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The International Classification of Diseases , 10th Revision, Clinical Modification (ICD-10-CM) introduced diagnosis codes for week of gestation. Our objective was to assess the validity of these codes among live births, which could have major utility in perinatal research and quality improvement.We used linked birth certificate and patient discharge data from births in California during 2016-2019 (N = 1,843,992). We identified gestational age using Z3A.xx ICD-10-CM diagnosis codes in birthing patient discharge data and compared it with the gold standard of obstetric estimate, as recorded on the birth certificate. We further assessed sensitivity and specificity of gestational age categories (≥37 weeks,37 weeks,32 weeks,28 weeks), given these categories are frequently of interest, and evaluated differences in validity of preterm birth (37 weeks' gestation) by patient characteristics.One-million seven-hundred seventy-thousand one-hundred three patients had a gestational age recorded in patient discharge and birth certificate data. When comparing gestational age in patient discharge data with birth certificate data, the concordance correlation coefficient was 0.96 (95% confidence interval [CI] = 0.96, 0.96) and the mean difference between the two measurements was 0.047 weeks (95% CI = 0.046, 0.047 weeks). Ninety-five percent of the differences between the two measurements were between -1.00 week and +1.09 weeks. Sensitivity and specificity were 0.94 to 1.00 for all gestational age categories and were 0.94 to 1.00 for preterm birth across sociodemographic groups.We found week-specific gestational age at delivery ICD-10-CM diagnosis codes in patient discharge data to have high validity when compared with the best obstetric estimate on the birth certificate.

INTRODUCTION: The objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases. METHODS: California linked birth certificate-patient discharge data for 2009-2011 (N=1,262,862) with complete costs and LOS were used in a secondary data analysis. Cost-to-charge ratios were used to estimate costs from charges, adjusting for inflation. Physician payments were estimated from mean payments for specific diagnosis related groups. Generalized linear models estimated the association between SMM and costs and LOS. RESULTS: Excluding readmissions and physician costs, SMM was associated with a 60% increase in hospital costs (marginal effect (ME) $3,550) and 33% increase in LOS (ME 0.9 days). These increased to 70% (ME $5,806) and 46% (ME 1.3 days) when physican costs and readmissions were included. The effects of SMM were roughly half as large for patients who only required a blood transfusion (49%, ME $4,056 and 31%, ME 0.9 days) as for patients who had another indicator for SMM (93%, ME $7,664 and 62%, ME 1.7 days). CONCLUSIONS: Postpartum hospital readmissions and physician costs are important and previously unreported contributors to the costs of SMM. Excess costs and LOS associated with SMM vary considerably by indication. Cost effects were larger than the LOS effects, indicating that SMM increases treatment intensity beyond increasing LOS, and reducing SMM may have broader health and cost benefits than previously understood.

To examine the association between severe maternal morbidity (SMM) and infant health using the additional infant costs and length of stay (LOS) as markers of added clinical complexity.Secondary data analysis using California linked birth certificate-patient discharge data for 2009-2011 (N = 1,260,457). Regression models were used to estimate the association between SMM and infant costs and LOS.The 16,687 SMM-exposed infants experienced a $6550 (33%) increase in costs and a 0.7 (18%) day increase in LOS. Preterm infants had ($11,258 (18%) added costs and 1.3 days (8.1%) longer LOS) than term infants ($2539 (38%) added costs and 0.5 days (22%) longer LOS).SMM was associated with increased infant costs and LOS, suggesting that SMM may have adverse health effects for infants, including term infants. The relatively larger effect on costs indicates an increase in treatment intensity (clinical severity) greater than additional LOS.

Perinatal Quality Collaboratives (PQCs) are now present in nearly all states and provide important tools and strategies for improving maternal outcomes. State PQCs can focus their strengths to address rural maternal health challenges using support groups of rural hospitals, of tertiary facilities that network with them, and of other PQCs to share best practices for rural hospitals to: (1) Support networks of care and telehealth; (2) Support remote education and training; (3) Implement rural appropriate versions of National Safety Bundles; (4) Engage and support providers beyond obstetricians; and (5) Engage community members and resources.

PURPOSE: Large-scale efforts to reduce cesarean deliveries have shown varied levels of impact; yet understanding factors that contribute to hospitals’ success are lacking. We aimed to characterize unit culture differences at hospitals that successfully reduced their cesarean rates compared with those that did not. METHODS: A mixed methods study of California hospitals participating in a statewide initiative to reduce cesarean delivery. Participants included nurses, obstetricians, family physicians, midwives, and anesthesiologists practicing at participating hospitals. Hospitals’ net change in nulliparous, term, singleton, and vertex cesarean delivery rates classified them as successful if they achieved either a minimum 5 percentage point reduction or rate of fewer than 24%. The Labor Culture Survey was used to quantify differences in unit culture. Key informant interviews were used to explore quantitative findings and characterize additional cultural barriers and facilitators. RESULTS: Out of 55 hospitals, 37 (n = 840 clinicians) meeting inclusion criteria participated in the Labor Culture Survey. Physicians’ individual attitudes differed by hospital success on 5 scales: best practices (P = .003), fear (P = .001), cesarean safety (P = .014), physician oversight (P

Background Rates of maternal mortality and severe maternal morbidity (SMM) are higher in the United States than in other high-resource countries and are increasing further. Objective To examine the association of maternal comorbid conditions, age, body mass index, and previous cesarean birth with occurrence of SMM. Design Population-based cohort study using linked delivery hospitalization discharge data and vital records. Setting California, 1997 to 2014. Patients All 9 179 472 mothers delivering in California during 1997 to 2014. Measurements SMM rate, total and without transfusion-only cases; 2019 maternal comorbidity index. Results Total SMM increased by 160% during this time, and SMM excluding transfusion-only cases increased by 53%. Medical comorbid conditions were associated with an increasing portion of SMM occurrences. Medical comorbid conditions increased over the study period by 111%, and obstetric comorbid conditions increased by 30% to 40%. Identified medical comorbid conditions had high relative risks ranging from 1.3 to 14.3 for total SMM and even higher relative risks for nontransfusion SMM (to 32.4). The obstetric comorbidity index that is most often used may be undervaluing the degree of association with SMM. Limitations Hospital discharge diagnosis files and birth certificate records can have misclassifications and may not include all relevant clinical data or social determinants. The period for analysis ended in 2014 to avoid the transition to the International Classification of Diseases, 10th Revision, Clinical Modification, and therefore missed more recent years. Conclusion Obstetric and, particularly, medical comorbid conditions are increasing among women who develop SMM. The maternal comorbidity index is a promising tool for patient risk assessment and case-mix adjustment, but refinement of factor weights may be indicated. Primary funding source National Institutes of Health.

