, and clinical characteristics using descriptive statistics., Results: Of the 56,735,977 EMS activations included in the 2018 and 2019 datasets, there were 8,614 out-of-hospital deliveries, 1,712 delivery complications, and 5,749 records for newborns. Most maternal (76%) out-of-hospital deliveries involved patients between the ages of 20-34 years, occurred on a weekday (73%), were treated by an advanced life support crew (85%), and occurred in a home or residence (73%). EMS-assisted field delivery was documented in 3,515 (34%) of all maternal activations but only 2% of activations with a delivery complication. Few patients received an EMS-administered medication (e.g., 0.4% received oxytocin). Supplemental oxygen was administered in 870 (15%) of newborn activations. Activations from counties with the most racial/ethnic diversity were more often treated by a BLS-level unit (16% vs. 12%, p  < 0.001), and activations from rural areas had significantly longer transport times (19.7 min [IQR 8.7, 32.8] vs. urban, 13.1 min [IQR 8.7, 19.7], p  < 0.001)., Conclusion: In this large, national repository of EMS patient care records from across the U.S., most activations for out-of-hospital delivery, delivery complication, or a newborn included only routine EMS care. There were potential disparities in level of care, clinical care provided, and measures of access to definitive care based on maternal and community factors. We also identified gaps in current practice, such as for postpartum hemorrhage, that could be addressed with changes in EMS clinical protocols and regulations.

Background: Obstetric anal sphincter injuries are associated with both short-term and long-term maternal morbidity. Antibiotic administration has been shown to decrease wound complications after obstetric anal sphincter injuries. However, the rate of antibiotic administration in a contemporary obstetrical population is not known., Objective: This study aimed to describe the rate of antibiotic administration for obstetric anal sphincter injuries, to characterize factors associated with antibiotic administration on the day of delivery among women with obstetric anal sphincter injuries, and to determine if there was an association between antibiotic administration and reduced wound complications., Study Design: This was a retrospective cohort study of women with a singleton vaginal birth complicated by obstetric anal sphincter injuries between 2016 and 2021 in a single healthcare system. Information about any antibiotic administration on the day of delivery was collected. Information on wound complications (determined by International Classification of Disease, 10th Revision, codes) that occurred within the first 6 months postpartum were available for patients who delivered at tertiary-care centers. Multivariable logistic regression analysis was used to identify factors associated with antibiotic administration and the association between antibiotics and wound complications., Results: During the study period, 1550 women met the inclusion criteria of whom 855 (55.2%) received antibiotics. Antibiotic administration was higher at tertiary-care hospitals than at community-based hospitals (68.7 vs 26.8%; P<.001). In the adjusted analysis, antibiotic administration was higher among women with a fourth-degree laceration (adjusted odds ratio, 2.72; 95% confidence interval, 1.69-4.37) and lower among women of Asian or Pacific Islander heritage (adjusted odds ratio, 0.88; 95% confidence interval, 0.80-0.97). At tertiary-care hospitals, 43 women (4.1%) had a wound complication, and more than 80% of those presented within the first 2 weeks postpartum. Antibiotic use was associated with reduced rates of wound complications (adjusted odds ratio, 0.34; 95% confidence interval, 0.13-0.91). All patients received a regimen with gram-positive bacterial coverage; there was no association between type of antibiotic regimen administered and wound complications., Conclusion: Any antibiotic administration on the day of delivery was associated with a decreased rate of wound complications after obstetric anal sphincter injuries. However, only about half of the women with obstetric anal sphincter injuries received antibiotics. Optimizing antibiotic administration may help to reduce the risk of complications in this population., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Women can develop childbirth-related posttraumatic stress disorder (CB-PTSD) in at-term delivery with healthy baby outcome as well as following pre-term delivery and neonatal complications, a potential added stressor. No study compares risk factors of CB-PTSD associated with different infant outcomes. We investigated CB-PTSD risk factors by comparing women with or without neonatal complications. Analysis reveals the importance of antepartum and birth-related risk factors in CB-PTSD above and beyond child outcomes, suggesting childbirth is an independent stressor capable of