Severe Obstetric Morbidity: Learning from the "Near Misses"
New criteria for identifying severe maternal morbidity reveal worrisome recent trends.
Although maternal death is a rare obstetric event in the U.S., our inability to standardize the definitions of severe maternal morbidities has hampered the effort to lower their incidence. CDC investigators used data from nationally representative hospital discharges to refine the criteria for identifying severe maternal morbidity. They expanded the diagnostic codes specific to obstetric complications; for example, they added codes for several types of injuries, cardiac monitoring, and cardiac surgery. They then determined morbidity trends from 1998 through 2009.
During 2008 and 2009, 1.3% of delivery hospitalizations involved at least one severe obstetric complication, a 75% increase compared with the period from 1998 through 1999. Rates of postpartum hospitalizations with severe morbidity indicators increased by 114%, and blood transfusions (the most common indication of severe morbidity) increased by 183%. Rates of cardiac surgery rose significantly (from 2.6 to 4.6 per 10,000 delivery hospitalizations), and a significant proportion of women who died had undergone at least one cardiac evaluation or treatment.
Comment: Improving the safety of childbirth has long been a global goal. The expanded index of severe maternal morbidity proposed by the CDC captures the perils of obstetrics in the modern day, reflecting the effects of advancing maternal age, other preexisting comorbidities (particularly in women who conceive with assisted reproductive technology), the obesity epidemic, and an ever-rising cesarean rate. Hospitals should use these data to guide quality-improvement efforts. Paramount in these efforts, providers who care for women during as well as before pregnancy must be mindful of these complications when providing reproductive counseling, even if that counsel means discouraging pregnancy for some women.
Published in Journal Watch Women's Health November 15, 2012
Callaghan WM et al. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 2012 Nov; 120:1029. (http://viajwat.ch/PWASra)
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