OBJECTIVE To evaluate the use of administrative data for identification of labor induction and to estimate the variation in cesarean delivery rates among low-risk women who underwent labor induction. METHODS A cross-sectional study was performed examining live births in California hospitals during 2016 and 2017 using birth certificate data linked with maternal patient discharge records. Initially, eight hospitals performed medical record reviews by using reVITALize definitions on 46,916 deliveries to assess the validity of induction identification by birth certificate or discharge diagnosis records or both. Hospital-level variation in cesarean delivery rates was then assessed among all California hospitals for women with low-obstetric-risk first births before and after further risk adjustment and after the exclusion of potential medical and obstetric indications for induction. Variation in physician-level cesarean delivery rates after induction at four large hospitals also was examined. The relationships between cesarean delivery rates among women with induced labors compared with noninduced labors and with the hospital rate of induction also were explored. RESULTS Identifying induction by a combination of discharge diagnosis codes and birth certificate data had the highest accuracy (92.9%, 95% CI 92.7-93.2). Among 917,225 births at 238 birthing hospitals, there were 99,441 nulliparous women with term, singleton, vertex pregnancies who were induced. The median cesarean delivery rate after labor induction for nulliparous women with term, singleton, vertex pregnancies was 32.2%, with a range of 18.5-84.6%. This wide variation was not reduced after risk adjustment or after exclusion of all women with induction indications. A similar wide variation was noted within geographic regions, neonatal intensive care levels, and among individual physicians in the same facility. Only very weak associations were found for the cesarean delivery rate after labor induction and either the rate after noninduced labor (R

Objective To assess whether there is a relationship between evening, night, and weekend births and severe unexpected neonatal morbidity in low-risk term singleton births. Methods We conducted a population-based, cross-sectional analysis. Severe unexpected neonatal morbidity as defined by the National Quality Forum specification 0716 was derived from linked birth certificate and hospital discharge summaries for 1,048,957 low-risk singleton term Californian births during 2011 through 2013. The association between the nursing shift (7 am-3 pm vs 3-11 pm and 11 pm -7 am) and weekday compared with weekend birth and the risk of severe unexpected neonatal morbidity was estimated using mixed effects logistic regression models. Results Severe unexpected neonatal morbidity was higher among births during the 3-11 pm evening shift (2.1%) and the 11 pm-7 am night shift (2.1%), compared with those during the 7 am-3 pm day shift (1.8%). The adjusted odds ratios (ORs) were 1.10 (95% CI 1.06-1.13) for the evening shift and 1.15 (1.11-1.19) for the night shift. The adjusted ORs of severe unexpected neonatal morbidity were increased only on Sunday, as compared with other days (adjusted OR 1.08, 95% CI 1.02-1.14). When our analysis was by perinatal region, the increase was seen in four of the nine perinatal regions. Conclusion After risk adjustment, the risk of severe unexpected morbidity in the low-risk singleton California birth cohort was significantly increased on Sundays and births during evening and night shifts. These elevations were detected in only four of California's nine perinatal regions. Further analysis at the individual hospital level is warranted.

To estimate racial and ethnic differences in rates of hospital-based care associated with postpartum depression. This is a retrospective cohort study using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes within data from the Office of Statewide Planning and Development in California. We included primiparous women who underwent delivery hospitalization from 2008 to 2012. The primary outcome was the first postpartum hospital encounter with a ICD-9-CM code for depression over a 9-month period after delivery. We examined the cumulative incidence of hospital-based care for postpartum depression by race/ethnicity. Logistic regression was used to estimate relative risk. The study cohort consisted of 984,167 primiparous women: 314,037 (32%) were non-Hispanic White; 59,754 (6%) were non-Hispanic Black; 150,855 (15%) were non-Hispanic Asian; 448,770 (46%) were Hispanic; and 10,399 (1%) were other races. The cumulative incidence of hospital-based care for postpartum depression was highest for Black women (39; 95% CI = 34–44 per 10,000 deliveries) and lowest for Asian women (7; 95% CI = 5–8 per 10,000 deliveries). Compared with White women, hospital-based care for postpartum depression was more likely to be provided to Black women (OR = 2.3; 95% CI = 1.9–2.7), whereas care was less likely for Asians (OR = 0.4; 95% CI = 0.3–0.5) and Hispanics (OR = 0.8; 95% CI = 0.7–1.0). Similar findings were observed after excluding women with antepartum depression, adjusting for sociodemographic and clinical variables, and stratifying according to care settings. Compared with White women, hospital-based care for postpartum depression more frequently impacts Black women. Identifying and improving inequities in access to and utilization of mental health care for postpartum women should be a maternal health priority.

Severe hypertension in pregnancy is a medical emergency. Although expeditious treatment within 30 to 60 minutes is recommended to reduce the risk of maternal death or severe morbidity, treatment is often delayed by more than 1 hour. In this statement, we propose a quality metric that facilities can use to track their rates of timely treatment of severe hypertension. We encourage facilities to adopt this metric so that future reports from different facilities will be based on a uniform definition of timely treatment.