evoking CB-PTSD., Competing Interests: Declaration of competing interest No financial or personal relationship to disclose. All authors declare no conflict of interest that can influence the study and reported results., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Importance: Unexpected complications in term newborns have been recently adopted by the Joint Commission as a marker of obstetric care quality., Objective: To understand the variation and patient and hospital factors associated with severe unexpected complications in term neonates among hospitals in the United States., Design, Setting, and Participants: This cross-sectional study collected data from all births in US counties with 1 obstetric hospital using county-identified birth certificate data and American Hospital Association annual survey data from January 1, 2015, through December 31, 2017. All live-born, term, singleton infants weighing at least 2500 g were included. The data analysis was performed from December 1, 2018, through June 30, 2019., Exposures: Severe unexpected newborn complication, defined as neonatal death, 5-minute Apgar score of 3 or less, seizure, use of assisted ventilation for at least 6 hours, or transfer to another facility., Main Outcomes and Measures: Between-hospital variation and patient and hospital factors associated with unexpected newborn complications., Results: A total of 1 754 852 births from 576 hospitals were included in the analysis. A wide range of hospital complication rates was found (range, 0.6-89.9 per 1000 births; median, 15.3 per 1000 births [interquartile range, 9.6-22.0 per 1000 births]). Hospitals with high newborn complication rates were more likely to care for younger, white, less educated, and publicly insured women with more medical comorbidities compared with hospitals with low complication rates. In the adjusted models, there was little effect of case mix to explain the observed between-county variation (11.3%; 95% CI, 10.0%-12.6%). Neonatal transfer was the primary factor associated with complication rates, especially among hospitals with the highest rates (66.0% of all complications). The risk for unexpected neonatal complication increased by more than 50% for those neonates born at hospitals without a neonatal intensive care unit compared with those with a neonatal intensive care unit (adjusted odds ratio, 1.55; 95% CI, 1.38-1.75)., Conclusions and Relevance: In this study, severe unexpected complication rates among term newborns varied widely. When included in the metric numerator, neonatal transfer was the primary factor associated with complications, especially among hospitals with the highest rates. Transfers were more likely to be necessary when infants were born in hospitals with lower levels of neonatal care. Thus, if this metric is to be used in its current form, it would appear that accreditors, regulatory bodies, and payers should consider adjusting for or stratifying by a hospital's level of neonatal care to avoid disincentivizing against appropriate transfers.

Objective: To identify the association of the Affordable Care Act's Medicaid expansion with payment for delivery, early access to prenatal care, preterm birth, and birth weights considered small for gestational age (SGA)., Methods: A difference-in-difference design was used to assess changes in outcomes before and after Medicaid expansion in expansion states, using nonexpansion states as a control group. We used national birth certificate data from 2009 to 2017. Difference-in-difference linear probability models were used to assess the effects of the policy implementation, adjusting for demographics, month of birth, state, year, and county-level unemployment rates. Standard errors were clustered at the state level. Two prespecified subgroup analyses were performed of nulliparous women and women with no more than a high school diploma., Results: The study sample included 8,701,889 women from 15 expansion states and 9,509,994 from 11 nonexpansion states. In the adjusted analysis, the percentage of Medicaid-covered deliveries increased by 2.3 absolute percentage points (95% CI 0.2-4.4, P=.04) in expansion states compared with nonexpansion states. There were no significant changes in the proportion of women who were uninsured, as there was a relative decrease in the percentage of deliveries covered by private insurance (-2.8 percentage points [95% CI -4.9 to -0.8, P=.01]). There were also no significant differences in the rate of women initiating prenatal care in the first trimester, preterm birth rates, or rates of low birth weight after the Medicaid expansion. Findings were similar in both subgroups., Conclusion: Medicaid expansion was associated with increased Medicaid coverage for childbirth in expansion states; similar gains in private coverage were seen in nonexpansion states. There were no associations with changes in early access to prenatal care, preterm birth, or SGA birth weights.