What are the key features of hospitals that consistently deliver safe care on labour and delivery? This is the primary question posed by Liberati and colleagues in this issue of BMJ Quality & Safety .1 The authors propose a framework distilled from observations on a group of high-performing units in the UK participating in a training activity to improve patient safety. This study combined ethnography with individual interviews and focus groups and involved over 400 hours of total observations at six different maternity care sites. The seven features in their resulting For Us framework correspond well to existing theoretical as well as applied quality improvement strategies. While we agree that their framework describes features that every labour and delivery unit should strive to include, this approach has some limitations in terms of generalisability. Specifically, Liberati and colleagues studied maternity units that are high performing, but their sample included only large-volume hospitals in what appear to be well-resourced settings. What is potentially missing is observations on underperforming units, and how these findings may or may not apply to smaller, lower resourced settings. Additionally, the structure of the UK’s National Health Service (NHS) also limits generalisability. For example, this is most analogous to employed physician models in the USA, with the potential advantage of a more organisationally oriented provider workforce. Given that most US hospitals do not have an employed provider model, we can’t assume that these factors will have the same impact in other models of care. In the USA, the Agency for Healthcare Research and Quality (AHRQ) developed a Culture of Safety framework that delineates four key features: (1) organisations recognise that their primary activities are inherently high risk and make it their goal to operate in a reliably safe manner; (2) organisations create a safe and blame-free reporting …

The experience of childbirth and its outcomes in the United States varies by race: Black and Hispanic infants face higher risks of neonatal morbidity and mortality even after accounting for clinical risk. Although perinatal disparities are rooted in a complex set of causes, there is increasing recognition that differential quality of care contributes to disparities.1–3 This has been most clearly demonstrated among preterm infants receiving care in the NICU. Minority infants and families are more likely to receive care in poor quality NICUs3,4 and within a NICU are more likely to receive worse care.1 In this issue of Pediatrics , Glazer et al5 found that in New York City, compared with white infants, Black and Hispanic term infants had increased risk of complications. The study confirms the grim reality of racial and ethnic disparities in infant outcomes in a low-risk population that accounts for 90% of all births. Disparities within individual hospitals were attenuated when adjusted for sociodemographic factors. However, the disparities measured across hospitals were significant. Prevalence of complications differed by race and ethnicity and by hospital. Infection rates demonstrated the widest variation: a sixfold difference between highest- and lowest-performing tertile of hospitals. Although other factors, such as data validity, case mix, and obstetric and neonatal practice variation may account for observed disparities between hospitals, and further investigation into underlying drivers of disparity is needed, this study adds to a growing body … Address correspondence to Ravi Dhurjati, PhD, Perinatal Health Systems, Department of Pediatrics, School of Medicine, Stanford University, 1265 Welch Rd, x1C31, Stanford CA 94035-5415. E-mail: dhurjati{at}stanford.edu

Surveillance of severe maternal morbidity (SMM) is critical for monitoring maternal health and evaluating clinical quality improvement efforts.To evaluate national and state trends in SMM rates from 2012 to 2019 and potential disruptions associated with the transition to International Classification of Diseases, 10th Revision, Clinical Modification and Procedure Coding System (ICD-10-CM/PCS) in October 2015.This repeated cross-sectional analysis examined delivery hospitalizations from 2012 through 2019 in the Healthcare Cost and Utilization Project's National Inpatient Sample and State Inpatient Databases, an all-payer compendium of hospital discharge records from community, nonrehabilitation hospitals. Trends were evaluated using segmented linear binomial regression models that allowed for discontinuities across the ICD-10-CM/PCS transition. Analyses were completed from April 2021 through March 2022.Time, ICD-10-CM/PCS coding system, and state.SMM rates, excluding blood transfusion, per 10 000 delivery hospitalizations, overall and by indicator.From 2012 to 2019, there were 5 964 315 delivery hospitalizations in the national sample representing a weighted total of 29.8 million deliveries with a mean (SD) maternal age of 28.6 (5.9) years. SMM rates increased from 69.5 per 10 000 in 2012 to 79.7 per 10 000 in 2019 (rate difference [RD], 10.2; 95% CI, 5.8 to 14.6) without a significant change across the ICD-10-CM/PCS transition (RD, -3.2; 95% CI, -6.9 to 0.6). Of 20 SMM indicators, rates for 10 indicators significantly increased while 3 significantly decreased; 5 of these changes were associated with ICD-10-CM/PCS transition. Acute kidney failure had the largest increase, from 6.4 to 15.3 per 10 000 delivery hospitalizations (RD, 8.9; 95% CI, 7.5 to 10.3) with no change associated with ICD transition (RD, -0.1; 95% CI, -1.2 to 1.1). Disseminated intravascular coagulation had the largest decrease from 31.3 to 21.2 per 10 000 (RD, 10.2; 95% CI, -12.8 to -7.5), with a significant drop associated with ICD transition (RD, -7.9; 95% CI, -10.2 to -5.6). State SMM rates significantly decreased for 1 state and significantly increased for 21 states from 2012 to 2019 and associations with ICD transition varied.In this cross-sectional study, overall US SMM rates increased from 2012 to 2019, which was not associated with the ICD-10-CM/PCS transition. However, data for certain indicators and states may not be comparable across coding systems; efforts are needed to understand SMM increases and state variation.

Sexual and/or gender minority people account for roughly 7.1% of the US population, and an estimated one-third are parents. Little is known about sexual and/or gender minority people who become pregnant, despite this population having documented healthcare disparities that may affect pregnancy.Our objective was to describe parental structures among birth parents and the prepregnancy characteristics of parents giving birth in likely sexual and/or gender minority parental structures from California birth certificates.We conducted a population-based study using birth certificate data from all live births in California from 2016 through 2020 (n=2,257,974). The state amended its birth certificate in 2016 to enable the recording of more diverse parental roles. Now, parents on birth certificates are classified as "parent giving birth" and "parent not giving birth" and people in either role can identify as "mother," "father," or "parent." We examined all potential combinations of parenting roles, and grouped parental structures of "mother-mother" and those designating a "father" as the "parent giving birth" into likely sexual and/or gender minority groups. We assessed the distribution of prepregnancy characteristics across parental structure groups ("mother-father," "sexual and/or gender minority," "mother only," "unclassified," and "missing both parental roles").Sexual and/or gender minority parents accounted for 6802 (0.3%) of live births in California over the 5-year study period. The most common sexual and/or gender minority parental structures were "mother-mother" (n=4310; 63% of the group) and "father-father" (n=1486; 22% of the group). Compared with "parents giving birth" in the "mother-father" structure (n=2,055,038; 91%), a higher proportion of "parents giving birth" in the "sexual and/or gender minority" group were aged ≥35 years, White, college-educated, and had commercial health insurance. In addition, a higher proportion had a high prepregnancy body mass index. Although likely underreported overall, the proportion of those who used assisted reproductive technology was much higher in the "sexual and/or gender minority" group (1.4%) than in the "mother-father" group (0.05%). Cigarette smoking in the 3 months before pregnancy was similar in both groups.Changes to the California birth certificate have revealed a multiplicity of parental structures. Our findings suggest that sexual and/or gender minority parents differ from other parental structures and from the general sexual and/or gender minority population and warrant further research.

Importance: Safe reduction of the cesarean delivery rate is a national priority. Objective: To evaluate the rates of cesarean delivery for nulliparous, term, singleton, vertex (NTSV) births in California in the context of a statewide multifaceted intervention designed to reduce the rates of cesarean delivery. Design, Setting, and Participants: Observational study of cesarean delivery rates from 2014 to 2019 among 7 574 889 NTSV births in the US and at 238 nonmilitary hospitals providing maternity services in California. From 2016 to 2019, California Maternal Quality Care Collaborative partnered with Smart Care California to implement multiple approaches to decrease the rates of cesarean delivery. Hospitals with rates of cesarean delivery greater than 23.9% for NTSV births were invited to join 1 of 3 cohorts for an 18-month quality improvement collaborative between July 2016 and June 2019. Exposures: Within the collaborative, multidisciplinary teams implemented multiple strategies supported by mentorship, shared learning, and rapid-cycle data feedback. Partnerships among nonprofit organizations, state governmental agencies, purchasers, and health plans addressed the external environment through transparency, award programs, and incentives. Main Outcomes and Measures: The primary outcome was the change in cesarean delivery rates for NTSV births in California and a difference-in-differences analysis was performed to compare cesarean delivery rates for NTSV births in California vs the rates in the rest of the US. A mixed multivariable logistic regression model that adjusted for patient-level and hospital-level confounders also was used to assess the collaborative and the external statewide actions. The cesarean delivery rates for NTSV births at hospitals participating in the collaborative were compared with the rates from the nonparticipating hospitals and the rates in the participating hospitals prior to participation in the collaborative. Results: A total of 7 574 889 NTSV births occurred in the US from 2014 to 2019, of which 914 283 were at 238 hospitals in California. All California hospitals were exposed to the statewide actions to reduce the rates of cesarean delivery, including the 149 hospitals that had baseline rates of cesarean delivery greater than 23.9% for NTSV births, of which 91 (61%) participated in the quality improvement collaborative. The rate of cesarean delivery for NTSV births in California decreased from 26.0% (95% CI, 25.8%-26.2%) in 2014 to 22.8% (95% CI, 22.6%-23.1%) in 2019 (relative risk, 0.88; 95% CI, 0.87-0.89). The rate of cesarean delivery for NTSV births in the US (excluding California births) was 26.0% in both 2014 and 2019 (relative risk, 1.00; 95% CI, 0.996-1.005). The difference-in-differences analysis revealed that the reduction in the rate of cesarean delivery for NTSV births in California was 3.2% (95% CI, 1.7%-3.5%) higher than in the US (excluding California). Compared with the hospitals and the periods not exposed to the collaborative activities, and after adjusting for patient characteristics and time using a modified stepped-wedge analysis, exposure to collaborative activities was associated with a lower odds of cesarean delivery for NTSV births (24.4% vs 24.6%; adjusted odds ratio, 0.87 [95% CI, 0.85-0.89]). Conclusions and Relevance: In this observational study of NTSV births in California from 2014 to 2019, the rates of cesarean delivery decreased over time in the setting of the implementation of a coordinated hospital-level collaborative and statewide initiatives designed to support vaginal birth.

INTRODUCTION Despite evidence supporting the safety of low-interventional approaches to intrapartum care, defined by the American College of Obstetricians and Gynecologists as "practices that facilitate a physiologic labor process and minimize intervention," little is known about how frequently such practices are utilized. We examined hospital use of low-interventional practices, as well as variation in utilization across hospitals. METHODS Data came from 185 California hospitals completing a survey of intrapartum care, including 9 questions indicating use of low- versus high-interventional practices (eg, use of intermittent auscultation, nonpharmacologic pain relief, and admission of women in latent labor). We performed a group-based latent class analysis to identify distinct groups of hospitals exhibiting different levels of utilization on these 9 measures. Multivariable logistic regression identified institutional characteristics associated with a hospital's likelihood of using low-interventional practices. Procedure rates and patient outcomes were compared between the hospital groups using bivariate analysis. RESULTS We identified 2 distinct groups of hospitals that tended to use low-interventional (n = 44, 23.8%) and high-interventional (n = 141, 76.2%) practices, respectively. Hospitals more likely to use low-interventional practices included those with midwife-led or physician-midwife collaborative labor management (adjusted odds ratio [aOR], 7.52; 95% CI, 2.53-22.37; P < .001) and those in rural locations (aOR, 3.73; 95% CI, 1.03-13.60; P = .04). Hospitals with a higher proportion of women covered by Medicaid or other safety-net programs were less likely to use low-interventional practices (aOR, 0.96; 95% CI, 0.93-0.99; P = .004), as were hospitals in counties with higher medical liability insurance premiums (aOR, 0.53; 95% CI, 0.33-0.85; P = .008). Hospitals in the low-intervention group had comparable rates of severe maternal and newborn morbidities but lower rates of cesarean birth and episiotomy compared with hospitals in the high-intervention group. DISCUSSION Only one-quarter of hospitals used low-interventional practices. Attention to hospital culture of care, incorporating the midwifery model of care, and addressing medical-legal concerns may help promote utilization of low-interventional intrapartum practices.

OBJECTIVE:To describe the clinical characteristics of stroke and opportunities to improve care in a cohort of preeclampsia-related maternal mortalities in California.METHODS:The California Pregnancy-Associated Mortality Review retrospectively examined a cohort of preeclampsia pregnancy-related death

Creating change at scale within a short time frame poses multiple challenges. Using the experience of the California Maternal Quality Care Collaborative, the authors illustrate how state perinatal quality collaboratives have been able to achieve this goal using a series of key steps: engage as many disciplines and partner organizations as possible; mobilize low-burden data to create a rapid-cycle data center to support the quality improvement efforts; provide up-to-date guidance for implementation using safety bundles and tool kits; and make available coaching and peer learning to support implementation through multihospital quality collaboratives. There are now multiple national resources available to support these efforts.

Objective To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from obstetric hemorrhage by the California Pregnancy-Associated Mortality Review Committee. Design Qualitative descriptive using thematic analysis. Sample A total of 159 QIOs identified from 33 cases of pregnancy-related deaths from obstetric hemorrhage in California from 2002 to 2007. Methods We coded and thematically organized the 159 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. Results Thematic findings indicated that facility Readiness would be improved through practice standardization, better organization of equipment to treat hemorrhage, and planning for care of women with risk factors for hemorrhage. Recognition of hemorrhage by health care providers could be improved through accurate assessment of blood loss, risk factors, and early clinical signs of deterioration. Provider Response could be improved through reducing delays in administering blood, seeking consultations, transferring women to higher levels of care within or outside of the facility, and moving on to other treatments if a woman does not respond to current treatment. Conclusion Hemorrhage is the most preventable cause of maternal death in California. Morbidity and mortality from hemorrhage can be prevented if birth facilities and maternity care clinicians align local practices with national safety guidelines.

Purpose Racial/ethnic disparities in severe maternal morbidity (SMM) are substantial, but little is known about whether these disparities are changing over time or the role of maternal and obstetric factors. Methods We examined disparities in SMM prevalence and trends using linked birth certificate and delivery discharge records from Californian births during 1997–2014 (n = 8,252,025). Results The prevalence of SMM was highest in non-Hispanic (NH) Black women (1.63%), lowest in NH White women (0.84%), and increased from 1997 to 2014 by approximately 170% in each racial/ethnic group. The magnitude of SMM disparities remained consistent over time. Compared with NH White women, the adjusted risk of SMM was higher in women who identified as Hispanic (RR 1.14; 95% CI 1.12, 1.16), Asian/Pacific Islander (RR 1.23; 95% CI 1.20, 1.26), NH Black (RR 1.27; 95% CI 1.23, 1.31), and American Indian/Alaska Native (RR 1.29; 95% CI 1.15, 1.44), accounting for comorbidities, anemia, cesarean birth, and other maternal characteristics. Conclusions The prevalence of SMM varied considerably by race/ethnicity but increased at similarly high rates among all racial/ethnic groups. Comorbidities, cesarean birth, and other factors did not fully explain the disparities in SMM, which remained persistent over time.

Objective To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from venous thromboembolism (VTE) by the California Pregnancy-Associated Mortality Review Committee. Design Qualitative, descriptive design using thematic analysis. Sample A total of 108 QIOs identified from 29 cases of pregnancy-related deaths from VTE in California from 2002 to 2007. Methods We coded and thematically organized the 108 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. Results Women's lack of awareness of the significance of severe VTE symptoms and the lack of a standardized approach to recognize and respond to VTE signs and symptoms were the most prevalent themes in the Readiness domain. Missing the signs and symptoms of VTE and the resultant missed or delayed diagnosis were predominant themes in the Recognition domain. For Response, issues related to lack of VTE prophylaxis were most frequently noted, along with other themes, including timing of treatment and appropriate follow-up after hospital discharge. Conclusion To decrease the occurrence of maternal death from VTE in the United States, consistent and thorough education regarding VTE signs and symptoms must be given to all women and their families during pregnancy and the postpartum period. Maternity care facilities and providers should implement preventive measures, including standardized use of VTE prophylaxis, improved methods to recognize the signs and symptoms of VTE, and improved follow-up after hospital discharge.

Objective To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from sepsis by the California Pregnancy-Associated Mortality Review Committee. Design Qualitative descriptive design using thematic analysis. Sample A total of 118 QIOs identified from 27 cases of pregnancy-related deaths from sepsis in California from 2002 to 2007. Methods We coded and thematically organized the 118 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. Results Women's delay in seeking care was the central theme in the Readiness domain. In the Recognition domain, health care providers missed the signs and symptoms of sepsis, including elevated temperature, elevated white blood cell count, increased heart rate, decreased blood pressure, mottled skin, preterm labor, headache, and pain. For Response, late antibiotic administration was a central theme; multiple emergent themes included administration of the wrong antibiotics, failure to investigate women's complaints of pain, lack of nurse/provider communication, and lack of follow-up care after hospital discharge. Conclusion To reverse the contribution of sepsis to the rising rate of maternal mortality in the United States, health care facilities and providers need to reduce barriers for women who seek care, recognize early symptoms, and respond with appropriate treatment. This could be achieved by implementation of the Maternal Early Warning Criteria, standardized guidelines such as those from the Surviving Sepsis campaign, and comprehensive discharge education.

To evaluate maternal and neonatal safety measures in a large-scale quality improvement program associated with reductions in nulliparous, term, singleton, vertex cesarean delivery rates.This is a cross-sectional study of the 2015-2017 California Maternal Quality Care Collaborative (CMQCC) statewide collaborative to support vaginal birth and reduce primary cesarean delivery. Hospitals with nulliparous, term, singleton, vertex cesarean delivery rates greater than 23.9% were solicited to join. Fifty-six hospitals with more than 119,000 annual births participated; 87.5% were community facilities. Safety measures were derived using data collected as part of routine care and submitted monthly to CMQCC: birth certificates, maternal and neonatal discharge diagnosis and procedure files, and selected clinical data elements submitted as supplemental data files. Maternal measures included chorioamnionitis, blood transfusions, third- or fourth-degree lacerations, and operative vaginal delivery. Neonatal measures included the severe unexpected newborn complications metric and 5-minute Apgar scores less than 5. Mixed-effect multivariable logistic regression model was used to calculate odds ratios (Ors) and 95% CIs.Among collaborative hospitals, the nulliparous, term, singleton, vertex cesarean delivery rate fell from 29.3% in 2015 to 25.0% in 2017 (2017 vs 2015 adjusted OR [aOR] 0.76, 95% CI 0.73-0.78). None of the six safety measures showed any difference comparing 2017 to 2015. As a sensitivity analysis, we examined the tercile of hospitals with the greatest decline (31.2%-20.6%, 2017 vs 2015 aOR 0.54, 95% CI 0.50-0.58) to evaluate whether they had greater risk of poor maternal and neonatal outcomes. Again, no measure was statistically worse, and the severe unexpected newborn complications composite actually declined (3.2%-2.2%, aOR 0.71, 95% CI 0.55-0.92).Mothers and neonates participating in a large-scale Supporting Vaginal Birth collaborative had no evidence of worsened birth outcomes, even in hospitals with large cesarean delivery rate reductions, supporting the safety of efforts to reduce primary cesarean delivery using American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine guidelines and enhanced labor support.

Objective To assess hospital unit culture and clinician attitudes associated with varying rates of primary cesarean delivery. Data Sources/Study Setting Intrapartum nurses, midwives, and physicians recruited from 79 hospitals in California participating in efforts to reduce cesarean overuse. Study Design Labor unit culture and clinician attitudes measured using a survey were linked to the California Maternal Data Center for birth outcomes and hospital covariates. Methods Association with primary cesarean delivery rates was assessed using multivariate Poisson regression adjusted for hospital covariates. Principal Findings 1718 respondents from 70 hospitals responded to the Labor Culture Survey. The “Unit Microculture” subscale was strongly associated with primary cesarean rate; the higher a unit scored on 8‐items describing a culture supportive of vaginal birth (eg, nurses are encouraged to spend time in rooms with patients, and doulas are welcomed), the cesarean rate decreased by 41 percent (95% CI = −47 to −35 percent, P

Background Severe maternal morbidity – life-threatening childbirth complications – has more than doubled in the United States over the past 15 years, affecting more than 50,000 women (1.4% of deliveries) annually. During this time period, maternal age, obesity, comorbidities, and cesarean delivery also increased and may be related to the rise in severe maternal morbidity. We sought to evaluate: (1) the association of advanced maternal age, pre-pregnancy obesity, pre-pregnancy comorbidities, and cesarean delivery with severe maternal morbidity, and (2) whether changes in the prevalence of these risk factors affected the trend of severe maternal morbidity. Methods This population-based cohort study used linked birth record and patient discharge data from live births in California during 2007–2014 (n = 3,556,206). We used multivariable logistic regression models to assess the association of advanced maternal age (≥35 years), pre-pregnancy obesity (body mass index ≥30 kg/m2), pre-pregnancy comorbidity (index of 12 conditions), and cesarean delivery with severe maternal morbidity prevalence and trends. Severe maternal morbidity was identified by an index of 18 diagnosis and procedure indicators. We estimated odds ratios, predicted prevalence, and population attributable risk percentages. Results The prevalence of severe maternal morbidity increased by 65% during 2007–2014. Advanced maternal age, pre-pregnancy obesity, and pre-pregnancy comorbidity also increased during this period, but cesarean delivery did not. None of these risk factors affected the increasing trend of severe maternal morbidity. However, the pre-pregnancy risk factors together were estimated to contribute to 13% (95% confidence interval: 12, 14%) of severe maternal morbidity cases in the study population overall, and cesarean delivery was estimated to contribute to 37% (95% confidence interval: 36, 38%) of cases. Conclusions Pre-pregnancy health and cesarean delivery are important risk factors for severe maternal morbidity but do not explain an increasing trend of severe maternal morbidity in California during 2007–2014. Investigation of other potential contributors is needed in order to identify ways to reverse the trend of severe maternal morbidity. Electronic supplementary material The online version of this article (10.1186/s12884-018-2169-3) contains supplementary material, which is available to authorized users.