Background: In 2015, the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists published guidelines that established levels of maternal care. These guidelines outlined the nursing, provider, and facility requirements for hospitals to be designated a birthing center or 1 of 4 levels of care. To date, these levels of maternal care have not been adopted widely; currently, no data exist on how these designations may affect maternal or neonatal outcomes., Objective: Because the levels of maternal care attempt to reflect a hospital's ability to treat patients with certain conditions that are associated with increased risk of complications, our objective was to compare outcomes among high- and low-risk patients between high- and low-acuity hospitals. We hypothesized that hospitals that cared for a high rate of high-risk patients, which we considered "high-acuity" centers, would have a lower risk of severe maternal morbidity among high-risk patients compared with low-acuity centers., Study Design: Deliveries were identified in the 2013 Nationwide Readmission Database. A patient's comorbidity index was assigned based on diagnosis and procedure codes with the use of previously validated methods; a comorbidity index of ≥3 has been associated with increased odds of severe maternal morbidity. Patients were classified as low, intermediate, or high risk by their comorbidity index for analysis. Patients at hospitals with <100 deliveries per year and transferred patients were excluded. A hospital was defined as low or high-acuity if it was in the bottom or top quartile, respectively, based on its percent of patients with a comorbidity index of ≥3. Log-binomial regression models were constructed to assess the effects of a patient's comorbidity index group on the risk of severe morbidity in high- and low-acuity hospitals. The models controlled for available patient and hospital factors. The regression used patient-level data with robust standard errors that were clustered at the level of the hospital. The Wald test was used to assess for the effect modification between comorbidity index group and hospital acuity., Results: From 1203 hospitals, 1,656,659 delivering patients met the inclusion criteria. There were 58.7% low-risk, 39.0% intermediate-risk, and 2.3% high-risk patients in the overall sample, and the overall rate of severe maternal morbidity was 1.2%. Less than 3.7% of delivering patients in low-acuity hospitals had a high-risk condition. In comparison, >7.1% patients in high-acuity centers had a high-risk condition. In the adjusted analysis, intermediate-risk patients had a slightly increased risk of morbidity in both low-acuity and high-acuity centers compared with low-risk patients (adjusted risk ratios, 1.53 [95% confidence interval, 1.33-1.77] vs 1.57 [95% confidence interval, 1.49-1.65]). However, there was a notable difference in the adjusted risk ratios for severe maternal morbidity in the high-risk population: the adjusted risk ratio was 9.55 (95% confidence interval, 6.83-13.35) in low-acuity hospitals compared with 6.50 (95% confidence interval, 5.94-7.09) in high-acuity hospitals., Conclusion: High-risk patients have a higher risk of severe maternal morbidity at low-acuity hospitals compared with high-acuity centers. These findings support the concept of regionalization of maternity care to improve outcomes for high-risk patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to explore the relationship between strength of preference for vaginal delivery, delivery mode undergone, and postpartum depression., Study Design: We conducted a secondary analysis of data from a longitudinal study of delivery-mode preferences. During an interview between 24-36 weeks of gestation, participants were asked whether they preferred vaginal or cesarean delivery; the strength of this preference was measured by the standard gamble metric. Depression was assessed antepartum and at 8-10 weeks and 6-8 months after delivery by using the Patient Health Questionnaire (PHQ-9). The primary outcome was PHQ-9 score at 8-10 weeks after delivery. We used multivariable regression analysis to assess the effect of strength of preference for vaginal delivery and delivery mode undergone on postpartum depression., Results: Of 160 participants, 33.1% were nulliparous, and 30.6% had a previous cesarean delivery. Most of the participants (92.4%) preferred vaginal delivery, but the strength of preference varied substantially. The mean strength-of-preference score (0-1 scale; higher scores denote stronger vaginal delivery preference) was 0.658 (SD, ±0.352). A significant interaction emerged between the effects of delivery mode and vaginal delivery preference score on postpartum PHQ-9 score (P = .047). Specifically, a stronger preference for vaginal delivery was associated with higher PHQ-9 scores among women who underwent cesarean delivery (P = .027) but not among women who underwent vaginal delivery (P = .761). The interaction between delivery mode and vaginal delivery preference score was no longer significant at 6-8 months after delivery., Conclusion: Women who have a strong antepartum preference for vaginal delivery and deliver by cesarean may be at increased risk for depression in the early postpartum period., (Published by Elsevier Inc.)