Many sexual and/or gender minority individuals build families through pregnancy and childbirth, but it is unknown whether they experience different clinical outcomes than those who are not sexual and/or gender minority individuals.To evaluate obstetrical and birth outcomes comparing couples who are likely sexual and/or gender minority patients compared with those who are not likely to be sexual and/or gender minority patients.We performed a population-based cohort study of live birth hospitalizations during 2016 to 2019 linked to birth certificates in California. California changed its birth certificate in 2016 to include gender-neutral fields such as "parent giving birth" and "parent not giving birth," with options for each role to specify "mother," "father," or "parent." We classified birthing patients in mother-mother partnerships and those who identified as a father in any partnership as likely sexual and/or gender minority and classified birthing patients in mother-father partnerships as likely not sexual and/or gender minority. We used multivariable modified Poisson regression models to estimate the risk ratios for associations between likely sexual and/or gender minority parental structures and outcomes. The models were adjusted for sociodemographic factors, comorbidities, and multifetal gestation selected by causal diagrams. We replicated the analyses after excluding multifetal gestations.In the final birthing patient sample, 1,483,119 were mothers with father partners, 2572 were mothers with mother partners, and 498 were fathers with any partner. Compared with birthing patients in mother-father partnerships, birthing patients in mother-mother partnerships experienced significantly higher rates of multifetal gestation (adjusted risk ratio, 3.9; 95% confidence interval, 3.4-4.4), labor induction (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3), postpartum hemorrhage (adjusted risk ratio, 1.4; 95% confidence interval, 1.3-1.6), severe morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.2-1.8), and nontransfusion severe morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.1-1.9). Severe morbidity was identified following the Centers for Disease Control and Prevention "severe maternal morbidity" index. Gestational diabetes mellitus, hypertensive disorders of pregnancy, cesarean delivery, preterm birth (37 weeks' gestation), low birthweight (2500 g), and low Apgar score (7 at 5 minutes) did not significantly differ in the multivariable analyses. No outcomes significantly differed between father birthing patients in any partnership and birthing patients in mother-father partnerships in either crude or multivariable analyses, though the risk of multifetal gestation was nonsignificantly higher (adjusted risk ratio, 1.5; 95% confidence interval, 0.9-2.7). The adjusted risk ratios for the outcomes were similar after restriction to singleton gestations.Birthing mothers with mother partners experienced disparities in several obstetrical and birth outcomes independent of sociodemographic factors, comorbidities, and multifetal gestation. Birthing fathers in any partnership were not at a significantly elevated risk of any adverse obstetrical or birth outcome considered in this study.

Background Cesarean delivery rates in the United States vary widely between hospitals, which cannot be fully explained by hospital or patient factors. Cultural factors are hypothesized to play a role in cesarean overuse, yet tools to measure labor culture are lacking. The aim of this study was to revise and validate a survey tool to measure hospital culture specific to cesarean overuse. Methods A panel of clinicians and researchers compiled an item bank from validated surveys, added newly created items, and performed four rounds of iterative revision and consolidation. Obstetricians, family physicians, midwives, anesthesiologists, and labor nurses were recruited from 79 hospitals in California. Exploratory factor analysis was used to reduce the number of survey items and identify latent constructs to form the basis of subscales. Confirmatory factor analysis examined reliability in 31 additional hospitals. Poisson regression assessed associations between hospitals' mean score on each individual item and cesarean rates. Results A total of 1718 individuals from 70 hospitals were included in the exploratory factor analysis. The final Labor Culture Survey (LCS) consisted of 29 items and six subscales: "Best Practices to Reduce Cesarean Overuse," "Fear of Vaginal Birth," "Unit Microculture," "Physician Oversight," "Maternal Agency," and "Cesarean Safety." Conclusions The revised LCS is a valid and reliable tool to measure constructs shown to be associated with cesarean rates. These findings support prior research that has shown that hospital culture is measurable, and that clinician attitudes are predictive of clinician behaviors. Unique to our survey is the construct of labor and delivery unit microculture.

Perinatal complications linked to maternal comorbidities contribute to increased healthcare utilization through an extended postpartum length of stay (LOS). Understanding factors influencing postpartum LOS may minimize the adverse effects associated with comorbidities and complications. The purpose of this study was to identify risk factors with the greatest odds of increasing postpartum LOS. Linked 2008-2009 hospital discharge and birth certificate data were used to examine comorbidities and complication codes in 1 015 424 births. The overall rate for an extended LOS (vaginal: >5 days/cesarean: >6 days) was 3.63 per 1000 live births. Complications were present in 17% of pregnancies; multiple complications were seen in 1%. Chronic hypertension was associated with an extended stay for both vaginal and cesarean births (odds ratio [OR] = 5.89 [95% CI, 4.39-7.88]; OR = 3.57 [95% CI, 3.05-4.17], respectively). Puerperal infections (OR = 6.86 [95% CI, 5.73-8.21]), eclampsia (OR = 17.07 [95% CI, 13.76-21.17]), and transfusions (OR = 11.66 [95% CI, 9.20-14.75]) occurred most frequently and conferred the highest odds of an extended stay for vaginal births. Cerebrovascular conditions (OR = 15.32 [95% CI, 11.90-19.60]) and infection (OR = 15.35 [95% CI, 10.11-23.32]) conferred the highest odds of an extended LOS for cesarean births. The earlier risk factors are recognized, the sooner processes can be initiated to optimize organizational preparation, thus decreasing adverse maternal outcomes and extended hospital stays.

Birth certificates are some of the most critical identity documents available to current residents of the United States, yet sexual and gender minority (SGM) parents frequently face barriers in obtaining accurate documents for their children. It is essential for SGM parents to have accurate birth certificates for their children at the time of birth registration so that they do not experience undue burden in raising their children and establishing their status as legal parents. In this analysis, we focused on the birth registration process in the US as they apply to SGM family-building and the assignation of parentage on birth certificates at the time of a child's birth. We utilized keyword-based search criteria to identify, collect, and tabulate official state policies related to birth registration. Birth registration policies rely on gendered, heteronormative assumptions about the sex and gender of a child's parents in all but three states when identifying the birthing person and in all but eight states when identifying the non-birthing person. We found additional barriers for SGM parents who give birth outside of a marriage or legal union. These barriers leave SGM parents particularly vulnerable to inaccuracies on their children's identity documents and incomplete recognition of their parental roles and rights. Existing birth registration policies also do little to ensure the inclusion of diverse family structures in administrative data collection. There are many ways to modify existing birth registration policies and enhance the inclusion of SGM parents within governmental administrative structures. We conclude with suggestions to improve upon existing birth registration systems by de-linking parental sex and gender from birthing role, parental role, and contribution to the pregnancy.

OBJECTIVE: To assess maternal and neonatal healthcare workers (HCWs) perspectives on well-being and patient safety amid the COVID-19 pandemic. STUDY DESIGN: Anonymous survey of HCW well-being, burnout, and patient safety over the prior conducted in June 2020. Results were analyzed by job position and burnout status. RESULT: We analyzed 288 fully completed surveys. In total, 66% of respondents reported symptoms of burnout and 73% felt burnout among their co-workers had significantly increased. Workplace strategies to address HCW well-being were judged by 34% as sufficient. HCWs who were "burned out" reported significantly worse well-being and patient safety attributes. Compared to physicians, nurses reported higher rates of unprofessional behavior (37% vs. 14%, p = 0.027) and difficulty focusing on work (59% vs. 36%, p = 0.013). CONCLUSION: Three months into the COVID-19 pandemic, HCW well-being was substantially compromised, with negative ramifications for patient safety.

Severe maternal morbidity (SMM) is a composite outcome measure that indicates serious, potentially life-threatening maternal health problems. There is great interest in defining SMM using administrative data for surveillance and research. In the United States, one common way of defining SMM at the population level is an index developed by the Centers for Disease Control and Prevention. Modifications to this index (e.g., exclusion of maternal blood transfusion) have been proposed; some research defines SMM using an index introduced by Bateman et al. (Obstet Gynecol. 2013;122(5):957–965). Birth certificate data are also increasingly being used to define SMM. We compared commonly used US definitions of SMM among all California births (2007–2012) using the kappa (κ) statistic and other measures. We also evaluated agreement between maternal morbidity fields on the birth certificate as compared with health insurance claims data. Concordance between the 7 definitions of SMM analyzed was generally low (i.e., κ

Objective To develop and validate an expanded obstetric comorbidity score for predicting severe maternal morbidity that can be applied consistently across contemporary U.S. patient discharge data sets. Methods Discharge data from birth hospitalizations in California during 2016-2017 were used to develop the score. The outcomes were severe maternal morbidity, defined using the Centers for Disease Control and Prevention index, and nontransfusion severe maternal morbidity (excluding cases where transfusion was the only indicator of severe maternal morbidity). We selected 27 potential patient-level risk factors for severe maternal morbidity, identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. We used a targeted causal inference approach integrated with machine learning to rank the risk factors based on adjusted risk ratios (aRRs). We used these results to assign scores to each comorbidity, which sum to a single numeric score. We validated the score in California and national data sets and compared the performance to that of a previously developed obstetric comorbidity index. Results Among 919,546 births, the rates of severe maternal morbidity and nontransfusion severe maternal morbidity were 168 and 74 per 10,000 births, respectively. The highest risk comorbidity was placenta accreta spectrum (aRR of 30.5 for severe maternal morbidity and 54.7 for nontransfusion severe maternal morbidity) and the lowest was gestational diabetes mellitus (aRR of 1.06 for severe maternal morbidity and 1.12 for nontransfusion severe maternal morbidity). Normalized scores based on the aRR were developed for each comorbidity, which ranged from 1 to 59 points for severe maternal morbidity and from 1 to 36 points for nontransfusion severe maternal morbidity. The overall performance of the expanded comorbidity scores was good (C-statistics were 0.78 for severe maternal morbidity and 0.84 for nontransfusion severe maternal morbidity in California data and 0.82 and 0.87, respectively, in national data) and improved on prior comorbidity indices developed for obstetric populations. Calibration plots showed good concordance between predicted and actual risks of the outcomes. Conclusion We developed and validated an expanded obstetric comorbidity score to improve comparisons of severe maternal morbidity rates across patient populations with different comorbidity case mixes.

Objective The aim of this study is to evaluate the contribution of pre-pregnancy obesity and overweight to peripartum cardiomyopathy. Study design This population-based study used linked birth record and maternal hospital discharge data from live births in California during 2007 to 2012 (n = 2,548,380). All women who had a diagnosis of peripartum cardiomyopathy during the childbirth hospitalization or who were diagnosed with peripartum cardiomyopathy during a postpartum hospital readmission within 5 months of birth were identified as cases. Pre-pregnancy body mass index (BMI, kg/m2) was classified as normal weight (18.5-24.9), overweight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2 (35.0-39.9), and obesity class 3 (≥40). Because of small numbers, we excluded women with underweight BMI, and in some analyses, we combined obesity classes into one group. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) expressing associations between BMI and peripartum cardiomyopathy, adjusted for maternal age, race/ethnicity, education, health care payer, parity, plurality, and comorbidities. Results The overall prevalence of peripartum cardiomyopathy during hospital admissions was 1.3 per 10,000 live births (n = 320). Unadjusted ORs were 1.32 (95% CI: 1.01-1.74) for women with overweight BMI and 2.03 (95% CI: 1.57-2.62) for women with obesity, compared with women with normal pre-pregnancy BMI. Adjusted ORs were 1.26 (95% CI: 0.95-1.66) for overweight women and 1.38 (95% CI: 1.04-1.84) for women with obesity. The ORs suggested a dose-response relationship with increasing levels of obesity, but the 95% CIs for the specific classes of obesity included 1.00. Conclusion Pre-pregnancy obesity was associated with an increased risk of peripartum cardiomyopathy. These findings underscore the importance of BMI during pregnancy. There is a need to recognize the increased risk of peripartum cardiomyopathy in women with high BMI, especially in the late postpartum period. Key points · Pre-pregnancy obesity affects maternal health.. · Effects may extend to peripartum cardiomyopathy.. · The risk includes peripartum cardiomyopathy that emerges postpartum..

State Perinatal Quality Collaboratives (PQCs) represent a major advance for scaling up quality improvement efforts for reducing maternal mortality and severe maternal morbidity. The critical roles of partners, rapid-cycle low-burden data systems, and linkage to maternal mortality review committees are reviewed. The choice of measures is also explored. California's experience with its PQC, data center, quality improvement efforts, and promising results for reduction of maternal mortality and morbidity from hemorrhage are presented. Early data from other states is also shared.