Objective: We sought to assess the relationship between strength of preference for vaginal birth and likelihood of vaginal delivery among women attempting this delivery mode., Study Design: We conducted a longitudinal study of mode of delivery preferences among women who were <36 weeks' pregnant. Participants completed a sociodemographic and clinical questionnaire and were asked if they preferred vaginal or cesarean delivery. Participants who preferred vaginal delivery completed a standard gamble exercise to assess the strength of this preference on a 0-to-1 scale (higher scores indicate stronger preference for vaginal delivery); those preferring cesarean delivery were assigned a value of 0. Data on clinical characteristics and delivery mode were obtained via telephone interview or chart review. Logistic regression was used to identify predictors of delivery mode among women who attempted a vaginal delivery., Results: Of 210 participants, 156 attempted a vaginal delivery. Their mean and median vaginal delivery preference scores were 0.70 (SD 0.31) and 0.75 (interquartile range, 0.50-0.99), respectively. In multivariate analyses, women with a prior cesarean delivery (adjusted odds ratio [aOR], 0.08; 95% confidence interval [CI], 0.02-0.39) or who delivered an infant ≥4000 g (aOR, 0.04; 95% CI, 0.01-0.28) had significantly lower odds of having a vaginal delivery. After controlling for potential confounders, participants with a stronger preference for vaginal delivery were at significantly higher odds of having a vaginal delivery (aOR, 1.54; 95% CI, 1.01-2.34 for every 0.2 increase on the 0-to-1 scale)., Conclusion: Among women who attempt a vaginal delivery, the strength of preference for vaginal birth is predictive of the delivery mode ultimately undergone., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Objective: To determine the optimal gestational age of delivery for women with placenta previa by accounting for both neonatal and maternal outcomes., Study Design: A decision-analytic model was designed comparing total maternal and neonatal quality-adjusted life years for delivery of women with previa at gestational ages from 34 to 38 weeks. At each week, we allowed for four different delivery strategies: (1) immediate delivery, without amniocentesis or steroids; (2) delivery 48 hours after steroid administration (without amniocentesis); (3) amniocentesis with delivery if fetal lung maturity (FLM) positive or retesting in one week if FLM negative; (4) amniocentesis with delivery if FLM testing is positive or administration of steroids if FLM negative., Results: Delivery at 36 weeks, 48 hours after steroids, for women with previa optimizes maternal and neonatal outcomes. In sensitivity analyses, these results were robust to a wide range of variation in input assumptions. If it is assumed that steroids offer no neonatal benefit at this gestational age, outright delivery at 36 weeks' gestation is the best strategy., Conclusion: Steroid administration at 35 weeks and 5 days followed by delivery at 36 weeks for women with placenta previa optimizes maternal and neonatal outcomes.

Background: The rates of induction of labor and elective induction of labor are increasing. Whether elective induction of labor improves outcomes or simply leads to greater complications and health care costs is commonly debated in the literature., Purpose: To compare the benefits and harms of elective induction of labor and expectant management of pregnancy., Data Sources: MEDLINE (through February 2009), Web of Science, CINAHL, Cochrane Central Register of Controlled Trials (through March 2009), bibliographies of included studies, and previous systematic reviews., Study Selection: Experimental and observational studies of elective induction of labor reported in English., Data Extraction: Two authors abstracted study design; patient characteristics; quality criteria; and outcomes, including cesarean delivery and maternal and neonatal morbidity., Data Synthesis: Of 6117 potentially relevant articles, 36 met inclusion criteria: 11 randomized, controlled trials (RCTs) and 25 observational studies. Overall, expectant management of pregnancy was associated with a higher odds ratio (OR) of cesarean delivery than was elective induction of labor (OR, 1.22 [95% CI, 1.07 to 1.39]; absolute risk difference, 1.9 percentage points [CI, 0.2 to 3.7 percentage points]) in 9 RCTs. Women at or beyond 41 completed weeks of gestation who were managed expectantly had a higher risk for cesarean delivery (OR, 1.21 [CI, 1.01 to 1.46]), but this difference was not statistically significant in women at less than 41 completed weeks of gestation (OR, 1.73 [CI, 0.67 to 4.5]). Women who were expectantly managed were more likely to have meconium-stained amniotic fluid than those who were electively induced (OR, 2.04 [CI, 1.34 to 3.09])., Limitations: There were no recent RCTs of elective induction of labor at less than 41 weeks of gestation. The 2 studies conducted at less than 41 weeks of gestation were of poor quality and were not generalizable to current practice., Conclusion: RCTs suggest that elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid. There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided.