Administrative Appointments


  • Medical Director, California Maternal Quality Care Collaborative (2006 - Present)

All Publications


  • Performance Characteristics of Sepsis Screening Tools During Delivery Admissions. Obstetrics and gynecology Main, E. K., Fuller, M., Kovacheva, V. P., Elkhateb, R., Azar, K., Caldwell, M., Chiem, V., Foster, M., Gibbs, R., Hughes, B. L., Johnson, R., Kottukapally, N., Cortes, M. S., Rosenstein, M. G., Shields, L. E., Sudat, S., Sutton, C. D., Toledo, P., Traylor, A., Wharton, K., Bauer, M. E. 2023

    Abstract

    To evaluate the screening performance characteristics of existing tools for the diagnosis of sepsis during delivery admissions.This was a case-control study using electronic health record data, including vital signs and laboratory results, for all delivery admissions of patients with sepsis from 59 nationally distributed hospitals. Patients with sepsis were matched by gestational age at delivery in a 1:4 ratio with patients without sepsis to create a comparison group. Patients with chorioamnionitis and sepsis were compared with a complete cohort of patients with chorioamnionitis without sepsis. Multiple screening criteria for sepsis were evaluated: the CMQCC (California Maternal Quality Care Collaborative), SIRS (Systemic Inflammatory Response Syndrome), the MEWC (the Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System), and the MEWT (Maternal Early Warning Trigger Tool). Sensitivity, false-positive rates, and C-statistics were reported for each screening tool. Analyses were stratified into cohort 1, which excluded patients with chorioamnionitis-endometritis, and cohort 2, which included those patients.Delivery admissions at 59 hospitals were extracted for patients with sepsis. Cohort 1 comprised 647 patients with sepsis, including 228 with end-organ injury, matched with a control group of 2,588 patients without sepsis. Cohort 2 comprised 14,591 patients with chorioamnionitis-endometritis, of whom 1,049 had sepsis and 238 had end-organ injury. In cohort 1, the CMQCC and the UKOSS pregnancy-adjusted criteria had the lowest false-positive rates (6.9% and 9.6%, respectively) and the highest C-statistics (0.92 and 0.91, respectively). Although other screening criteria, such as SIRS and the MEWC, had similar sensitivities, it was at the cost of much higher false-positive rates (21.3% and 38.3%, respectively). In cohort 2, including all patients with chorioamnionitis-endometritis, the highest C-statistics were again for the CMQCC (0.67) and UKOSS (0.64). All screening tools had high false-positive rates, but the false-positive rates for the CMQCC and UKOSS were substantially lower than those for SIRS and the MEWC.During delivery admissions, the CMQCC and UKOSS pregnancy-adjusted screening criteria have the lowest false-positive results while maintaining greater than 90% sensitivity rates. Performance of all screening tools was degraded in the setting of chorioamnionitis-endometritis.

    View details for DOI 10.1097/AOG.0000000000005477

    View details for PubMedID 38086055

  • Performance Characteristics of Sepsis Screening Tools During Antepartum and Postpartum Admissions. Obstetrics and gynecology Bauer, M. E., Fuller, M., Kovacheva, V., Elkhateb, R., Azar, K., Caldwell, M., Chiem, V., Foster, M., Gibbs, R., Hughes, B. L., Johnson, R., Kottukapally, N., Rosenstein, M. G., Cortes, M. S., Shields, L. E., Sudat, S., Sutton, C. D., Toledo, P., Traylor, A., Wharton, K., Main, E. 2023

    Abstract

    To evaluate the performance characteristics of existing screening tools for the prediction of sepsis during antepartum and postpartum readmissions.This was a case-control study using electronic health record data obtained between 2016 and 2021 from 67 hospitals for antepartum sepsis admissions and 71 hospitals for postpartum readmissions up to 42 days. Patients in the sepsis case group were matched in a 1:4 ratio to a comparison cohort of patients without sepsis admitted antepartum or postpartum. The following screening criteria were evaluated: the CMQCC (California Maternal Quality Care Collaborative) initial sepsis screen, the non-pregnancy-adjusted SIRS (Systemic Inflammatory Response Syndrome), the MEWC (Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System) obstetric SIRS, and the MEWT (Maternal Early Warning Trigger Tool). Time periods were divided into early pregnancy (less than 20 weeks of gestation), more than 20 weeks of gestation, early postpartum (less than 3 days postpartum), and late postpartum through 42 days. False-positive screening rates, C-statistics, sensitivity, and specificity were reported for each overall screening tool and each individual criterion.We identified 525 patients with sepsis during an antepartum hospitalization and 728 patients with sepsis during a postpartum readmission. For early pregnancy and more than 3 days postpartum, non-pregnancy-adjusted SIRS had the highest C-statistics (0.78 and 0.83, respectively). For more than 20 weeks of gestation and less than 3 days postpartum, the pregnancy-adjusted sepsis screening tools (CMQCC and UKOSS) had the highest C-statistics (0.87-0.94). The MEWC maintained the highest sensitivity rates during all time periods (81.9-94.4%) but also had the highest false-positive rates (30.4-63.9%). The pregnancy-adjusted sepsis screening tools (CMQCC, UKOSS) had the lowest false-positive rates in all time periods (3.9-10.1%). All tools had the lowest C-statistics in the periods of less than 20 weeks of gestation and more than 3 days postpartum.For admissions early in pregnancy and more than 3 days postpartum, non-pregnancy-adjusted sepsis screening tools performed better than pregnancy-adjusted tools. From 20 weeks of gestation through up to 3 days postpartum, using a pregnancy-adjusted sepsis screening tool increased sensitivity and minimized false-positive rates. The overall false-positive rate remained high.

    View details for DOI 10.1097/AOG.0000000000005480

    View details for PubMedID 38086052

  • Chronic Hypertension in Pregnancy and Racial-Ethnic Disparities in Complications. Obstetrics and gynecology Leonard, S. A., Formanowski, B. L., Phibbs, C. S., Lorch, S., Main, E. K., Kozhimannil, K. B., Passarella, M., Bateman, B. T. 2023

    Abstract

    To evaluate whether there are individual- and population-level associations between chronic hypertension and pregnancy complications, and to assess differences across seven racial-ethnic groups.This population-based study used linked vital statistics and hospitalization discharge data from all live and stillbirths in California (2008-2018), Michigan (2008-2020), Oregon (2008-2020), Pennsylvania (2008-2014), and South Carolina (2008-2020). We used multivariable log-binomial regression models to estimate risk ratios (RRs) and population attributable risk (PAR) percentages with 95% CIs for associations between chronic hypertension and several obstetric and neonatal outcomes, selected based on prior evidence and pathologic pathways. We adjusted models for demographic factors (race and ethnicity, payment method, educational attainment), age, body mass index, obstetric history, delivery year, and state, and conducted analyses stratified across seven racial-ethnic groups.The study included 7,955,713 pregnancies, of which 168,972 (2.1%) were complicated by chronic hypertension. Chronic hypertension was associated with several adverse obstetric and neonatal outcomes, with the largest adjusted PAR percentages observed for preeclampsia with severe features or eclampsia (22.4; 95% CI 22.2-22.6), acute renal failure (13.6; 95% CI 12.6-14.6), and pulmonary edema (10.7; 95% CI 8.9-12.6). Estimated RRs overall were similar across racial-ethnic groups, but PAR percentages varied. The adjusted PAR percentages (95% CI) for severe maternal morbidity-a widely used composite of acute severe events-for people who were American Indian or Alaska Native, Asian, Black, Latino, Native Hawaiian or Other Pacific Islander, White, and Multiracial or Other were 5.0 (1.1-8.8), 3.7 (3.0-4.3), 9.0 (8.2-9.8), 3.9 (3.6-4.3), 11.6 (6.4-16.5), 3.2 (2.9-3.5), and 5.5 (4.2-6.9), respectively.Chronic hypertension accounts for a substantial fraction of obstetric and neonatal morbidity and contributes to higher complication rates, particularly for people who are Black or Native Hawaiian or Other Pacific Islander.

    View details for DOI 10.1097/AOG.0000000000005342

    View details for PubMedID 37678888

  • Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care. Obstetrics and gynecology Bauer, M. E., Albright, C., Prabhu, M., Heine, R. P., Lennox, C., Allen, C., Burke, C., Chavez, A., Hughes, B. L., Kendig, S., Le Boeuf, M., Main, E., Messerall, T., Pacheco, L. D., Riley, L., Solnick, R., Youmans, A., Gibbs, R. 2023; 142 (3): 481-492

    Abstract

    Sepsis in obstetric care is one of the leading causes of maternal death in the United States, with Black, Asian/Pacific Islander, and American Indian/Alaska Native obstetric patients experiencing sepsis at disproportionately higher rates. State maternal mortality review committees have determined that deaths are preventable much of the time and are caused by delays in recognition, treatment, and escalation of care. The "Sepsis in Obstetric Care" patient safety bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people by preventing infection and recognizing and treating infection early to prevent progression to sepsis. This is one of several core patient safety bundles developed by AIM (the Alliance for Innovation on Maternal Health) to provide condition- or event-specific clinical practices that should be implemented in all appropriate care settings. As with other bundles developed by AIM, the "Sepsis in Obstetric Care" patient safety bundle is organized into five domains: Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, and Respectful, Equitable, and Supportive Care. The Respectful, Equitable, and Supportive Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into the elements of each domain.

    View details for DOI 10.1097/AOG.0000000000005304

    View details for PubMedID 37590980

  • Hospital-level variation in racial disparities in low-risk nulliparous cesarean birth rates. American journal of obstetrics & gynecology MFM Main, E. K., Chang, S. C., Tucker, C. M., Sakowski, C., Leonard, S. A., Rosenstein, M. G. 2023: 101145

    Abstract

    Nationally, rates of cesarean birth are highest among Black patients, compared with other racial/ethnic groups. These observed inequities are a relatively new phenomenon (in the 1980s, cesarean birth rates among Black patients were lower than average) indicating an opportunity to narrow the gap. Cesarean birth rates vary greatly among hospitals, masking racial disparities that are unseen when rates are reported in aggregate.This study explored reasons for the current large Black-White disparity in first-birth cesarean rates by first examining the hospital-level variation in first-birth cesarean rates among different racial/ethnic groups. We then identified hospitals that had low first-birth cesarean rates among Black patients and compared them to hospitals with high rates. We sought to identify differences in facility or patient characteristics could provide insights for the racial disparity.A population cross-sectional study was performed on 1,267,493 California live births from 2018 through 2020 using birth certificate data linked with maternal patient discharge records. Annual nulliparous term singleton vertex cesarean delivery (first-birth) rates were calculated for the most common racial/ethnic groups statewide and for each hospital. Self-identified race/ethnicity categories as selected on the birth certificate were used. Relative risk (RR) and 95% confidence intervals for first-birth cesarean comparing 2019 to 2015 were estimated using a log-binomial model for each racial/ethnic group. Patient and hospital characteristics were compared between hospitals that had first-birth cesarean rates <23.9% for Black patients compared with hospitals with rates ≥23.9% for Black patients.Hospitals with at least 30 nulliparous term singleton vertex Asian, Black, Hispanic and White patients each were identified. Black patients had a very different distribution with significantly higher rate (28.4%), wider standard deviation (7.1) and interquartile range (6.5) than other racial groups (P<0.01). 29 hospitals with a low first-birth cesarean rate among Black patients were identified using the Healthy People 2020 target of 23.9% and compared to 106 hospitals with higher rates. The low group has a cesarean rate of 19.9% compared to 30.7% in the higher group. There were no significant differences between the groups in hospital characteristics (ownership, delivery volume, Neonatal level, proportion of midwife deliveries) or patient characteristics (age, education, insurance, onset of prenatal care, BMI, hypertension, diabetes). Among the 106 hospitals that did not meet the target for Black patients, 63 met it for white patients with a mean rate of 21.4%. In the same hospitals the mean rate for Black patients was 29.5%. Cesarean indications among Black patients in the group that did not meet the 23.9% target were significantly higher for all indications: labor dystocia, fetal concern (spontaneous labor), and no labor (e.g. macrosomia), all indications with a high degree of subjectivity.The statewide cesarean rate for Black patients is significantly higher and has substantially greater hospital variation than other racial or ethnic groups. The lack of difference in facility or patient characteristics between hospitals with low cesarean rates among Black patients and those with high rates suggests unconscious bias and structural racism potentially play important roles in creating these racial differences.

    View details for DOI 10.1016/j.ajogmf.2023.101145

    View details for PubMedID 37648109

  • Clinical and Physician Factors Associated With Failed Operative Vaginal Delivery. Obstetrics and gynecology Panelli, D. M., Leonard, S. A., Joudi, N., Judy, A. E., Bianco, K., Gilbert, W. M., Main, E. K., El-Sayed, Y. Y., Lyell, D. J. 2023

    Abstract

    To examine clinical and physician factors associated with failed operative vaginal delivery among individuals with nulliparous, term, singleton, vertex (NTSV) births.This was a retrospective cohort study of individuals with NTSV live births with an attempted operative vaginal delivery by a physician between 2016 and 2020 in California. The primary outcome was cesarean birth after failed operative vaginal delivery, identified using linked diagnosis codes, birth certificates, and physician licensing board data stratified by device type (vacuum or forceps). Clinical and physician-level exposures were selected a priori, defined using validated indices, and compared between successful and failed operative vaginal delivery attempts. Physician experience with operative vaginal delivery was estimated by calculating the number of operative vaginal delivery attempts made per physician during the study period. Multivariable mixed effects Poisson regression models with robust standard errors were used to estimate risk ratios of failed operative vaginal delivery for each exposure, adjusted for potential confounders.Of 47,973 eligible operative vaginal delivery attempts, 93.2% used vacuum and 6.8% used forceps. Of all operative vaginal delivery attempts, 1,820 (3.8%) failed; the success rate was 97.3% for vacuum attempts and 82.4% for forceps attempts. Failed operative vaginal deliveries were more likely with older patient age, higher body mass index, obstructed labor, and neonatal birth weight more than 4,000 g. Between 2016 and 2020, physicians who attempted more operative vaginal deliveries were less likely to fail. When vacuum attempts were successful, physicians who conducted them had a median of 45 vacuum attempts during the study period, compared with 27 attempts when vacuum attempts were unsuccessful (adjusted risk ratio [aRR] 0.95, 95% CI 0.93-0.96). When forceps attempts were successful, physicians who conducted them had a median of 19 forceps attempts, compared with 11 attempts when forceps attempts were unsuccessful (aRR 0.76, 95% CI 0.64-0.91).In this large, contemporary cohort with NTSV births, several clinical factors were associated with operative vaginal delivery failure. Physician experience was associated with operative vaginal delivery success, more notably for forceps attempts. These results may provide guidance for physician training in maintenance of operative vaginal delivery skills.

    View details for DOI 10.1097/AOG.0000000000005181

    View details for PubMedID 37141591

  • Addressing Adverse Childhood and Adult Experiences During Prenatal Care. Obstetrics and gynecology Johnson, S., Kasparian, N. A., Cullum, A. S., Flanagan, T., Ponting, C., Kowalewski, L., Main, E. K. 2023

    Abstract

    Adverse childhood and adult experiences can affect health outcomes throughout life and across generations. The perinatal period offers a critical opportunity for obstetric clinicians to partner with patients to provide support and improve outcomes. This article draws on stakeholder input, expert opinion, and available evidence to provide recommendations for obstetric clinicians' inquiry about and response to pregnant patients' past and present adversity and trauma during prenatal care encounters. Trauma-informed care is a universal intervention that can proactively address adversity and trauma and support healing, even if a patient does not explicitly disclose past or present adversity. Inquiry about past and present adversity and trauma provides an avenue to offer support and to create individualized care plans. Preparatory steps to adopting a trauma-informed approach to prenatal care include initiating education and training for practice staff, prioritizing addressing racism and health disparities, and establishing patient safety and trust. Inquiry about adversity and trauma, as well as resilience factors, can be implemented gradually over time through open-ended questions, structured survey measures, or a combination of both techniques. A range of evidence-based educational resources, prevention and intervention programs, and community-based initiatives can be included within individualized care plans to improve perinatal health outcomes. These practices will be further developed and improved by increased clinical training and research, as well as through broad adoption of a trauma-informed approach and collaboration across specialty areas.

    View details for DOI 10.1097/AOG.0000000000005199

    View details for PubMedID 37141600

  • Racial/Ethnic Disparities in Costs, Length of Stay, and Severity of Severe Maternal Morbidity. American journal of obstetrics & gynecology MFM Phibbs, C. M., Kristensen-Cabrera, A., Kozhimannil, K. B., Leonard, S. A., Lorch, S. A., Main, E. K., Schmitt, S. K., Phibbs, C. S. 2023: 100917

    Abstract

    BACKGROUND: In contrast to other high-resource countries, the US has experienced increases in the rates of severe maternal morbidity. The US also has pronounced racial/ethnic disparities in severe maternal morbidity, especially for non-Hispanic Black people, who have twice the rate as non-Hispanic White people.OBJECTIVE(S): The objective of this study was to examine if the racial/ethnic disparities in severe maternal morbidity extended beyond the rates of these complications to include disparities in maternal costs and lengths of stay, which could indicate differences in the case severity.STUDY DESIGN: This study used California's linkage of birth certificates to inpatient maternal and infant discharge data for 2009-2011. Of the 1.5 million linked records, 250,000 were excluded due to incomplete data, for a final sample of 1,262,862. Cost-to-charge ratios were used to estimate costs from charges (including readmissions) after adjusting for inflation to December 2017. Mean diagnostic-related group-specific reimbursement was used to estimate physician payments. We used the Centers for Disease Control and Prevention definition of severe maternal morbidity, including readmissions up to 42 days postpartum. Adjusted Poisson regression models estimated the differential risk of severe maternal morbidity for each racial/ethnic group, compared with the non-Hispanic White group. Generalized linear models estimated the associations of race/ethnicity with costs and length of stay.RESULTS: Asian/Pacific Islander, Non-Hispanic Black, Hispanic, and Other race/ethnicity patients all had higher rates of severe maternal morbidity than non-Hispanic White patients. The largest disparity was between non-Hispanic White and non-Hispanic Black patients, with unadjusted overall rates of severe maternal morbidity of 1.34% and 2.62%, respectively (adjusted risk ratio 1.61, p<0.001). Among patients with severe maternal morbidity, the adjusted regression estimates showed that non-Hispanic Black patients had 23% (p<0.001) higher costs (marginal effect $5,023) and 24% (p<0.001) longer hospital stays (marginal effect 1.4 days) compared to non-Hispanic White patients. These effects changed when cases where a blood transfusion was the only indication of severe maternal morbidity were excluded, with 29% higher costs (p<0.001) and 15% longer length of stay (p<0.001). For other racial/ethnic groups, the increases in costs and length of stay were smaller than those observed for non-Hispanic Black patients, and many were not significant different from non-Hispanic White patients. Hispanic patients had higher rates of severe maternal morbidity than non-Hispanic White patients but significantly lower costs and length of stay.CONCLUSION(S): There were racial/ethnic differences in the costs and length of stay among patients with severe maternal morbidity across the groupings that we examined. The differences were especially large for non-Hispanic Black patients compared with non-Hispanic White patients. Non-Hispanic Black patients experienced twice the rate of severe maternal morbidity; additionally, the higher relative costs and longer lengths of stay for non-Hispanic Black patients with severe maternal morbidity supports greater case severity in that population. These findings suggest that efforts to address racial/ethnic inequities in maternal health need to consider differences in case severity in addition to the differences in the rates of severe maternal morbidity and that these differences in case severity merit additional investigation.

    View details for DOI 10.1016/j.ajogmf.2023.100917

    View details for PubMedID 36882126

  • State Perinatal Quality Collaborative for Reducing Severe Maternal Morbidity From Hemorrhage: A Cost-Effectiveness Analysis. Obstetrics and gynecology Wiesehan, E. C., Keesara, S. R., Krissberg, J. R., Main, E. K., Goldhaber-Fiebert, J. D. 2023

    Abstract

    To evaluate the cost effectiveness of California's statewide perinatal quality collaborative for reducing severe maternal morbidity (SMM) from hemorrhage.A decision-analytic model using open source software (Amua 0.30) compared outcomes and costs within a simulated cohort of 480,000 births to assess the annual effect in the state of California. Our model captures both the short-term costs and outcomes that surround labor and delivery and long-term effects over a person's remaining lifetime. Previous studies that evaluated the effectiveness of the CMQCC's (California Maternal Quality Care Collaborative) statewide perinatal quality collaborative initiative-reduction of hemorrhage-related SMM by increasing recognition, measurement, and timely response to postpartum hemorrhage-provided estimates of intervention effectiveness. Primary cost data received from select hospitals within the study allowed for the estimation of collaborative costs, with all other model inputs derived from literature. Costs were inflated to 2021 dollars with a cost-effectiveness threshold of $100,000 per quality-adjusted life-year (QALY) gained. Various sensitivity analyses were performed including one-way, scenario-based, and probabilistic sensitivity (Monte Carlo) analysis.The collaborative was cost effective, exhibiting strong dominance when compared with the baseline or standard of care. In a theoretical cohort of 480,000 births, collaborative implementation added 182 QALYs (0.000379/birth) by averting 913 cases of SMM, 28 emergency hysterectomies, and one maternal mortality. Additionally, it saved $9 million ($17.78/birth) due to averted SMM costs. Although sensitivity analyses across parameter uncertainty ranges provided cases where the intervention was not cost saving, it remained cost effective throughout all analyses. Additionally, scenario-based sensitivity analysis found the intervention cost effective regardless of birth volume and implementation costs.California's statewide perinatal quality collaborative initiative to reduce SMM from hemorrhage was cost effective-representing an inexpensive quality-improvement initiative that reduces the incidence of maternal morbidity and mortality, and potentially provides cost savings to the majority of birthing hospitals.

    View details for DOI 10.1097/AOG.0000000000005060

    View details for PubMedID 36649352

  • Institutional Racism: A Key Contributor to Perinatal Health Inequity. Pediatrics Dhurjati, R., Main, E., Profit, J. 2021

    View details for DOI 10.1542/peds.2021-050768

    View details for PubMedID 34429337

  • Hospital Quality Improvement Interventions, Statewide Policy Initiatives, and Rates of Cesarean Delivery for Nulliparous, Term, Singleton, Vertex Births in California. JAMA Rosenstein, M. G., Chang, S., Sakowski, C., Markow, C., Teleki, S., Lang, L., Logan, J., Cape, V., Main, E. K. 2021; 325 (16): 1631–39

    Abstract

    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.

    View details for DOI 10.1001/jama.2021.3816

    View details for PubMedID 33904868

  • Obstetric comorbidity scores and disparities in severe maternal morbidity across marginalized groups. American journal of obstetrics & gynecology MFM Leonard, S. A., Main, E. K., Lyell, D. J., Carmichael, S. L., Kennedy, C. J., Johnson, C., Mujahid, M. S. 2021: 100530

    Abstract

    A recently developed obstetric comorbidity scoring system enables comparisons of severe maternal morbidity rates independent of health status at the time of birth hospitalization. However, the scoring system has not been evaluated in racial-ethnic and socioeconomic groups or used to assess disparities in severe maternal morbidity.To evaluate the performance of applying an obstetric comorbidity scoring system across racial-ethnic and socioeconomic groups and to determine the effect of comorbidity score risk adjustment on disparities in severe maternal morbidity.We analyzed a population-based cohort of live births in California during 2011-2017 with linked birth certificate and birth hospitalization discharge data (n = 3,308,554). We updated a previously developed comorbidity scoring system to include ICD-9-CM and ICD-10-CM diagnosis codes, and applied the scoring system in subpopulations (groups) defined by race-ethnicity, nativity, payment method, and educational attainment. We then calculated risk-adjusted rates of severe maternal morbidity (including and excluding blood transfusion-only cases) in each group and estimated disparities for these outcomes before and after adjustment for the comorbidity score using logistic regression.The obstetric comorbidity scores performed consistently across groups (C-statistics ranged from 0.68-0.76; calibration curves demonstrated overall excellent prediction of absolute risk). All non-White groups had significantly elevated rates of severe maternal morbidity before and after risk adjustment for comorbidities compared to the White group (1.3% before, 1.3% after): American Indian-Alaska Native (2.1% before, 1.8% after), Asian (1.5% before, 1.7% after), Black (2.5% before, 2.0% after), Latinx (1.6% before, 1.7% after), Pacific Islander (2.2% before, 1.9% after), and Multi-race groups (1.7% before, 1.6% after). Risk adjustment also modestly increased disparities for the foreign-born group and non-commercial insurance groups. Increasing educational attainment was associated with decreasing severe maternal morbidity rates, which was largely unaffected by comorbidity risk adjustment. The pattern of results was the same whether or not transfusion-only cases were included as severe maternal morbidity.These results support the use of an updated comorbidity scoring system to assess disparities in severe maternal morbidity. Disparities in severe maternal morbidity decreased in magnitude for some racial-ethnic and socioeconomic groups and increased in magnitude for others after adjustment for the comorbidity score.

    View details for DOI 10.1016/j.ajogmf.2021.100530

    View details for PubMedID 34798329

  • Safe care on maternity units: a multidimensional balancing act. BMJ quality & safety White VanGompel, E. n., Main, E. K. 2021

    View details for DOI 10.1136/bmjqs-2020-012601

    View details for PubMedID 33452141

  • Hospital-Level Variation in the Frequency of Cesarean Delivery Among Nulliparous Women Who Undergo Labor Induction. Obstetrics and gynecology Main, E. K., Chang, S., Cheng, Y. W., Rosenstein, M. G., Lagrew, D. C. 2020

    Abstract

    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<0.08) or the rate of nulliparous labor induction (R<0.12).CONCLUSION: The large variation of cesarean delivery rates after induction of labor suggests that clinical management plays an important role in achieving induction success.

    View details for DOI 10.1097/AOG.0000000000004139

    View details for PubMedID 33156193

  • Singleton preterm birth rates for racial and ethnic groups during the coronavirus disease 2019 pandemic in California. American journal of obstetrics and gynecology Main, E. K., Chang, S., Carpenter, A. M., Wise, P. H., Stevenson, D. K., Shaw, G. M., Gould, J. B. 2020

    View details for DOI 10.1016/j.ajog.2020.10.033

    View details for PubMedID 33203528

  • Birth Hospital and Racial/Ethnic Differences in Severe Maternal Morbidity in the State of California. American journal of obstetrics and gynecology Mujahid, M. S., Kan, P., Leonard, S. A., Hailu, E. M., Wall-Wieler, E., Abrams, B., Main, E., Profit, J., Carmichael, S. L. 2020

    Abstract

    BACKGROUND: Birth hospital has recently emerged as a potentially key contributor to disparities in severe maternal morbidity, but investigations remain limited.OBJECTIVES: We leveraged state-wide data from California to examine whether birth hospital explained racial/ethnic differences in severe maternal morbidity.METHODS: This cohort study used data on all births ≥20 weeks in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least one of 21 diagnoses and procedures (e.g. eclampsia, blood transfusion, hysterectomy). Mixed effects logistic regression models (i.e. women nested within hospitals) were used to compare racial/ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, co-morbidities, and hospital characteristics. We also estimated risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percent reduction in severe maternal morbidity if each group of racially/ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic White women.RESULTS: Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian/Pacific Islander; 1.1% White; 1.6% American Indian/Alaska Native and Mixed Race referred to as "Other"). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, odds of severe maternal morbidity was greater among non-White women compared to Whites in a given hospital (Odds Ratios and 95% Confidence Intervals; Black =1.25 (1.19-1.31), US-born Hispanic=1.25 (1.20-1.29), Foreign-born Hispanic=1.17 (1.11-1.24), Asian/Pacific Islander=1.26 (1.21-1.32), "Other"=1.31 (1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of White women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared to 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and White women and accounted for 16.1-24.2% of the differences for all other racial/ethnic groups.CONCLUSION: In California, excess odds of severe maternal morbidity among racially/ethnically minoritized women was not fully explained by birth hospital. Structural causes of racial/ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.

    View details for DOI 10.1016/j.ajog.2020.08.017

    View details for PubMedID 32798461

  • An Expanded Obstetric Comorbidity Scoring System for Predicting Severe Maternal Morbidity. Obstetrics and gynecology Leonard, S. A., Kennedy, C. J., Carmichael, S. L., Lyell, D. J., Main, E. K. 2020

    Abstract

    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.

    View details for DOI 10.1097/AOG.0000000000004022

    View details for PubMedID 32769656

  • Reduction in Racial Disparities in Severe Maternal Morbidity from Hemorrhage in a Large-scale Quality Improvement Collaborative. American journal of obstetrics and gynecology Main, E. K., Chang, S. C., Dhurjati, R. n., Cape, V. n., Profit, J. n., Gould, J. B. 2020

    Abstract

    Eliminating persistent racial/ethnic disparities in maternal mortality and morbidity is a public health priority. National strategies to improve maternal outcomes are increasingly focused on quality improvement collaboratives. However, the effectiveness of quality collaboratives for reducing racial disparities in maternity care is understudied.To evaluate the impact of a hemorrhage quality improvement collaborative on racial disparities in severe maternal morbidity (SMM) from hemorrhage.We conducted a cross-sectional study from 2011 to 2016 among 99 hospitals that participated in a hemorrhage quality improvement collaborative in California. The focus of the quality collaborative was to implement the national maternal hemorrhage safety bundle consisting of 17 evidence-based recommendations for practice and care processes known to improve outcomes. This analysis included 54,311 women from the baseline period (January 2011 through December 2014) and 19,165 women from the post-intervention period (October 2015 through December 2016) with a diagnosis of obstetric hemorrhage during delivery hospitalization. We examined whether racial/ethnic-specific SMM rates in these women with obstetric hemorrhage were reduced from the baseline to the post-intervention period. In addition, we conducted Poisson Generalized Estimating Equation models to estimate relative risks (RRs) and 95% confidence intervals (CIs) for SMM comparing each racial/ethnic group to White.During the baseline period, the rate of SMM among women with hemorrhage was 22.1% (12,002/54,311) with the highest rate observed among Blacks (28.6%, 973/3,404), and the lowest among Whites (19.8%, 3,124/15,775). The overall rate fell to 18.5% (3,553/19,165) in the post-intervention period. Both Black and White mothers benefited from the intervention, but the benefit among Blacks exceeded that of Whites (9.0% vs. 2.1% absolute rate reduction). The baseline risk of SMM was 1.34 times higher among Black mothers compared to Whites (RR: 1.34, 95% CI: 1.27-1.42), and it was reduced to 1.22 (1.05-1.40) in the post-intervention period. Sociodemographic and clinical factors explained a part of the Black-White differences. After controlling for these factors, the Black-White RR was 1.22 (95% CI: 1.15-1.30) at baseline and narrowed to 1.07 (1.92-1.24) in the post-intervention period. Results were similar when excluding SMM cases with transfusion alone. After accounting for maternal risk factors, the Black-White RR for SMM excluding transfusion alone was reduced from a baseline of 1.33 (95% CI: 1.16-1.52) to 0.99 (0.76-1.29) in the post-intervention period. The most important clinical risk factor for disparate Black rates for both SMM and SMM excluding transfusion alone was cesarean delivery, potentially providing another opportunity for quality improvement.A large-scale quality improvement collaborative reduced rates of SMM due to hemorrhage in all races and reduced the performance gap between Blacks and Whites. Improving access to highly effective treatments has the potential to decrease disparities for care-sensitive acute hospital-focused morbidities.

    View details for DOI 10.1016/j.ajog.2020.01.026

    View details for PubMedID 31978432

  • Time of Birth and the Risk of Severe Unexpected Complications in Term Singleton Neonates. Obstetrics and gynecology Gould, J. B., Abreo, A. M., Chang, S. C., Main, E. K. 2020

    Abstract

    To assess whether there is a relationship between evening, night, and weekend births and severe unexpected neonatal morbidity in low-risk term singleton births.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.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.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.

    View details for DOI 10.1097/AOG.0000000000003922

    View details for PubMedID 32649496

  • Low-Interventional Approaches to Intrapartum Care: Hospital Variation in Practice and Associated Factors. Journal of midwifery & women's health Lundsberg, L. S., Main, E. K., Lee, H. C., Lin, H., Illuzzi, J. L., Xu, X. 2019

    Abstract

    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.

    View details for DOI 10.1111/jmwh.13017

    View details for PubMedID 31502407

  • National Partnership for Maternal Safety: Consensus Bundle on Obstetric Care for Women With Opioid Use Disorder. Obstetrics and gynecology Krans, E. E., Campopiano, M., Cleveland, L. M., Goodman, D., Kilday, D., Kendig, S., Leffert, L. R., Main, E. K., Mitchell, K. T., OʼGurek, D. T., DʼOria, R., McDaniel, D., Terplan, M. 2019

    Abstract

    The opioid epidemic is a public health crisis, and pregnancy-associated morbidity and mortality due to substance use highlights the need to prioritize substance use as a major patient safety issue. To assist health care providers with this process and mitigate the effect of substance use on maternal and fetal safety, the National Partnership for Maternal Safety within the Council on Patient Safety in Women's Health Care has created a patient safety bundle to reduce adverse maternal and neonatal health outcomes associated with substance use. The Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder provides a series of evidence-based recommendations to standardize and improve the quality of health care services for pregnant and postpartum women with opioid use disorder, which should be implemented in every maternity care setting. A series of implementation resources have been created to help providers, hospitals, and health systems translate guidelines into clinical practice, and multiple state-level Perinatal Quality Collaboratives are developing quality improvement initiatives to facilitate the bundle-adoption process. Structure, process, and outcome metrics have also been developed to monitor the adoption of evidence-based practices and ensure consistency in clinical care.

    View details for DOI 10.1097/AOG.0000000000003381

    View details for PubMedID 31306323

  • Systolic Hypertension, Preeclampsia-Related Mortality, and Stroke in California. Obstetrics and gynecology Judy, A. E., McCain, C. L., Lawton, E. S., Morton, C. H., Main, E. K., Druzin, M. L. 2019; 133 (6): 1151–59

    Abstract

    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 deaths in California from 2002 to 2007. Stroke cases were identified among preeclampsia deaths, and case summaries were reviewed with attention to clinical variables, particularly hypertension. Health care provider- and patient-related contributing factors were also examined.RESULTS: Among 54 preeclampsia pregnancy-related deaths that occurred in California from 2002 to 2007, 33 were attributed to stroke. Systolic blood pressure exceeded 160 mm Hg in 96% of cases, and diastolic blood pressure was 110 or higher in 65% of cases. Hemolysis, elevated liver enzymes, and low platelet count syndrome was present in 38% (9/24) of cases with available laboratory data; eclampsia occurred in 36% of cases. Headache was the most frequent symptom (87%) preceding stroke. Elevated liver transaminases were the most common laboratory abnormality (71%). Only 48% of women received antihypertensive treatment. A good-to-strong chance to alter outcome was identified in stroke cases 66% (21/32), with delayed response to clinical warning signs in 91% (30/33) of cases and ineffective treatment in 76% (25/33) cases being the most common areas for improvement.CONCLUSION: Stroke is the major cause of maternal mortality associated with preeclampsia or eclampsia. All but one patient in this series of strokes demonstrated severe elevation of systolic blood pressure, whereas other variables were less consistently observed. Antihypertensive treatment was not implemented in the majority of cases. Opportunities for care improvement exist and may significantly affect maternal mortality.

    View details for DOI 10.1097/AOG.0000000000003290

    View details for PubMedID 31135728

  • Creating Change at Scale Quality Improvement Strategies used by the California Maternal Quality Care Collaborative OBSTETRICS AND GYNECOLOGY CLINICS OF NORTH AMERICA Markow, C., Main, E. K. 2019; 46 (2): 317-+
  • Creating Change at Scale: Quality Improvement Strategies used by the California Maternal Quality Care Collaborative. Obstetrics and gynecology clinics of North America Markow, C., Main, E. K. 2019; 46 (2): 317–28

    Abstract

    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.

    View details for PubMedID 31056133

  • Cesarean overuse and the culture of care. Health services research White VanGompel, E., Perez, S., Datta, A., Wang, C., Cape, V., Main, E. 2019

    Abstract

    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<0.001). Discordant attitudes between nurses and physicians were associated with increased cesarean rates.CONCLUSIONS: Hospital unit culture, clinician attitudes, and consistency between professions are strongly associated with primary cesarean rates. Improvement efforts to reduce cesarean overuse must address culture of care as a key part of the change process.

    View details for PubMedID 30790273

  • The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity BMC Pregnancy and Childbirth Leonard, S. A., Main, E. K., Carmichael, S. L. 2019; 19 (16)
  • Racial and ethnic disparities in severe maternal morbidity prevalence and trends. Annals of epidemiology Leonard, S. A., Main, E. K., Scott, K. A., Profit, J. n., Carmichael, S. L. 2019

    Abstract

    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.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).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.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.

    View details for PubMedID 30928320

  • Measuring labor and delivery unit culture and clinicians' attitudes toward birth: Revision and validation of the Labor Culture Survey. Birth (Berkeley, Calif.) White VanGompel, E., Perez, S., Wang, C., Datta, A., Cape, V., Main, E. 2018

    Abstract

    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.

    View details for PubMedID 30407646

  • Addressing Maternal Mortality And Morbidity In California Through Public-Private Partnerships. Health affairs (Project Hope) Main, E. K., Markow, C., Gould, J. 2018; 37 (9): 1484–93

    Abstract

    In 2006, noting a rise in maternal deaths and complications, the California Department of Public Health launched efforts to investigate maternal deaths. In that year, the California Maternal Quality Care Collaborative was formed as a public-private partnership to lead maternal quality improvement activities. Key steps undertaken over the next decade included linking public health surveillance to actions, mobilizing a broad range of public and private partners, developing a rapid-cycle Maternal Data Center to support and sustain quality improvement initiatives, and implementing a series of data-driven large-scale quality improvement projects. While US maternal mortality has worsened in the 2010s, by 2013 California's rate had been cut in half to a three-year average of 7.0 maternal deaths per 100,000 live births. The state's rate had become comparable to the average rate in Western Europe (7.2 per 100,000). In this article we describe the key steps undertaken by the California Department of Public Health and the California Maternal Quality Care Collaborative that supported change at large scale. Special challenges for implementation are also discussed.

    View details for PubMedID 30179538

  • Addressing Maternal Mortality And Morbidity In California Through Public-Private Partnerships HEALTH AFFAIRS Main, E. K., Markow, C., Gould, J. 2018; 37 (9): 1484–93
  • Do provider birth attitudes influence cesarean delivery rate: a cross-sectional study BMC PREGNANCY AND CHILDBIRTH VanGompel, E., Main, E. K., Tancredi, D., Melnikow, J. 2018; 18: 184

    Abstract

    When used judiciously, cesarean sections can save lives; but in the United States, prior research indicates that cesarean birth rates have risen beyond the threshold to help women and infants and become a contributor to increased maternal mortality and rising healthcare costs. Healthy People 2020 has set the goal for nulliparous, term, singleton, vertex (NTSV) cesarean birth rate at no more than 23.9% of births. Currently, cesarean rates vary from 6% to 69% in US hospitals, unexplained by clinical or demographic factors. This wide variation in cesarean use is also seen among individual providers of intrapartum care. Previous research of birth attitudes found providers of intrapartum care hold widely differing views, which may be a key underlying factor influencing practice variation; however, further study is needed to determine if differences in attitudes are associated with differences in clinical outcomes. The purpose of this study was to estimate the association between individual provider attitudes towards birth and their low-risk primary cesarean rate.Four hundred providers were drawn from a stratified random sample of all California providers of intrapartum care in 2013 and surveyed for their attitudes towards various aspects of labor and birth. Providers' NTSV cesarean birth rates were obtained for 2013 and 2014. Covariates included gender, years of experience, practice location, and primary hospital's NTSV cesarean rate. We used adjusted multivariate Poisson regression to compare cesarean rates and linear regression to compare attitude scores of providers meeting versus not meeting the Healthy People 2020 (HP2020) goal.Two hundred nine total participants (obstetricians, family physicians, and midwives) completed surveys, of which 109 perform cesareans. Providers' NTSV cesarean rate was significantly associated with their composite attitudes score [IRR for each one-point increase 1.21 (95% CI 1.002-1.45)]. Physicians meeting the HP2020 goal held attitudes which were significantly more favorable towards vaginal birth: mean 2.70 (95% CI 2.58-2.83) versus 2.91 (95% CI 2.82-3.00), p < 0.01.Provider attitudinal differences are associated with NTSV cesarean rates. Those meeting the HP2020 goal hold attitudes more favorable towards vaginal birth. These findings may present a modifiable target for quality improvement initiatives to decrease low risk primary cesareans.

    View details for PubMedID 29843622

  • Improving Maternal Safety at Scale with the Mentor Model of Collaborative Improvement JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Main, E. K., Dhurjati, R., Cape, V., Vasher, J., Abreo, A., Chang, S., Gould, J. B. 2018; 44 (5): 250–59

    Abstract

    Obstetric safety bundles, consisting of action steps shown to improve outcomes, have been developed to address the most common and preventable causes of maternal morbidity and mortality. Implementing these best practices across all birthing facilities remains an important and challenging clinical and public health priority.The California Maternal Quality Care Collaborative (CMQCC) developed an innovative external mentor model for large-scale collaborative improvement in which participating organizations were subdivided into small teams of six to eight hospitals, led by a paired dyad of physician and nurse leaders. The mentor model preserves the active sharing that enhances improvement across a large group of facilities working on the same project while enabling individualized attention to teams. The mentor model was tested by implementing the obstetric hemorrhage safety bundle (which consists of 17 key practices in four domains) in multiple California hospitals.A total of 126 hospitals were engaged to simultaneously implement the safety bundle. The adoption rates for the recommended practices in the four action domains were (1) Readiness, 78.9%; (2) Recognition and Prevention, 76.5%; (3) Response, 63.1%; and (4) Reporting and Systems Learning, 58.7%. Mentors (31/40) and participating teams (48 responses from 39/126 hospitals) provided feedback in an exit survey. Among the respondents, 64.5% of mentors and 72.9% of participants agreed that compared to a traditional collaborative structure, the mentor model was better suited for quality improvement at scale.The mentor model was successful in providing individualized support to teams and enabled implementation of the hemorrhage safety bundle across a diverse group of 126 hospitals.

    View details for DOI 10.1016/j.jcjq.2017.11.005

    View details for Web of Science ID 000432378500003

    View details for PubMedID 29759258

  • Reducing Maternal Mortality and Severe Maternal Morbidity Through State-based Quality Improvement Initiatives. Clinical obstetrics and gynecology Main, E. K. 2018

    Abstract

    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.

    View details for PubMedID 29505420

  • The National Network of State Perinatal Quality Collaboratives: A Growing Movement to Improve Maternal and Infant Health JOURNAL OF WOMENS HEALTH Henderson, Z. T., Ernst, K., Simpson, K., Berns, S., Suchdev, D. B., Main, E., McCaffrey, M., Lee, K., Rouse, T., Olson, C. K. 2018; 27 (3): 221–26

    Abstract

    State Perinatal Quality Collaboratives (PQCs) are networks of multidisciplinary teams working to improve maternal and infant health outcomes. To address the shared needs across state PQCs and enable collaboration, Centers for Disease Control and Prevention (CDC), in partnership with March of Dimes and perinatal quality improvement experts from across the country, supported the development and launch of the National Network of Perinatal Quality Collaboratives (NNPQC). This process included assessing the status of PQCs in this country and identifying the needs and resources that would be most useful to support PQC development. National representatives from 48 states gathered for the first meeting of the NNPQC to share best practices for making measurable improvements in maternal and infant health. The number of state PQCs has grown considerably over the past decade, with an active PQC or a PQC in development in almost every state. However, PQCs have some common challenges that need to be addressed. After its successful launch, the NNPQC is positioned to ensure that every state PQC has access to key tools and resources that build capacity to actively improve maternal and infant health outcomes and healthcare quality.

    View details for PubMedID 29634446

  • The Impact of Maternal Obesity and Race/Ethnicity on Perinatal Outcomes: Independent and Joint Effects OBESITY Snowden, J. M., Mission, J. F., Marshall, N. E., Quigley, B., Main, E., Gilbert, W. M., Chung, J. H., Caughey, A. B. 2016; 24 (7): 1590–98

    Abstract

    Independent and joint impacts of maternal race/ethnicity and obesity on adverse birth outcomes, including pre-eclampsia, low birth weight, and macrosomia, were characterized.Retrospective cohort study of all 2007 California births was conducted using vital records and claims data. Maternal race/ethnicity and maternal body mass index (BMI) were the key exposures; their independent and joint impact on outcomes using regression models was analyzed.Racial/ethnic minority women of normal weight generally had higher risk as compared with white women of normal weight (e.g., African-American women, pre-eclampsia adjusted odds ratio [aOR] 1.60, 95% confidence interval [CI]: 1.48-1.74 vs. white women). However, elevated BMI did not usually confer additional risk (e.g., pre-eclampsia aOR comparing African-American women with excess weight with white women with excess weight, 1.17, 95% CI: 0.89-1.54). Obesity was a risk factor for low birth weight only among white women (excess weight aOR, 1.24, 95% CI: 1.04-1.49 vs. white women of normal weight) and not among racial/ethnic minority women (e.g., African-American women, 0.95, 95% CI: 0.83-1.08).These findings add nuance to our understanding of the interplay between maternal race/ethnicity, BMI, and perinatal outcomes. While the BMI/adverse outcome gradient appears weaker in racial/ethnic minority women, this reflects the overall risk increase in racial/ethnic minority women of all body sizes.

    View details for PubMedID 27222008

  • The Goldilocks Quandary of Health Care Resources Too Little, Too Much, or Just Right? OBSTETRICS AND GYNECOLOGY Morgan, D. M., Main, E., Gee, R. E. 2016; 127 (6): 1039–44

    Abstract

    Appropriate use of health care resources is a priority for improving the quality of care. Overutilization affects almost all specialties including obstetrics and gynecology. Initiatives such as the Choosing Wisely campaign and the Joint Commission Perinatal Care Measures have brought attention to issues of overuse. The decision of these campaigns to focus on eliminating nonmedically indicated inductions before 39 weeks of gestation is an example of how more appropriate health care use can reduce complications and save millions of dollars. Cesarean delivery, hysterectomy, and prophylactic oophorectomy are procedures with high levels of variation in utilization, and the use of an intrauterine device is an example of underutilization. Efforts to promote adherence to best practices such as those directed at nonmedically indicated inductions could lead to more appropriate use of these interventions and improve women's health care.

    View details for PubMedID 27159743

  • Measuring severe maternal morbidity: validation of potential measures AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Main, E. K., Abreo, A., McNulty, J., Gilbert, W., McNally, C., Poeltler, D., Lanner-Cusin, K., Fenton, D., Gipps, T., Melsop, K., Greene, N., Gould, J. B., Kilpatrick, S. 2016; 214 (5)

    Abstract

    Both maternal mortality rate and severe maternal morbidity rate have risen significantly in the United Sates. Recently, the Centers for Disease Control and Prevention introduced International Classification of Diseases, 9th revision, criteria for defining severe maternal morbidity with the use of administrative data sources; however, those criteria have not been validated with the use of chart reviews.The primary aim of the current study was to validate the Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria for the identification of severe maternal morbidity. This analysis initially required the development of a reproducible set of clinical conditions that were judged to be consistent with severe maternal morbidity to be used as the clinical gold standard for validation. Alternative criteria for severe maternal morbidity were also examined.The 67,468 deliveries that occurred during a 12-month period from 16 participating California hospitals were screened initially for severe maternal morbidity with the presence of any of 4 criteria: (1) Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, diagnosis and procedure codes; (2) prolonged postpartum length of stay (>3 standard deviations beyond the mean length of stay for the California population); (3) any maternal intensive care unit admissions (with the use of hospital billing sources); and (4) the administration of any blood product (with the use of transfusion service data). Complete medical records for all screen-positive cases were examined to determine whether they satisfied the criteria for the clinical gold standard (determined by 4 rounds of a modified Delphi technique). Descriptive and statistical analyses that included area under the receiver operating characteristic curve and C-statistic were performed.The Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria had a reasonably high sensitivity of 0.77 and a positive predictive value of 0.44 with a C-statistic of 0.87. The most important source of false-positive cases were mothers whose only criterion was 1-2 units of blood products. The Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria screen rate ranged from 0.51-2.45% among hospitals. True positive severe maternal morbidity ranged from 0.05-1.13%. When hospitals were grouped by their neonatal intensive care unit level of care, severe maternal morbidity rates were statistically lower at facilities with lower level neonatal intensive care units (P < .0001).The Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria can serve as a reasonable administrative metric for measuring severe maternal morbidity at population levels. Caution should be used with the use of these criteria for individual hospitals, because case-mix effects appear to be strong.

    View details for DOI 10.1016/j.ajog.2015.11.004

    View details for Web of Science ID 000375452100025

    View details for PubMedID 26582168

  • Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy OBSTETRICAL & GYNECOLOGICAL SURVEY Hameed, A. B., Lawton, E. S., McCain, C. L., Morton, C. H., Mitchell, C., Main, E. K., Foster, E. 2016; 71 (2): 63–65
  • Clues for understanding hospital variation among obstetric services AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Main, E. K. 2015; 213 (4): 443–44

    View details for PubMedID 26410202

  • National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage OBSTETRICS AND GYNECOLOGY Main, E. K., Goffman, D., Scavone, B. M., Low, L., Bingham, D., Fontaine, P. L., Gorlin, J. B., Lagrew, D. C., Levy, B. S. 2015; 126 (1): 155–62
  • The National Partnership for Maternal Safety: A Call to Action for Anesthesiologists ANESTHESIA AND ANALGESIA Scavone, B. M., Main, E. K. 2015; 121 (1): 14–16

    View details for DOI 10.1213/ANE.0000000000000784

    View details for Web of Science ID 000356669300006

    View details for PubMedID 26086504

  • Pregnancy-Related Mortality in California Causes, Characteristics, and Improvement Opportunities OBSTETRICS AND GYNECOLOGY Main, E. K., McCain, C. L., Morton, C. H., Holtby, S., Lawton, E. S. 2015; 125 (4): 938-947

    Abstract

    To compare specific maternal and clinical characteristics and contributing factors among the five leading causes of pregnancy-related mortality to develop focused clinical and public health prevention programs.California pregnancy-related deaths from 2002-2005 were identified with enhanced surveillance using linked birth and death certificates. A multidisciplinary committee reviewed medical records, autopsy reports, and coroner reports to determine cause of death, clinical and demographic characteristics, chance to alter outcome, contributing factors (at health care provider, facility, and patient levels), and quality improvement opportunities. The five leading causes of death were compared with each other and with the overall California birth population.Among the 207 pregnancy-related deaths, the five leading causes were cardiovascular disease, preeclampsia or eclampsia, hemorrhage, venous thromboembolism, and amniotic fluid embolism. Among the leading causes of death, we identified differing patterns for race, maternal age, body mass index, timing of death, and method of delivery. Overall, there was a good-to-strong chance to alter the outcome in 41% of deaths, with the highest rates of preventability among hemorrhage (70%) and preeclampsia (60%) deaths. Health care provider, facility, and patient contributing factors also varied by cause of death.Pregnancy-related mortality should not be considered a single clinical entity. Reducing mortality requires in-depth examination of individual causes of death. The five leading causes exhibit different characteristics, degrees of preventability, and contributing factors, with the greatest improvement opportunities identified for hemorrhage and preeclampsia. These findings provide additional support for hospital, state, and national maternal safety programs.

    View details for DOI 10.1097/AOG.0000000000000746

    View details for Web of Science ID 000351595200026

    View details for PubMedID 25751214

  • Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy. American journal of obstetrics and gynecology 2015

    Abstract

    Maternal mortality rates rose markedly from 2002 to 2006 in California, prompting an in-depth maternal mortality review in a state that comprises one twelfth of the US birth cohort. Cardiovascular disease has emerged as the leading cause of pregnancy-related death in the United States. The primary aim of this analysis was to describe the incidence and type of cardiovascular disease as a cause of pregnancy-related mortality in California. The secondary aims were to describe racial/ethnic and socioeconomic disparities, risk factors, birth outcomes, timing of death and diagnosis, and signs and symptoms of cardiovascular disease and identify contributing factors.The California Pregnancy-Associated Mortality Review retrospectively examined a case series of 64 cardiovascular pregnancy-related deaths from 2002 through 2006. Two cardiologists independently reviewed complete inpatient and outpatient medical records including laboratory, radiology, electrocardiogram, chest X-ray, echocardiograms, and autopsy findings for each cardiovascular death and classified cause of death by type of cardiovascular disease. Demographic data, racial disparities, risk factors, signs and symptoms, timing of diagnosis and death, birth outcomes, and contributing factors were analyzed using bivariate comparisons with noncardiovascular pregnancy-related deaths and population-based data.Among 2,741,220 California women who gave birth, 864 died while pregnant or within 1 year of pregnancy; 257 of the deaths were deemed pregnancy related, and of these, 64 (25%) were attributed to cardiovascular disease. There were 42 deaths caused by cardiomyopathy, and the pregnancy-related mortality rate from cardiomyopathy was 1.54 per 100,000 births. Dilated cardiomyopathy existed in 29 cases, of which 15 met the definition of peripartum cardiomyopathy. Women with cardiovascular disease were more likely than women who died from noncardiovascular causes to be African-American (39.1% vs 16.1%; P < .01) and more likely to use illicit substances (23.7% vs 9.4%; P < .01). Thirty-seven percent were obese and 20% had a concomitant diagnosis of hypertension or preeclampsia during pregnancy. Health care decisions in the diagnosis or treatment of cardiovascular disease during and after pregnancy contributed to the fatal outcomes.African-American race, substance use, and obesity were risk factors for pregnancy-related cardiovascular disease mortality. Chronic disease prevention and better recognition and response to cardiovascular disease during pregnancy are needed to reduce maternal mortality.

    View details for PubMedID 25979616

  • Executive Summary of the reVITALize Initiative Standardizing Obstetric Data Definitions OBSTETRICS AND GYNECOLOGY Menard, M., Main, E. K., Currigan, S. M. 2014; 124 (1): 150–53

    Abstract

    Precision in language has become critically important with the evolution of the electronic medical record and proliferation of measurement in vital statistics and health care. Taking the opportunity to standardize clinical definitions is a fundamental step in building a robust national data infrastructure that is useful and useable for clinicians and patients. The reVITALize Initiative leads and coordinates a national multidisciplinary movement to standardize obstetric data definitions for written and verbal clinical communication, electronic health record data capture, vital statistics and public health surveillance, measurement, quality improvement, reporting, and research.

    View details for PubMedID 24901267

  • California Pregnancy-Associated Mortality Review: Mixed Methods Approach for Improved Case Identification, Cause of Death Analyses and Translation of Findings MATERNAL AND CHILD HEALTH JOURNAL Mitchell, C., Lawton, E., Morton, C., McCain, C., Holtby, S., Main, E. 2014; 18 (3): 518-526

    Abstract

    After several decades of declining rates, maternal mortality climbed in California from a three-year moving average of 9.4 deaths per 100,000 live births in 1999-2001 to a high of 14.0 deaths per 100,000 live births in 2006-2008 (p < 0.001). The Maternal, Child and Adolescent Health Division of the California Department of Public Health developed a mixed method approach to identify and investigate maternal deaths to inform prevention strategies. This paper describes the methodology of the California Pregnancy-Associated Mortality Review (CA-PAMR) and its advantages for improved surveillance, cause of death analysis, and translation of findings. From 2002 to 2004, 1,598,792 live births occurred in California and 555 women died while pregnant or within one year of pregnancy. A screening algorithm identified cases for review that were likely to be pregnancy-related. Medical records were then abstracted and reviewed by a multidisciplinary committee to determine cause of death, contributing factors, and opportunities for quality improvement. Mixed methods were used to analyze, synthesize and translate Committee recommendations for improved care. Of 211 cases selected for review, 145 deaths were determined to be pregnancy-related. CA-PAMR methods corrected misclassification of cases and more accurately identified the leading causes of death. Cardiovascular disease emerged as the leading cause of pregnancy-related deaths (20%), and African-American women were disproportionately represented among cardiovascular deaths. Overall, the chance to prevent the fatal outcome appeared good or strong in 40% of cases reviewed. The CA-PAMR methodology resulted in additional case finding, improved accuracy of the causes of pregnancy-related deaths, and evidence to guide development of prevention and quality improvement efforts.

    View details for DOI 10.1007/s10995-013-1267-0

    View details for Web of Science ID 000333026600002

    View details for PubMedID 23584929

  • Maternal Mortality Time for National Action OBSTETRICS AND GYNECOLOGY Main, E. K., Menard, M. 2013; 122 (4): 735–36

    View details for PubMedID 24084528

  • In Reply. Obstetrics and gynecology Leonard, S. A., Phibbs, C. S., Main, E. K., Kozhimannil, K. B., Bateman, B. T. 2024; 143 (1): e18-e19

    View details for DOI 10.1097/AOG.0000000000005457

    View details for PubMedID 38096558

  • Trends and Disparities in Severe Maternal Morbidity Indicator Categories During Childbirth Hospitalization in California from 1997-2017. American journal of perinatology El Ayadi, A. M., Lyndon, A., Kan, P., Mujahid, M. S., Main, E. K., Carmichael, S. 2023

    Abstract

    Objective Severe maternal morbidity (SMM) is increasing and characterized by substantial racial and ethnic disparities. Analyzing trends and disparities across time by etiologic or organ system groups instead of an aggregated index may inform specific, actionable pathways to equitable care. We explored trends and racial and ethnic disparities in seven SMM categories at childbirth hospitalization. Study Design We analyzed California birth cohort data on all live and stillbirths ≥20 weeks gestation from 1997-2017 (n=10,580,096) using the Centers for Disease Control and Prevention's SMM index. Cases were categorized into seven non-mutually exclusive indicator categories (cardiac, renal, respiratory, hemorrhage, sepsis, other obstetric, and other medical SMM). We compared prevalence and trends in SMM indicator categories overall and by racial and ethnic group using logistic and linear regression. Results SMM occurred in 1.16% of births and non-transfusion SMM in 0.54%. Hemorrhage SMM occurred most frequently (27 per 10,000 births), followed by other obstetric (11), respiratory (7), and sepsis, cardiac, and renal SMM (5). Hemorrhage, renal, respiratory, and sepsis SMM increased over time for all racial and ethnic groups. The largest disparities were for Black individuals, including over three-fold increased odds of other medical SMM. Renal and sepsis morbidity had the largest relative increases over time (717% and 544%). Sepsis and hemorrhage SMM had the largest absolute changes over time (17 per 10,000 increase). Disparities increased over time for respiratory SMM among Black, US-born Hispanic, and non-US-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals. Disparities decreased over time for sepsis SMM among Black individuals yet remained substantial. Conclusion Our research further supports the critical need to address SMM and disparities as a significant public health priority in the United States and suggests that examining SMM subgroups may reveal helpful nuance for understanding trends, disparities and potential needs for intervention.

    View details for DOI 10.1055/a-2223-3520

    View details for PubMedID 38057087

  • State Variation in Severe Maternal Morbidity Among Individuals with Medicaid Insurance. Obstetrics and gynecology Hirai, A. H., Vladutiu, C. J., Main, E. K., Moore, J. 2023; 142 (4): 989

    View details for DOI 10.1097/AOG.0000000000005356

    View details for PubMedID 37734096

  • Racial and Ethnic Disparities in Anemia and Severe Maternal Morbidity. Obstetrics and gynecology Igbinosa, I. I., Leonard, S. A., Noelette, F., Davies-Balch, S., Carmichael, S. L., Main, E., Lyell, D. J. 2023

    Abstract

    To evaluate antepartum anemia prevalence by race and ethnicity, to assess whether such differences contribute to severe maternal morbidity (SMM), and to estimate the contribution of antepartum anemia to SMM and nontransfusion SMM by race and ethnicity.We conducted a population-based cohort study using linked vital record and birth hospitalization data for singleton births at or after 20 weeks of gestation in California from 2011 through 2020. Pregnant patients with hereditary anemias, out-of-hospital births, unlinked records, and missing variables of interest were excluded. Antepartum anemia prevalence and trends were estimated by race and ethnicity. Centers for Disease Control and Prevention criteria were used for SMM and nontransfusion SMM indicators. Multivariable logistic regression modeling was used to estimate risk ratios (RRs) for SMM and nontransfusion SMM by race and ethnicity after sequential adjustment for social determinants, parity, obstetric comorbidities, delivery, and antepartum anemia. Population attributable risk percentages were calculated to assess the contribution of antepartum anemia to SMM and nontransfusion SMM by race and ethnicity.In total, 3,863,594 births in California were included. In 2020, Black pregnant patients had the highest incidence of antepartum anemia (21.5%), followed by Pacific Islander (18.2%), American Indian-Alaska Native (14.1%), multiracial (14.0%), Hispanic (12.6%), Asian (10.6%), and White pregnant patients (9.6%). From 2011 to 2020, the prevalence of anemia increased more than100% among Black patients, and there was a persistent gap in prevalence among Black compared with White patients. Compared with White patients, the adjusted risk for SMM was high among most racial and ethnic groups; adjustment for anemia after sequential modeling for known confounders decreased SMM risk most for Black pregnant patients (approximated RR 1.47, 95% CI 1.42-1.53 to approximated RR 1.27, 95% CI 1.22-1.37). Compared with White patients, the full adjusted nontransfusion SMM risk remained high for most groups except Hispanic and multiracial patients. Within each racial and ethnic group, the population attributable risk percentage for antepartum anemia and SMM was highest for multiracial patients (21.4%, 95% CI 17.5-25.0%), followed by Black (20.9%, 95% CI 18.1-23.4%) and Hispanic (20.9%, 95% CI 19.9-22.1%) patients. The nontransfusion SMM population attributable risk percentages for Asian, Black, and White pregnant patients were less than 8%.Antepartum anemia, most prevalent among Black pregnant patients, contributed to disparities in SMM by race and ethnicity. Nearly one in five to six SMM cases among Black, Hispanic, American Indian-Alaska Native, Pacific Islander, and multiracial pregnant patients is attributable in part to antepartum anemia.

    View details for DOI 10.1097/AOG.0000000000005325

    View details for PubMedID 37678935

  • Perinatal Care Measures Are Incomplete If They Do Not Assess The Birth Parent-Infant Dyad As A Whole. Health affairs (Project Hope) Handley, S. C., Formanowski, B., Passarella, M., Kozhimannil, K. B., Leonard, S. A., Main, E. K., Phibbs, C. S., Lorch, S. A. 2023; 42 (9): 1266-1274

    Abstract

    Measures of perinatal care quality and outcomes often focus on either the birth parent or the infant. We used linked vital statistics and hospital discharge data to describe a dyadic measure (including both the birth parent and the infant) for perinatal care during the birth hospitalization. In this five-state cohort of 2010-18 births, 21.6 percent of birth parent-infant dyads experienced at least one complication, and 9.6 percent experienced a severe complication. Severe infant complications were eight times more prevalent than severe birth parent complications. Among birth parents with a severe complication, the co-occurrence of a severe infant complication ranged from 2 percent to 51 percent, whereas among infants with a severe complication, the co-occurrence of a severe birth parent complication was rare, ranging from 0.04 percent to 5 percent. These data suggest that measures, clinical interventions, public reporting, and policies focused on either the birth parent or the infant are incomplete in their assessment of a healthy dyad. Thus, clinicians, administrators, and policy makers should evaluate dyadic measures, incentivize positive outcomes for both patients (parent and infant), and create policies that support the health of the dyad.

    View details for DOI 10.1377/hlthaff.2023.00398

    View details for PubMedID 37669487

  • Obstetric Volume and Severe Maternal Morbidity Among Low-Risk and Higher-Risk Patients Giving Birth at Rural and Urban US Hospitals. JAMA health forum Kozhimannil, K. B., Leonard, S. A., Handley, S. C., Passarella, M., Main, E. K., Lorch, S. A., Phibbs, C. S. 2023; 4 (6): e232110

    Abstract

    Identifying hospital factors associated with severe maternal morbidity (SMM) is essential to clinical and policy efforts.To assess associations between obstetric volume and SMM in rural and urban hospitals and examine whether these associations differ for low-risk and higher-risk patients.This retrospective cross-sectional study of linked vital statistics and patient discharge data was conducted from 2022 to 2023. Live births and stillbirths (≥20 weeks' gestation) at hospitals in California (2004-2018), Michigan (2004-2020), Pennsylvania (2004-2014), and South Carolina (2004-2020) were included. Data were analyzed from December 2022 to May 2023.Annual birth volume categories (low, medium, medium-high, and high) for hospitals in urban (10-500, 501-1000, 1001-2000, and >2000) and rural (10-110, 111-240, 241-460, and >460) counties.The main outcome was SMM (excluding blood transfusion); covariates included age, payer status, educational attainment, race and ethnicity, and obstetric comorbidities. Analyses were stratified for low-risk and higher-risk obstetric patients based on presence of at least 1 clinical comorbidity.Among more than 11 million urban births and 519 953 rural births, rates of SMM ranged from 0.73% to 0.50% across urban hospital volume categories (high to low) and from 0.47% to 0.70% across rural hospital volume categories (high to low). Risk of SMM was elevated for patients who gave birth at rural hospitals with annual birth volume of 10 to 110 (adjusted risk ratio [ARR], 1.65; 95% CI, 1.14-2.39), 111 to 240 (ARR, 1.37; 95% CI, 1.10-1.70), and 241 to 460 (ARR, 1.26; 95% CI, 1.05-1.51), compared with rural hospitals with greater than 460 births. Increased risk of SMM occurred for low-risk and higher-risk obstetric patients who delivered at rural hospitals with lower birth volumes, with low-risk rural patients having notable discrepancies in SMM risk between low (ARR, 2.32; 95% CI, 1.32-4.07), medium (ARR, 1.66; 95% CI, 1.20-2.28), and medium-high (ARR, 1.68; 95% CI, 1.29-2.18) volume hospitals compared with high volume (>460 births) rural hospitals. Among hospitals in urban counties, there was no significant association between birth volume and SMM for low-risk or higher-risk obstetric patients.In this cross-sectional study of births in US rural and urban counties, risk of SMM was elevated for low-risk and higher-risk obstetric patients who gave birth in lower-volume hospitals in rural counties, compared with similar patients who gave birth at rural hospitals with greater than 460 annual births. These findings imply a need for tailored quality improvement strategies for lower volume hospitals in rural communities.

    View details for DOI 10.1001/jamahealthforum.2023.2110

    View details for PubMedID 37354537

  • Measuring Severe Maternal Morbidity: Nothing Is Simple JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Main, E. K. 2023; 49 (3): 127-128

    View details for DOI 10.1016/j.jcjq.2023.01.005

    View details for Web of Science ID 000947213100001

    View details for PubMedID 36717343

  • Racial/ethnic disparities in severe maternal morbidity: An intersectional lifecourse approach. Annals of the New York Academy of Sciences Hailu, E. M., Carmichael, S. L., Berkowitz, R. L., Snowden, J. M., Lyndon, A., Main, E., Mujahid, M. S. 2022

    Abstract

    Despite long-existing calls to address alarming racial/ethnic gaps in severe maternal morbidity (SMM), research that considers the impact of intersecting social inequities on SMM risk remains scarce. Invoking intersectionality theory, we sought to assess SMM risk at the nexus of racial/ethnic marginalization, weathering, and neighborhood/individual socioeconomic disadvantage. We used birth hospitalization records from California across 20 years (1997-2017, N = 9,806,406) on all live births ≥20 weeks gestation. We estimated adjusted average predicted probabilities of SMM at the combination of levels of race/ethnicity, age, and neighborhood deprivation or individual socioeconomic status (SES). The highest risk of SMM was observed among Black birthing people aged ≥35 years who either resided in the most deprived neighborhoods or had the lowest SES. Black birthing people conceptualized to be better off due to their social standing (aged 20-34 years and living in the least deprived neighborhoods or college graduates) had comparable and at times worse risk than White birthing people conceptualized to be worse off (aged ≥35 years and living in the most deprived neighborhoods or had a high-school degree or less). Our findings highlight the need to explicitly address structural racism as the driver of racial/ethnic health inequities and the imperative to incorporate intersectional approaches.

    View details for DOI 10.1111/nyas.14901

    View details for PubMedID 36166238

  • Validation of ICD-10-CM Diagnosis Codes for Gestational Age at Birth. Epidemiology (Cambridge, Mass.) Leonard, S. A., Panelli, D. M., Gould, J. B., Gemmill, A., Main, E. K. 2022

    Abstract

    The International Classification of Diseases Clinical Modification 10th Revision (ICD-CM-10) 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.1,770,103 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% CI: 0.96, 0.96) and the mean difference between the two measurements was 0.047 (95% CI: 0.046, 0.047) weeks. 95% 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.

    View details for DOI 10.1097/EDE.0000000000001557

    View details for PubMedID 36166206

  • Hospital variation in extremely preterm birth. Journal of perinatology : official journal of the California Perinatal Association Goldstein, G. P., Kan, P., Phibbs, C. S., Main, E., Shaw, G. M., Lee, H. C. 2022

    Abstract

    Given that regionalization of extremely preterm births (EPTBs) is associated with improved infant outcomes, we assessed between-hospital variation in EPTB stratified by hospital level of neonatal care, and determined the proportion of variance explained by differences in maternal and hospital factors.We assessed 7,046,253 births in California from 1997 to 2011, using hospital discharge, birth, and death certificate data. We estimated the association between maternal and hospital factors and EPTB using multivariable regression, calculated hospital-specific EPTB frequencies, and estimated between-hospital variances and median odds ratios, stratified by hospital level of care.Hospital frequencies of EPTB ranged from 0% to 2.5%. Between-hospital EPTB frequencies varied substantially, despite stratifying by hospital level of care and accounting for confounding factors.Our results demonstrate differences in EPTBs among hospitals with level 1 and 2 neonatal care, an area to target for future research and quality improvement.

    View details for DOI 10.1038/s41372-022-01505-3

    View details for PubMedID 36104499

  • Risk factors and pregnancy outcomes vary among Asian American, Native Hawaiian, and Pacific Islander individuals giving birth in California. Annals of epidemiology Bane, S., Abrams, B., Mujahid, M., Ma, C., Shariff-Marco, S., Main, E., Profit, J., Xue, A., Palaniappan, L., Carmichael, S. L. 2022

    Abstract

    OBJECTIVE: To compare frequencies of risk factors and pregnancy outcomes in ethnic groups versus the combined total of Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations.METHODS: Using linked birth and fetal death certificate and maternal hospital discharge data (California 2007-2018), we estimated frequencies of 15 clinical and sociodemographic exposures and 11 pregnancy outcomes. Variability across 15 AANHPI groups was compared using a heat map and compared to frequencies for the total group (n=904,232).RESULTS: AANHPI groups varied significantly from each other and the combined total regarding indicators of social disadvantage (e.g., range for high school-level educational or less: 6.4% Korean-55.8% Samoan) and sociodemographic factors (e.g., maternal age <20 years: 0.2% Chinese-8.8% Guamanian) that are related to adverse pregnancy outcomes. Perinatal outcomes varied significantly (e.g., severe maternal morbidity: 1.2% Korean-1.9% Filipino). No single group consistently had risk factors or outcome prevalence at the extremes, i.e., no group was consistently better or worse off across examined factors.CONCLUSIONS: Substantial variability in perinatal risk factors and outcomes exists across AANHPI groups. Aggregation into "AANHPI" is not appropriate for outcome reporting.

    View details for DOI 10.1016/j.annepidem.2022.09.004

    View details for PubMedID 36115627

  • How State Perinatal Quality Collaboratives Can Improve Rural Maternity Care. Clinical obstetrics and gynecology Main, E. K., Sakowski, C. 2022

    Abstract

    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.

    View details for DOI 10.1097/GRF.0000000000000748

    View details for PubMedID 36162095

  • Trends in Severe Maternal Morbidity in the US Across the Transition to ICD-10-CM/PCS From 2012-2019. JAMA network open Hirai, A. H., Owens, P. L., Reid, L. D., Vladutiu, C. J., Main, E. K. 2022; 5 (7): e2222966

    Abstract

    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.

    View details for DOI 10.1001/jamanetworkopen.2022.22966

    View details for PubMedID 35900764

  • Associations Between State-Level Severe Maternal Morbidity and Other Perinatal Indicators. JAMA network open Hirai, A. H., Owens, P. L., Reid, L. D., Vladutiu, C. J., Main, E. K. 2022; 5 (7): e2224621

    View details for DOI 10.1001/jamanetworkopen.2022.24621

    View details for PubMedID 35900765

  • Sexual and/or Gender Minority Parental Structures among California Births, 2016-2020. American journal of obstetrics & gynecology MFM Berrahou, I. K., Leonard, S. A., Zhang, A., Main, E. K., Obedin-Maliver, J. 2022: 100653

    Abstract

    BACKGROUND: Sexual and/or gender minority (SGM) people account for roughly 7.1% of the U.S. population, and an estimated one-third are parents. Little is known about SGM people who become pregnant, despite this population having documented health care disparities that may impact pregnancy.OBJECTIVES: Our objective was to describe parental structures among birth parents and the pre-pregnancy characteristics of parents giving birth in likely sexual and/or gender minority (SGM) parental structures from California birth certificates.STUDY DESIGN: 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 all structures designating a "father" as the "parent giving birth" into likely SGM groups. We assessed the distribution of pre-pregnancy characteristics across parental structure groups ("mother-father," "SGM," "mother only," "unclassified," and "missing both parental roles").RESULTS: SGM parents accounted for 6,802 (0.3%) of live births in California over the 5-year study period. The most common SGM parental structures were "mother-mother" (n=4,310; 63% of the group) and "father-father" (n=1,486; 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 "SGM" group were 35 years or older, white, college-educated, and had commercial health insurance. In addition, a higher proportion had a high pre-pregnancy body mass index. Although likely underreported overall, the proportion who used assisted reproductive technology was much higher among those in the "SGM" group (1.4%) than in the "mother-father" group (0.05%). Cigarette smoking in the three months prior to pregnancy was similar in both groups.CONCLUSION: Changes to the California birth certificate have revealed a multiplicity of parental structures. Our findings suggest that SGM parents differ from other parental structures and from the general SGM population and warrant further research.

    View details for DOI 10.1016/j.ajogmf.2022.100653

    View details for PubMedID 35462057

  • Sexual and/or gender minority disparities in obstetric and birth outcomes. American journal of obstetrics and gynecology Leonard, S. A., Berrahou, I., Zhang, A., Monseur, B., Main, E. K., Obedin-Maliver, J. 2022

    Abstract

    Many sexual and/or gender minority individuals build families through pregnancy and childbirth, but it is unknown whether they experience different clinical outcomes than non-sexual and/or gender minority individuals.To evaluate obstetric and birth outcomes among likely sexual and/or gender minority patients in comparison with likely non-sexual and/or gender minority patients.We performed a population-based cohort study of live birth hospitalizations during 2016-2019 linked to birth certificates in California. California changed its birth certificate in 2016 to include gender-neutral fields "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 risk ratios for associations between likely sexual and/or gender minority parental structures and outcomes. Models were adjusted for sociodemographic factors, comorbidities, and multifetal gestation selected by causal diagrams. We replicated analyses after excluding multifetal gestations.In the final birthing patient sample, 1,483,119 were mothers with father partners, 2,572 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 (aRR 3.9, 95% CI 3.4-4.4), labor induction (aRR 1.2, 95% CI 1.1-1.3), postpartum hemorrhage (aRR 1.4, 95% CI 1.3-1.6), severe morbidity (aRR 1.4, 95% CI 1.2-1.8), and non-transfusion severe morbidity (aRR 1.4, 95% CI 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 birth, preterm birth (<37 weeks' gestation), low birthweight (<2,500 g), and low Apgar score (<7 at 5 minutes) did not significantly differ in 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, although the risk of multifetal gestation was non-significantly higher (aRR 1.5, 95% CI 0.9-2.7). Adjusted risk ratios for outcomes were similar after restriction to singleton gestations.Birthing mothers with mother partners experienced disparities in several obstetric and birth outcomes, independent of sociodemographic factors, comorbidities, and multifetal gestation. Birthing fathers in any partnership were not at significantly elevated risk of any adverse obstetric or birth outcome considered in this study.

    View details for DOI 10.1016/j.ajog.2022.02.041

    View details for PubMedID 35358492

  • Composite Perinatal Morbidity Metrics: Getting closer but still with challenges. Paediatric and perinatal epidemiology Main, E. K. 2022; 36 (2): 202-204

    View details for DOI 10.1111/ppe.12849

    View details for PubMedID 35188671

  • The effect of severe maternal morbidity on infant costs and lengths of stay. Journal of perinatology : official journal of the California Perinatal Association Phibbs, C. M., Kozhimannil, K. B., Leonard, S. A., Lorch, S. A., Main, E. K., Schmitt, S. K., Phibbs, C. S. 2022

    Abstract

    OBJECTIVE: 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.STUDY DESIGN: 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.RESULTS: 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).CONCLUSIONS: 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.

    View details for DOI 10.1038/s41372-022-01343-3

    View details for PubMedID 35184145

  • A Comprehensive Analysis of the Costs of Severe Maternal Morbidity. Women's health issues : official publication of the Jacobs Institute of Women's Health Phibbs, C. M., Kozhimannil, K. B., Leonard, S. A., Lorch, S. A., Main, E. K., Schmitt, S. K., Phibbs, C. S. 1800

    Abstract

    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 through 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 the 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 a 33% increase in LOS (ME 0.9days). These increased to 70% (ME $5,806) and 46% (ME 1.3days) when physician costs and readmissions were included. The effects of SMM were roughly one-half as large for patients who only required a blood transfusion (49% [ME $4,056] and 31% [ME 0.9days]) as for patients who had another indicator for SMM (93% [ME $7,664] and 62% [ME 1.7days]).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 decreasing SMM may have broader health and cost benefits than previously understood.

    View details for DOI 10.1016/j.whi.2021.12.006

    View details for PubMedID 35031196

  • Validation of ICD-10-CM Diagnosis Codes for Gestational Age at Birth Leonard, S. A., Gould, J. B., Main, E. K. MOSBY-ELSEVIER. 2022: S429
  • HOSPITAL VARIATION IN EXTREMELY PRETERM BIRTH Goldstein, G. P., Kan, P., Phibbs, C., Main, E., Shaw, G. M., Lee, H. BMJ PUBLISHING GROUP. 2022: 215
  • Obstetric and birth outcomes among sexual and/or gender minority patients, California, 2016-2019 Leonard, S. A., Berrahou, I., Zhang, A., Main, E. K., Obedin-Maliver, J. MOSBY-ELSEVIER. 2022: S69-S70
  • Constructing a cohort of nulliparous, term, singleton, vertex births from electronic health records Callahan, A., Murugappan, G., Main, E. K., Leonard, S. A. MOSBY-ELSEVIER. 2022: S521-S522
  • Health Disparities in Antepartum Anemia: The Intersection of Race and Social Determinants of Health Igbinosa, I., Leonard, S. A., Noelette, F., Mujahid, M., Main, E. K., Lyell, D. J. MOSBY-ELSEVIER. 2022: S529-S530
  • Ways Forward in Preventing Severe Maternal Morbidity and Maternal Health Inequities: Conceptual Frameworks, Definitions, and Data, from a Population Health Perspective. Women's health issues : official publication of the Jacobs Institute of Women's Health Carmichael, S. L., Abrams, B., El Ayadi, A., Lee, H. C., Liu, C., Lyell, D. J., Lyndon, A., Main, E. K., Mujahid, M., Tian, L., Snowden, J. M. 1800

    View details for DOI 10.1016/j.whi.2021.11.006

    View details for PubMedID 34972599

  • Birth registration policies in the United States and their relevance to sexual and/or gender minority families: Identifying existing strengths and areas of improvement. Social science & medicine (1982) Zhang, A., Berrahou, I., Leonard, S. A., Main, E. K., Obedin-Maliver, J. 1800; 293: 114633

    Abstract

    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.

    View details for DOI 10.1016/j.socscimed.2021.114633

    View details for PubMedID 34933243

  • Hospital Quality Improvement Interventions, Statewide Policy Initiatives, and Rates of Cesarean Delivery for Nulliparous, Term, Singleton, Vertex Births in California OBSTETRICAL & GYNECOLOGICAL SURVEY Rosenstein, M. G., Chang, S., Sakowski, C., Markow, C., Teleki, S., Lang, L., Logan, J., Cape, V., Main, E. K. 2021; 76 (10): 593-595
  • COST-EFFECTIVENESS OF A STATE PERINATAL QUALITY COLLABORATIVE FOR REDUCING SEVERE MATERNAL MORBIDITY FROM HEMORRHAGE Wiesehan, E., Keesara, S., Krissberg, J., Main, E., Goldhaber-Fiebert, J. D. SAGE PUBLICATIONS INC. 2021: E8-E9
  • Culture That Facilitates Change: A Mixed Methods Study of Hospitals Engaged in Reducing Cesarean Deliveries ANNALS OF FAMILY MEDICINE VanGompel, E., Perez, S. L., Datta, A., Carlock, F. R., Cape, V., Main, E. K. 2021; 19 (3): 249-257

    View details for DOI 10.1370/afm.2675

    View details for Web of Science ID 000650175800010

  • Severe Maternal Morbidity: A Comparison of Definitions and Data Sources. American journal of epidemiology Snowden, J. M., Lyndon, A., Kan, P., El Ayadi, A., Main, E., Carmichael, S. L. 2021

    Abstract

    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 US, one common way of defining SMM at the population level is an index developed by the Centers for Disease Control and Prevention. Modifications have been proposed to this index (e.g., excluding maternal transfusion); some research defines SMM using an index introduced by Bateman et al. Birth certificate data are also increasingly being used to define SMM. We compared commonly used US definitions of SMM to each other among all California births, 2007-2012, using the Kappa statistic and other measures. We also evaluated agreement between maternal morbidity fields on the birth certificate compared to claims data. Concordance was generally low between the 7 definitions of SMM analyzed (i.e., kappa < 0.4 for 13 of 21 two-way comparisons), Low concordance was particularly driven by presence/absence of transfusion and claims data versus birth certificate definitions. Low agreement between administrative data-based definitions of SMM highlights that results can be expected to differ between them. Further research is needed on validity of SMM definitions, using more fine-grained data sources.

    View details for DOI 10.1093/aje/kwab077

    View details for PubMedID 33755046

  • Maternal and neonatal health care worker well-being and patient safety climate amid the COVID-19 pandemic. Journal of perinatology : official journal of the California Perinatal Association Haidari, E., Main, E. K., Cui, X., Cape, V., Tawfik, D. S., Adair, K. C., Sexton, B. J., Profit, J. 2021

    Abstract

    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.

    View details for DOI 10.1038/s41372-021-01014-9

    View details for PubMedID 33727700

  • Enhanced maternal mortality surveillance identifies higher mortality ratios and greater racial/ethnic disparity than death certificates Krakowiak, P., Sun, D., McCain, C., Morton, C. H., Ramos, D. E., Reynen, D. J., Main, E. K., Mitchell, C. MOSBY-ELSEVIER. 2021: S229–S230
  • Measuring Variation in Interpregnancy Interval: Identifying Hotspots for Improvement Initiatives. American journal of perinatology Karakash, S. D., Main, E. K., Chang, S. C., Shaw, G. M., Stevenson, D. K., Gould, J. B. 2021

    Abstract

     The study aimed to determine if single year birth certificate data can be used to identify regional and hospital variation in rates of short interpregnancy interval (IPI < 6 months). IPI was estimated for multiparous women ages 15 to 44 years with singleton live births between 2015 and 2016. Perinatal outcomes, place of birth, maternal race, and data for IPI calculations were obtained by using birth certificates. IPI frequencies are presented as observed rates. The cohort included 562,039 multiparous women. Short IPI rates were similar to those obtained with analyses by using linked longitudinal data and confirmed the association with preterm birth. Short IPI rates varied by race and Hispanic nativity. There was substantial hospital (0.8-9%) and regional (2.9-6.2%) variation in short IPI rates. IPI rates can be reliably obtained from current year birth certificate data. This can be a useful tool for quality improvement projects targeting interventions and rapidly assessing their progress to promote optimal birth spacing.· Near-real time regional and hospital IPI rates can be reliably obtained from current year birth certificate data.. · Substantial variations in rates of short IPI exist between hospital and perinatal regions.. · IPI rates from individual birth certificates can be a tool to target and assess interventions..

    View details for DOI 10.1055/s-0041-1728819

    View details for PubMedID 33940645

  • Association of Maternal Comorbidity With Severe Maternal Morbidity: A Cohort Study of California Mothers Delivering Between 1997 and 2014. Annals of internal medicine Main, E. K., Leonard, S. A., Menard, M. K. 2020; 173 (11_Supplement): S11–S18

    Abstract

    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 9179472 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.

    View details for DOI 10.7326/M19-3253

    View details for PubMedID 33253023

  • Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Cardiovascular Disease Van Otterloo, L., Main, E., Seacrist, M., Morton, C. H. ELSEVIER SCIENCE INC. 2020: S13
  • Weight gain during pregnancy and the risk of severe maternal morbidity by prepregnancy BMI. The American journal of clinical nutrition Leonard, S. A., Abrams, B., Main, E. K., Lyell, D. J., Carmichael, S. L. 2020

    Abstract

    BACKGROUND: High and low prepregnancy BMI are risk factors for severe maternal morbidity (SMM), but the contribution of gestational weight gain (GWG) is not well understood.OBJECTIVES: We evaluated associations between GWG and SMM by prepregnancy BMI group.METHODS: We analyzed administrative records from 2,483,684 Californian births (2007-2012), utilizing z score charts to standardize GWG for gestational duration. We fit the z scores nonlinearly and categorized GWG as above, within, or below the Institute of Medicine (IOM) recommendations after predicting equivalent GWG at term from the z score charts. SMM was defined using a validated index. Associations were estimated using multivariable logistic regression models.RESULTS: We found generally shallow U-shaped relations between GWG z score and SMM in all BMI groups, except class 3 obesity (≥40kg/m2), for which risk was lowest with weight loss. The weight gain amount associated with the lowest risk of SMM was within the IOM recommendations for underweight and class 2 obesity, but above the IOM recommendations for normal weight, overweight, and class 1 obesity. The adjusted risk ratios (RRs) and 95% CIs for GWG below the IOM recommendations, compared with GWG within the recommendations, were the following for underweight, normal weight, overweight, class 1 obesity, class 2 obesity, and class 3 obesity: 1.13 (0.99, 1.29), 1.09 (1.04, 1.14), 1.10 (1.01, 1.19), 1.07 (0.95, 1.21), 1.03 (0.88, 1.22), and 0.89 (0.73, 1.08), respectively. For GWG above the recommendations, the corresponding RRs and 95% CIs were 0.99 (0.84, 1.15), 1.04 (0.99, 1.08), 0.98 (0.92, 1.04), 1.03 (0.95, 1.13), 1.07 (0.94, 1.23), and 1.08 (0.91, 1.30), respectively.CONCLUSIONS: High and low GWG may be modestly associated with increased risk of SMM across BMI groups, except in women with class 3 obesity, for whom low weight gain and weight loss may be associated with decreased risk of SMM.

    View details for DOI 10.1093/ajcn/nqaa033

    View details for PubMedID 32119734

  • Racial and Ethnic Disparities in Hospital-Based Care Associated with Postpartum Depression. Journal of racial and ethnic health disparities Chan, A. L., Guo, N. n., Popat, R. n., Robakis, T. n., Blumenfeld, Y. Y., Main, E. n., Scott, K. A., Butwick, A. J. 2020

    Abstract

    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.

    View details for DOI 10.1007/s40615-020-00774-y

    View details for PubMedID 32474833

  • Pre-pregnancy Obesity and the Risk of Peripartum Cardiomyopathy. American journal of perinatology Cho, S. H., Leonard, S. A., Lyndon, A. n., Main, E. K., Abrams, B. n., Hameed, A. B., Carmichael, S. L. 2020

    Abstract

     The aim of this study is to evaluate the contribution of pre-pregnancy obesity and overweight to peripartum cardiomyopathy. 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. 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. 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.· Pre-pregnancy obesity affects maternal health.. · Effects may extend to peripartum cardiomyopathy.. · The risk includes peripartum cardiomyopathy that emerges postpartum..

    View details for DOI 10.1055/s-0040-1712451

    View details for PubMedID 32512606

  • Quality and Safety Programs in Obstetrics and Gynecology. Clinical obstetrics and gynecology Main, E. K. 2019

    View details for DOI 10.1097/GRF.0000000000000482

    View details for PubMedID 31305486

  • Measuring labor and delivery unit culture and clinicians' attitudes toward birth: Revision and validation of the Labor Culture Survey BIRTH-ISSUES IN PERINATAL CARE VanGompel, E., Perez, S., Wang, C., Datta, A., Cape, V., Main, E. 2019; 46 (2): 300–310

    View details for DOI 10.1111/birt.12406

    View details for Web of Science ID 000468219400011

  • Systolic Hypertension, Preeclampsia-Related Mortality, and Stroke in California. Obstetrics and gynecology Judy, A. E., McCain, C. L., Lawton, E. S., Morton, C. H., Main, E. K., Druzin, M. L. 2019

    Abstract

    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 deaths in California from 2002 to 2007. Stroke cases were identified among preeclampsia deaths, and case summaries were reviewed with attention to clinical variables, particularly hypertension. Health care provider- and patient-related contributing factors were also examined.RESULTS: Among 54 preeclampsia pregnancy-related deaths that occurred in California from 2002 to 2007, 33 were attributed to stroke. Systolic blood pressure exceeded 160 mm Hg in 96% of cases, and diastolic blood pressure was 110 or higher in 65% of cases. Hemolysis, elevated liver enzymes, and low platelet count syndrome was present in 38% (9/24) of cases with available laboratory data; eclampsia occurred in 36% of cases. Headache was the most frequent symptom (87%) preceding stroke. Elevated liver transaminases were the most common laboratory abnormality (71%). Only 48% of women received antihypertensive treatment. A good-to-strong chance to alter outcome was identified in stroke cases 66% (21/32), with delayed response to clinical warning signs in 91% (30/33) of cases and ineffective treatment in 76% (25/33) cases being the most common areas for improvement.CONCLUSION: Stroke is the major cause of maternal mortality associated with preeclampsia or eclampsia. All but one patient in this series of strokes demonstrated severe elevation of systolic blood pressure, whereas other variables were less consistently observed. Antihypertensive treatment was not implemented in the majority of cases. Opportunities for care improvement exist and may significantly affect maternal mortality.

    View details for PubMedID 31083120

  • Racial and ethnic disparities in severe maternal morbidity prevalence and trends ANNALS OF EPIDEMIOLOGY Leonard, S. A., Main, E. K., Scott, K. A., Profit, J., Carmichael, S. L. 2019; 33: 30–36
  • Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Preeclampsia/Eclampsia JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Morton, C. H., Seacrist, M. J., VanOtterloo, L. R., Main, E. K. 2019; 48 (3): 275–87

    Abstract

    To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from preeclampsia/eclampsia by the California Pregnancy-Associated Mortality Review Committee.Qualitative descriptive design using thematic analysis.A total of 242 QIOs identified from 54 cases of pregnancy-related deaths from preeclampsia/eclampsia in California between 2002 and 2007.We coded and thematically organized the 242 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.Standardized Policies and Protocols to manage severe hypertension and respond to obstetric emergencies was the main theme identified in the Readiness domain. For Recognition, issues related to Missed Clinical Warning Signs of worsening preeclampsia/eclampsia were predominant. In the Response domain, the themes Inadequate Assessment and Treatment of severe hypertension and Coordination of Care were most frequently noted.Findings from our study suggest numerous opportunities to improve care and outcomes for women who died of preeclampsia/eclampsia in California from 2002 to 2007. Facilities need to adopt and implement standardized policies and protocols about the diagnosis and treatment of preeclampsia/eclampsia. Clinician education about key warning signs is critical, as is ensuring that women understand the signs and symptoms that warrant immediate clinical attention. Death from preeclampsia/eclampsia is very preventable, and efforts to reduce maternal mortality and morbidity from this serious condition of pregnancy are needed at all levels.

    View details for DOI 10.1016/j.jogn.2019.02.008

    View details for Web of Science ID 000467251700004

    View details for PubMedID 30980787

  • Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Sepsis JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Seacrist, M. J., Morton, C. H., VanOtterloo, L. R., Main, E. K. 2019; 48 (3): 311–20

    Abstract

    To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from sepsis by the California Pregnancy-Associated Mortality Review Committee.Qualitative descriptive design using thematic analysis.A total of 118 QIOs identified from 27 cases of pregnancy-related deaths from sepsis in California from 2002 to 2007.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.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.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.

    View details for DOI 10.1016/j.jogn.2019.02.007

    View details for Web of Science ID 000467251700007

    View details for PubMedID 30974075

  • Translating Maternal Mortality Review Into Quality Improvement Opportunities in Response to Pregnancy-Related Deaths in California JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Morton, C. H., VanOtterloo, L. R., Seacrist, M. J., Main, E. K. 2019; 48 (3): 252–62

    Abstract

    To describe quality improvement opportunities (QIOs) associated with the five leading causes of pregnancy-related death in California and the methods by which the QIOs were collected by the California Pregnancy-Associated Mortality Review committee.Qualitative, descriptive design using thematic analysis.A total of 907 QIOs identified from 203 cases of pregnancy-related deaths from cardiovascular disease, preeclampsia/eclampsia, hemorrhage, venous thromboembolism, and sepsis that occurred in California from 2002 to 2007.We coded and thematically organized QIO data 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. We refer to the domains collectively as the 4R Framework.We identified key themes across the five leading causes of death. In the Readiness domain, themes were related to overall facility readiness and helping women be prepared and knowledgeable about pregnancy and childbirth. Themes that emerged as central in the Recognition domain addressed the need for clinicians to better recognize risk factors and women's signs and symptoms to ensure an accurate diagnosis. In the Response domain, three themes were predominant, and they were related to the coordination of care, timing of treatment, and follow-up care.Results from our study show the utility and transferability of the first three domains of the 4R Framework as applied to quality improvement data from a large statewide maternal mortality review. Nursing leadership is necessary to support and guide national, statewide, and local efforts to improve the quality of maternity care through the implementation of quality improvement at the system, facility, clinician, and patient levels.

    View details for DOI 10.1016/j.jogn.2019.03.003

    View details for Web of Science ID 000467251700002

    View details for PubMedID 30981725

  • Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Obstetric Hemorrhage JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Seacrist, M. J., VanOtterloo, L. R., Morton, C. H., Main, E. K. 2019; 48 (3): 288–99

    Abstract

    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.Qualitative descriptive using thematic analysis.A total of 159 QIOs identified from 33 cases of pregnancy-related deaths from obstetric hemorrhage in California from 2002 to 2007.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.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.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.

    View details for DOI 10.1016/j.jogn.2019.03.002

    View details for Web of Science ID 000467251700005

    View details for PubMedID 30981726

  • Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Venous Thromboembolism JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING VanOtterloo, L. R., Seacrist, M. J., Morton, C. H., Main, E. K. 2019; 48 (3): 300–310

    Abstract

    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.Qualitative, descriptive design using thematic analysis.A total of 108 QIOs identified from 29 cases of pregnancy-related deaths from VTE in California from 2002 to 2007.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.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.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.

    View details for DOI 10.1016/j.jogn.2019.02.006

    View details for Web of Science ID 000467251700006

    View details for PubMedID 30986370

  • Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Cardiovascular Disease JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING VanOtterloo, L. R., Morton, C. H., Seacrist, M. J., Main, E. K. 2019; 48 (3): 263–74

    Abstract

    To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from cardiovascular disease (CVD) by the California Pregnancy-Associated Mortality Review committee.Qualitative descriptive design using thematic analysis.A total of 269 QIOs identified from 87 pregnancy-related deaths from CVD in California from 2002 to 2007.We coded and thematically organized the 269 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.The most prevalent theme within the Readiness domain was the care of women in a facility or a department within a facility that was not equipped to handle the severity of their CVD conditions. For Recognition, a common theme was an underappreciation of the severity of illness, including high-risk factors and clinical warning signs, which led to inaccurate diagnoses, such as anxiety or asthma, and missed diagnoses of CVD. The lack of recognition of CVD led to delays in treatment or inaccurate treatment, the leading themes in the Response domain.Identification of CVD or its risk factors during pregnancy can lead to timely, multidisciplinary approaches to management and birth in facilities that offer appropriately trained health care professionals and appropriate equipment. Maternal mortality can be reduced if signs and symptoms of CVD in women are recognized early and treatment modalities are implemented quickly during pregnancy, childbirth, and the postpartum period.

    View details for DOI 10.1016/j.jogn.2019.03.001

    View details for Web of Science ID 000467251700003

    View details for PubMedID 30998902

  • Cesarean overuse and the culture of care HEALTH SERVICES RESEARCH VanGompel, E., Perez, S., Datta, A., Wang, C., Cape, V., Main, E. 2019; 54 (2): 417–24
  • The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity. BMC pregnancy and childbirth Leonard, S. A., Main, E. K., Carmichael, S. L. 2019; 19 (1): 16

    Abstract

    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.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.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.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.

    View details for DOI 10.1186/s12884-018-2169-3

    View details for PubMedID 30626349

    View details for PubMedCentralID PMC6327483

  • Risk of severe maternal morbidity in relation to prepregnancy body mass index: Roles of maternal co-morbidities and caesarean birth. Paediatric and perinatal epidemiology Leonard, S. A., Carmichael, S. L., Main, E. K., Lyell, D. J., Abrams, B. n. 2019

    Abstract

    An association between prepregnancy body mass index (BMI) and severe maternal morbidity (SMM) has been reported, but evidence has been mixed and potential explanations have not been examined.To evaluate the association between prepregnancy BMI and SMM in a large, diverse birth cohort and assess potential mediation by obesity-related co-morbidities and caesarean birth.This cohort study used linked birth certificate and hospitalisation discharge records from Californian births during 2007-2012. We assessed associations between prepregnancy BMI and SMM, and used inverse probability weighting for multiple mediators to estimate relative and absolute natural direct and indirect effects accounting for mediation by co-morbidities (hypertensive conditions, diabetes, asthma) and caesarean birth.Among 2 650 182 births, the prevalence of SMM was 1.42%. Adjusted risk ratios for the total association between prepregnancy BMI category and SMM were 1.12 (95% confidence interval [CI] 1.07, 1.18) for underweight, 1.02 (95% CI 0.99, 1.04) for overweight, 1.04 (95% CI 1.00, 1.07) for obesity class 1, 1.14 (95% CI 1.09, 1.20) for obesity class 2, and 1.28 (95% CI 1.22, 1.36) for obesity class 3 compared to women with normal weight. After accounting for mediation by co-morbidity and caesarean birth, the risk ratios were 1.19 (95% CI 1.14, 1.26) for underweight, 0.91 (95% CI 0.89, 0.94) for overweight, 0.86 (95% CI 0.84, 0.89) for obesity class 1, 0.88 (95% CI 0.84, 0.92) for obesity class 2, and 0.89 (95% CI 0.83, 0.95) for obesity class 3.Co-morbidities and caesarean birth explained an association between high prepregnancy BMI and SMM. These findings suggest that promotion of healthy prepregnancy weight, along with management of co-morbidities and support of vaginal birth in pregnant women with high BMI, could reduce the risk of SMM. However, these mediators did not reduce the elevated risk of SMM observed in women with low BMI.

    View details for DOI 10.1111/ppe.12555

    View details for PubMedID 31106879

  • In Reply. Obstetrics and gynecology Judy, A. E., McCain, C. L., Lawton, E. S., Morton, C. H., Main, E. K., Druzin, M. L. 2019; 134 (4): 880–81

    View details for DOI 10.1097/AOG.0000000000003494

    View details for PubMedID 31568351

  • Reducing Maternal Mortality and Severe Maternal Morbidity Through State-based Quality Improvement Initiatives CLINICAL OBSTETRICS AND GYNECOLOGY Main, E. K. 2018; 61 (2): 319–31
  • The National Network of State Perinatal Quality Collaboratives: A Growing Movement to Improve Maternal and Infant Health. Journal of women's health (2002) Henderson, Z. T., Ernst, K., Simpson, K. R., Berns, S. D., Suchdev, D. B., Main, E., McCaffrey, M., Lee, K., Rouse, T. B., Olson, C. K. 2018; 27 (2): 123-127

    Abstract

    State Perinatal Quality Collaboratives (PQCs) are networks of multidisciplinary teams working to improve maternal and infant health outcomes. To address the shared needs across state PQCs and enable collaboration, Centers for Disease Control and Prevention, in partnership with March of Dimes and perinatal quality improvement experts from across the country, supported the development and launch of the National Network of PQCs National Network of Perinatal Quality Collaboratives (NNPQC). This process included assessing the status of PQCs in this country and identifying the needs and resources that would be most useful to support PQC development. National representatives from 48 states gathered for the first meeting of the NNPQC to share best practices for making measurable improvements in maternal and infant health. The number of state PQCs has grown considerably over the past decade, with an active PQC or a PQC in development in almost every state. However, PQCs have some common challenges that need to be addressed. After its successful launch, the NNPQC is positioned to ensure that every state PQC has access to key tools and resources that build capacity to actively improve maternal and infant health outcomes and healthcare quality.

    View details for DOI 10.1089/jwh.2017.6844

    View details for PubMedID 29389242

  • TIME OF BIRTH AND THE RISK OF SEVERE UNEXPECTED COMPLICATIONS IN TERM SINGLETON NEWBORNS Gould, J. B., Abreo, A., Main, E. K. WILEY. 2017: 13
  • Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Main, E. K., Cape, V., Abreo, A., Vasher, J., Woods, A., Carpenter, A., Gould, J. B. 2017; 216 (3)

    Abstract

    Obstetric hemorrhage is the leading cause of severe maternal morbidity and of preventable maternal mortality in the United States. The California Maternal Quality Care Collaborative developed a comprehensive quality improvement tool kit for hemorrhage based on the national patient safety bundle for obstetric hemorrhage and noted promising results in pilot implementation projects.We sought to determine whether these safety tools can be scaled up to reduce severe maternal morbidity in women with obstetric hemorrhage using a large maternal quality collaborative.We report on 99 collaborative hospitals (256,541 annual births) using a before-and-after model with 48 noncollaborative comparison hospitals (81,089 annual births) used to detect any systemic trends. Both groups participated in the California Maternal Data Center providing baseline and rapid-cycle data. Baseline period was the 48 months from January 2011 through December 2014. The collaborative started in January 2015 and the postintervention period was the 6 months from October 2015 through March 2016. We modified the Institute for Healthcare Improvement collaborative model for achieving breakthrough improvement to include the mentor model whereby 20 pairs of nurse and physician mentors experienced in quality improvement gave additional support to small groups of 6-8 hospitals. The national hemorrhage safety bundle served as the template for quality improvement action. The main outcome measurement was the composite Centers for Disease Control and Prevention severe maternal morbidity measure, for both the target population of women with hemorrhage and the overall delivery population. The rate of adoption of bundle elements was used as an indicator of hospital engagement and intensity.Compared to baseline period, women with hemorrhage in collaborative hospitals experienced a 20.8% reduction in severe maternal morbidity while women in comparison hospitals had a 1.2% reduction (P < .0001). Women in hospitals with prior hemorrhage collaborative experience experienced an even larger 28.6% reduction. Fewer mothers with transfusions accounted for two thirds of the reduction in collaborative hospitals and fewer procedures and medical complications, the remainder. The rate of severe maternal morbidity among all women in collaborative hospitals was 11.7% lower and women in hospitals with prior hemorrhage collaborative experience had a 17.5% reduction. Improved outcomes for women were noted in all hospital types (regional, medium, small, health maintenance organization, and nonhealth maintenance organization). Overall, 54% of hospitals completed 14 of 17 bundle elements, 76% reported regular unit-based drills, and 65% reported regular posthemorrhage debriefs. Higher rate of bundle adoption was associated with improvement of maternal morbidity only in hospitals with high initial rates of severe maternal morbidity.We used an innovative collaborative quality improvement approach (mentor model) to scale up implementation of the national hemorrhage bundle. Participation in the collaborative was strongly associated with reductions in severe maternal morbidity among hemorrhage patients. Women in hospitals in their second collaborative had an even greater reduction in morbidity than those approaching the bundle for the first time, reinforcing the concept that quality improvement is a long-term and cumulative process.

    View details for DOI 10.1016/j.ajog.2017.01.017

    View details for Web of Science ID 000397089700033

    View details for PubMedID 28153661

  • Relationship of Hospital Staff Coverage and Delivery Room Resuscitation Practices to Birth Asphyxia. American journal of perinatology Tu, J. H., Profit, J., Melsop, K., Brown, T., Davis, A., Main, E., Lee, H. C. 2017; 34 (3): 259-263

    Abstract

    Objective The objective of this study was to assess utilization of specialist coverage and checklists in perinatal settings and to examine utilization by birth asphyxia rates. Design This is a survey study of California maternity hospitals concerning checklist use to prepare for delivery room resuscitation and 24-hour in-house specialist coverage (pediatrician/neonatologist, obstetrician, and obstetric anesthesiologist) and results linked to hospital birth asphyxia rates (preterm and low weight births were excluded). Results Of 253 maternity hospitals, 138 responded (55%); 59 (43%) indicated checklist use, and in-house specialist coverage ranged from 38% (pediatrician/neonatologist) to 54% (anesthesiology). In-house coverage was more common in urban versus rural hospitals for all specialties (p < 0.0001), but checklist use was not significantly different (p = 0.88). Higher birth volume hospitals had more specialist coverage (p < 0.0001), whereas checklist use did not differ (p = 0.3). In-house obstetric coverage was associated with lower asphyxia rates (odds ratio: 0.34; 95% confidence interval [CI]: 0.20, 0.58) in a regression model accounting for other providers. Checklist use was not associated with birth asphyxia (odds ratio: 1.12; 95% CI: 0.75, 1.68). Conclusion Higher birth volume and urban hospitals demonstrated greater in-house specialist coverage, but checklist use was similar across all hospitals. Current data suggest that in-house obstetric coverage has greater impact on asphyxia than other specialist coverage or checklist use.

    View details for DOI 10.1055/s-0036-1586505

    View details for PubMedID 27487231

  • Leading Change on Labor and Delivery: Reducing Nulliparous Term Singleton Vertex (NTSV) Cesarean Rates JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Main, E. K. 2017; 43 (2): 51–52

    View details for DOI 10.1016/j.jcjq.2016.11.009

    View details for Web of Science ID 000424157800001

    View details for PubMedID 28334562

  • Opportunities for maternal transport for delivery of very low birth weight infants JOURNAL OF PERINATOLOGY Robles, D., Blumenfeld, Y. J., Lee, H. C., Gould, J. B., Main, E., Profit, J., Melsop, K., Druzin, M. 2017; 37 (1): 32-35

    Abstract

    To assess frequency of very low birth weight (VLBW) births at non-level III hospitals.Retrospective cohort study using linked California birth certificate and discharge data of 2008 to 2010 for deliveries of singleton or first-born infant of multiple gestations with birth weight 400 to 1500 g. Delivery rates by neonatal level of care were obtained. Risk of delivery at non-level III centers was estimated in univariable and multivariable models.Of the 1 508 143 births, 13 919 (9.2%) were VLBW; birth rate at non-level III centers was 14.9% (8.4% in level I and 6.5% in level II). Median rate of VLBW births was 0.3% (range 0 to 4.7%) annually at level I and 0.5% (range 0 to 1.6%) at level II hospitals. Antepartum stay for >24 h occurred in 14.0% and 26.9% of VLBW births in level I and level II hospitals, respectively.Further improvement is possible in reducing VLBW infant delivery at suboptimal sites, given the window of opportunity for many patients.Journal of Perinatology advance online publication, 29 September 2016; doi:10.1038/jp.2016.174.

    View details for DOI 10.1038/jp.2016.174

    View details for Web of Science ID 000391517000007

  • Rapid reduction of the NTSV CS rate in multiple community hospitals using a multi-dimensional QI approach Lagrew, D. C., Mills, M., Mikes, K., Chan, K., Trial, J., Deeds, T., Rubinstein, B., Main, E. MOSBY-ELSEVIER. 2017: S471–S472
  • Confirmed severe maternal morbidity is associated with high rate of preterm delivery. American journal of obstetrics and gynecology Kilpatrick, S. J., Abreo, A., Gould, J., Greene, N., Main, E. K. 2016; 215 (2): 233 e1-7

    Abstract

    Because severe maternal morbidity (SMM) is increasing in the United States, affecting up to 50,000 women per year, there was a recent call to review all mothers with SMM to better understand their morbidity and improve outcomes. Administrative screening methods for SMM have recently been shown to have low positive predictive value for true SMM after chart review. To ultimately reduce maternal morbidity and mortality we must better understand risk factors, and preventability issues about true SMM such that interventions could be designed to improve care.Our objective was to determine risk factors associated with true SMM identified from California delivery admissions, including the relationship between SMM and preterm delivery.In this retrospective cohort study, SMM cases were screened for using International Classification of Diseases, Ninth Revision codes for severe illness and procedures, prolonged postpartum length of stay, intensive care unit admission, and transfusion from all deliveries in 16 hospitals from July 2012 through June 2013. Charts of screen-positive cases were reviewed and true SMM diagnosed based on expert panel agreement. Underlying disease diagnosis was determined. Women with true-positive SMM were compared to SMM-negative women for the following variables: maternal age, ethnicity, gestational age at delivery, prior cesarean delivery, and multiple gestation.In all, 491 women had true SMM and 66,977 women did not have SMM for a 0.7% rate of true SMM. Compared to SMM-negative women, SMM cases were significantly more likely to be age >35 years (33.6 vs 23.8%; P < .0001), be African American (14.1 vs 7.9%; P < .0001), have had a multiple gestation (9.7 vs 2.1%; P < .0001), and, for the multiparous women, have had a prior cesarean delivery (58 vs 30.2%; P < .0001). Preterm delivery was significantly more common in SMM women compared to SMM-negative women (41 vs 8%; P < .0001), including delivery <32 weeks (18 vs 2%; P < .0001). The most common underlying disease was obstetric hemorrhage (42%) followed by hypertensive disorders (20%) and placental hemorrhage (14%). Only 1.6% of women with SMM had cardiovascular disease as the underlying disease category.An extremely high proportion of women with severe morbidity (42.5%) delivered preterm with 17.8% delivering <32 weeks, which underscores the importance of access to appropriate-level care for mothers with SMM and their newborns. Further, the extremely high rate of preterm delivery (75%) in women with placental hemorrhage in combination with their 63% prior cesarean delivery rate highlights another risk of prior cesarean delivery: subsequent preterm delivery. These data provide a reminder that a cesarean delivery could be a contributing factor to not only hemorrhage-related SMM, but also to increased subsequent preterm delivery, more reason to continue national efforts to safely reduce initial cesarean deliveries.

    View details for DOI 10.1016/j.ajog.2016.02.026

    View details for PubMedID 26899903

  • Variation in transfusion rates and Maternal Levels of Care: Implications for quality indicators and the measurement of Severe Maternal Morbidity (SMM) Gilbert, W., Abreo, A., McNally, C., Poeltler, D., Main, E. MOSBY-ELSEVIER. 2016: S275–S276
  • Relationship between ICU Admissions and Severe Maternal Morbidity McNulty, J., Kilpatrick, S., Arbreo, A., Fenton, D., Main, E. MOSBY-ELSEVIER. 2016: S129–S130
  • Severe maternal morbidity is associated with high rate of preterm delivery Kilpatrick, S., Abreo, A., Lanner-Cusin, K., Main, E. MOSBY-ELSEVIER. 2016: S28
  • National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Main, E. K., Goffman, D., Scavone, B. M., Low, L., Bingham, D., Fontaine, P. L., Gorlin, J. B., Lagrew, D. C., Levy, B. S. 2015; 44 (4): 462–70

    View details for DOI 10.1111/1552-6909.12723

    View details for Web of Science ID 000357898600003

    View details for PubMedID 26058596

  • National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage JOURNAL OF MIDWIFERY & WOMENS HEALTH Main, E. K., Goffman, D., Scavone, B. M., Low, L. K., Bingham, D., Fontaine, P. L., Gorlin, J. B., Lagrew, D. C., Levy, B. S. 2015; 60 (4): 458-464

    Abstract

    Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

    View details for DOI 10.1111/jmwh.12345

    View details for Web of Science ID 000359355400015

    View details for PubMedID 26059199

  • National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage ANESTHESIA AND ANALGESIA Main, E. K., Goffman, D., Scavone, B. M., Low, L. K., Bingham, D., Fontaine, P. L., Gorlin, J. B., Lagrew, D. C., Levy, B. S. 2015; 121 (1): 142-148

    Abstract

    Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

    View details for DOI 10.1097/AOG.0000000000000869

    View details for Web of Science ID 000356671400001

    View details for PubMedID 26091046

  • Pregnancy Outcomes in the Super Obese, Stratified by Weight Gain Above and Below Institute of Medicine Guidelines OBSTETRICS AND GYNECOLOGY Swank, M. L., Marshall, N. E., Caughey, A. B., Main, E. K., Gilbert, W. M., Melsop, K. A., Chung, J. H. 2014; 124 (6): 1105–10

    Abstract

    To examine the association of antenatal weight gain above and below the 2009 Institute of Medicine (IOM) guidelines in the super-obese population (body mass index [BMI] of 50 or higher) on the maternal and neonatal morbidities of gestational hypertension or preeclampsia (pregnancy-induced hypertension), gestational diabetes mellitus, cesarean delivery, birth weight more than 4,000 g and more than 4,500 g, low birth weight, and preterm birth.The effect of gestational weight gain was assessed in this retrospective cohort study using California birth certificate and patient discharge diagnosis data. Unconditional logistic regression was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) as a function of antenatal weight gain. Weight gain within 2009 IOM guidelines (11-20 pounds) served as the reference group.The study population consisted of 1,034 women. Women gaining below, within, and above IOM guidelines accounted for 38.3, 23.5, and 38.2%, respectively. Weight gain below IOM guidelines was not associated with a statistically increased odds of preterm birth (OR 1.82, 95% CI 0.60-5.59) or low birth weight (OR 1.20, 95% CI 0.57-2.49); however, birth weight more than 4,000 g was significantly reduced (OR 0.50, 95% CI 0.32-0.77). Excessive weight gain statistically increased the odds of pregnancy-induced hypertension (OR 1.96, 95% CI 1.26-3.03) and cesarean delivery (OR 1.40, 95% CI 1.00-1.97) while not appearing to protect against the delivery of low-birth-weight neonates (OR 0.84, 95% CI 0.40-1.78).Weight gain below the current guidelines in the super-obese cohort is not associated with an increase in maternal or neonatal risk while decreasing the odds of delivering a macrosomic neonate. Women with BMIs of 50 or higher may warrant separate gestational weight gain recommendations.

    View details for PubMedID 25415161

  • The Impact of Change in Pregnancy Body Mass Index on Macrosomia OBESITY Swank, M. L., Caughey, A. B., Farinelli, C. K., Main, E. K., Melsop, K. A., Gilbert, W. M., Chung, J. H. 2014; 22 (9): 1997–2002

    Abstract

    To examine the impact of change in body mass index (BMI) during pregnancy on the incidence of macrosomia.This is a retrospective cohort study using 2007 linked birth certificate and discharge diagnosis data from the state of California. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated for the outcome of macrosomia, as a function of a categorical change in pregnancy BMI: BMI loss (<-0.5), no change (-0.5 to 0.5), minimal (0.6 to 5), moderate (5.1 to 10), and excessive (>10). The impact of pregnancy change in BMI was determined for the entire cohort and then stratified by prepregnancy BMI category. Minimal BMI change served as the reference group.The study population consisted of 436,414 women. Overall, women with moderate and excessive BMI changes had aORs of 1.66 and 3.21, respectively, for macrosomia, when compared with women with minimal BMI change. When stratified by prepregnancy BMI, normal (aOR 3.85) and overweight women (aOR 2.96) with antenatal BMI change greater than 10 had the highest odds of macrosomia.Excessive change in pregnancy BMI results in an increased odds of macrosomia. This finding was most pronounced in the normal and overweight women.

    View details for DOI 10.1002/oby.20790

    View details for Web of Science ID 000341578000012

    View details for PubMedID 24890506

  • The impact of change in pregnancy body mass index on cesarean delivery JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE Swank, M. L., Caughey, A. B., Farinelli, C. K., Main, E. K., Melsop, K. A., Gilbert, W. M., Chung, J. H. 2014; 27 (8): 795–800

    Abstract

    To examine the impact of pregnancy changes in body mass index (BMI) on the incidence of cesarean delivery.This is a retrospective cohort study using linked birth certificate and discharge diagnosis data from the year 2007. Adjusted odds ratios (aOR) were calculated for the outcome of cesarean delivery, as a function of a categorical change in pregnancy BMI (kg/m(2)): BMI loss (BMI change<-0.5), no change (-0.5 to 0.5), minimal (0.6 to 5), moderate (5.1 to 10) and excessive (>10). The impact of pregnancy change in BMI was determined for the entire cohort and then stratified by prepregnancy BMI category.The study population consisted of 436 414 women with singleton gestations. When compared to women with no net change in BMI, women with excessive BMI changes collectively had a 80% increased incidence of cesarean delivery (aOR = 1.78). By prepregnancy obesity class, the aOR for cesarean delivery in women with excessive BMI change were: normal weight (aOR = 2.25), overweight (aOR = 2.39), obese class I (aOR = 2.23), obese class II (aOR = 2.56) and obese class III (aOR = 2.08).The odds of cesarean delivery were uniformly increased in all prepregnancy BMI categories as net BMI change increased. These data illustrate that all women, not just the overweight and obese, are at significantly increased risk of cesarean delivery with excessive BMI change during pregnancy.

    View details for DOI 10.3109/14767058.2013.845657

    View details for Web of Science ID 000334738800005

    View details for PubMedID 24047475

  • The impact of change in pregnancy body mass index on the development of gestational hypertensive disorders JOURNAL OF PERINATOLOGY Swank, M. L., Caughey, A. B., Farinelli, C. K., Main, E. K., Melsop, K. A., Gilbert, W. M., Chung, J. H. 2014; 34 (3): 181–85

    Abstract

    To examine the impact of change in body mass index (BMI) during pregnancy on the incidence of gestational hypertension/preeclampsia.This is a retrospective cohort study using linked California birth certificate and discharge diagnosis data from the year 2007. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated for the outcome of gestational hypertension/preeclampsia, as a function of a categorical change in pregnancy BMI: BMI loss (<-0.5), no change (-0.5 to 0.5), minimal (0.6 to 5), moderate (5.1 to 10) and excessive (>10). The impact of change in pregnancy BMI was evaluated for the entire cohort and then as a function of prepregnancy BMI category. Women with no change in pregnancy BMI served as the reference group.The study population consisted of 436 414 women with singleton gestations. Overall, women with excessive BMI change had a nearly twofold increased odds of gestational hypertension/preeclampsia (aOR=1.94; 95% CI=1.72 to 2.20). By prepregnancy BMI class, overweight and obese women who had a moderate change in pregnancy BMI also had increased odds of developing gestational hypertension/preeclampsia with aOR ranging from 1.73 to 1.97.Regardless of prepregnancy BMI category, women with excessive BMI change have a higher chance of developing gestational hypertension/preeclampsia. Overweight and obese women with moderate BMI change may also be at increased risk.

    View details for PubMedID 24384780

  • Maternal Mortality: Time for National Action Reply OBSTETRICS AND GYNECOLOGY Menard, M., Main, E. 2014; 123 (2): 362–63

    View details for PubMedID 24451666

  • The impact of pre-pregnancy body mass index and gestational weight gain on failed trial of labor after cesarean Chung, J., Swank, M., Main, E., Melsop, K., Gilbert, W., Caughey, A. MOSBY-ELSEVIER. 2014: S309–S310
  • Maternal height and perinatal outcomes in normal weight women Marshall, N., Snowden, J., Darney, B., Main, E., Gilbert, W., Chung, J., Caughey, A. MOSBY-ELSEVIER. 2014: S252
  • Influence of Fetal Sex, Maternal Obesity, and Gestational Weight Gain on Perinatal Outcomes. Marshall, N. E., Snowden, J. M., O'Tierney-Ginn, P. F., Melsap, K., Chung, J., Main, E., Gilbert, W., Caughey, A. B. SAGE PUBLICATIONS INC. 2013: 309A–310A
  • The impact of gestational change in body mass index (BMI) on adverse pregnancy outcomes among women with gestational diabetes 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Chung, J., Swank, M., Main, E., Melsop, K., Gilbert, W., Caughey, A. MOSBY-ELSEVIER. 2013: S122–S123
  • The impact of change in pregnancy body mass index on gestational hypertension/preeclampsia 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Swank, M., Caughey, A., Farinelli, C., Main, E., Melsop, K., Gilbert, W., Chung, J. MOSBY-ELSEVIER. 2013: S274–S274
  • Impact of gestational weight gain by BMI class on cesarean delivery in nulliparous women 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Marshall, N., Halloran, D., Chung, J., Snowden, J., Cheng, Y., Melsap, K., Main, E., Gilbert, W., Caughey, A. MOSBY-ELSEVIER. 2013: S303–S304
  • The impact of change in pregnancy body mass index on cesarean delivery 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Swank, M., Caughey, A., Farinelli, C., Main, E., Melsop, K., Gilbert, W., Chung, J. MOSBY-ELSEVIER. 2013: S339–S339
  • The impact of change in pregnancy body mass index on macrosomia 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Swank, M., Caughey, A., Farinelli, C., Main, E., Melsop, K., Gilbert, W., Chung, J. MOSBY-ELSEVIER. 2013: S190–S190
  • The impact of change in pregnancy body mass index on preterm birth and low birthweight 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Swank, M., Caughey, A., Farinelli, C., Main, E., Melsop, K., Gilbert, W., Chung, J. MOSBY-ELSEVIER. 2013: S191–S191
  • Prevalence of non-medically indicated induction of labor among women of varying body mass index in California 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Snowden, J., Cheng, Y., Darney, B., Marshall, N., Chung, J., Main, E., Gilbert, W., Melsop, K., Caughey, A. MOSBY-ELSEVIER. 2013: S299–S300
  • Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery OBSTETRICS AND GYNECOLOGY Main, E. K., Morton, C. H., Melsop, K., Hopkins, D., Giuliani, G., Gould, J. B. 2012; 120 (5): 1194-1198

    Abstract

    Cesarean delivery rates in California and the United States rose by 50% between 1998 and 2008 and vary widely among states, regions, hospitals, and health care providers. The leading driver of both the rise and the variation is first-birth cesarean deliveries performed during labor. With the large increase in primary cesarean deliveries, repeat cesarean delivery now has emerged as the largest single indication. The economic costs, health risks, and negligible benefits for most mothers and newborns of these higher rates point to the urgent need for a new approach to working with women in labor. This commentary analyzes the high rates and wide variations and presents evidence of costs and risks associated with cesarean deliveries (complete discussion provided in the California Maternal Quality Care Collaborative White Paper at www.cmqcc.org/white_paper). All stakeholders need to ask whether society can afford the costs and complications of this high cesarean delivery rate and whether they can work together toward solutions. The factors involved in the rise in cesarean deliveries point to the need for a multistrategy approach, because no single strategy is likely to be effective or lead to sustained change. We outline complementary strategies for reducing the rates and offer recommendations including clinical improvement strategies with careful examination of labor management practices; payment reform to eliminate negative or perverse incentives; education to recognize the value of vaginal birth; and full transparency through public reporting and continued public engagement.

    View details for DOI 10.1097/AOG.0b013e31826fc13d

    View details for Web of Science ID 000310512500027

    View details for PubMedID 23090538

  • Neonatal Outcomes After Implementation of Guidelines Limiting Elective Delivery Before 39 Weeks of Gestation OBSTETRICS AND GYNECOLOGY Oshiro, B., Branch, W., Main, E. 2012; 119 (3): 656

    View details for DOI 10.1097/AOG.0b013e318248a84a

    View details for Web of Science ID 000300637400025

    View details for PubMedID 22353967

  • Decisions Required for Operating a Maternal Mortality Review Committee: The California Experience SEMINARS IN PERINATOLOGY Main, E. K. 2012; 36 (1): 37–41

    Abstract

    Maternal mortality is a current and important issue for obstetrics. The challenge is to structure case reviews so that they develop real data that can inform and direct quality improvement activities. In this article, we describe a series of decisions we have made in California to organize and run our maternal mortality review committee. These include defining the goal of the reviews, selection of cases, composition of the committee, basic review issues, and the definitions used for analysis (eg, cause of death, contributing factors, role of cesarean delivery, preventability, identifying quality improvement opportunities). It is expected that each maternal mortality review committee will have somewhat different approaches based on local resources and case mix.

    View details for DOI 10.1053/j.semperi.2011.09.008

    View details for Web of Science ID 000299860900008

    View details for PubMedID 22280864

  • A State-Wide Obstetric Hemorrhage Quality Improvement Initiative MCN-THE AMERICAN JOURNAL OF MATERNAL-CHILD NURSING Bingham, D., Lyndon, A., Lagrew, D., Main, E. K. 2011; 36 (5): 297-304

    Abstract

    The mission of the California Maternal Quality Care Collaborative is to eliminate preventable maternal death and injury and to promote equitable maternity care in California. This article describes California Maternal Quality Care Collaborative's (CMQCC's) statewide multistakeholder quality improvement initiative to improve readiness, recognition, response, and reporting of maternal hemorrhage at birth and details the essential role of nurses in its success. PROJECT DESIGN AND APPROACH: In partnership with the State Department of Maternal, Child, and Adolescent Health, CMQCC identified maternal hemorrhage as a significant quality improvement opportunity. CMQCC organized a multidisciplinary, multistakeholder task force to develop a strategy for addressing obstetric (OB) hemorrhage. PROJECT DESCRIPTION: The OB Hemorrhage Task Force, co-chaired by nurse and physician team leaders, identified four priorities for action and developed a comprehensive hemorrhage guideline. CMQCC is using a multilevel strategy to disseminate the guideline, including an open access toolkit, a minimal support-mentoring model, a county partnership model, and a 30-hospital learning collaborative.In participating hospitals, nurses have been the primary drivers in developing both general and massive hemorrhage policies and procedures, ensuring the availability of critical supplies, organizing team debriefing after a stage 2 (or greater) hemorrhage, hosting skills stations for measuring blood loss, and running obstetric (OB) hemorrhage drills. Each of these activities requires effort and leadership skill, even in hospitals where clinicians are convinced that these changes are needed. In some hospitals, the burden to convince physicians of the value of these new practices has rested primarily upon nurses. Thus, the statewide initiative in which nurse and physician leaders work together models the value of teamwork and provides a real-time demonstration of the potential for effective interdisciplinary collaboration to make a difference in the quality of care that can be achieved. Nurses provide significant leadership in multidisciplinary, multistakeholder quality projects in California. Ensuring that nurses have the opportunity to participate in formal leadership of these teams and are represented at all workgroup levels is critical to the overall initiative. Nurses brought key understanding of operational issues within and across departments, mobilized engagement across the state through the regional perinatal programs, and developed innovative approaches to solving clinical problems during implementation. Nursing leadership and integrated participation was especially critical in considering the needs of lower-resource settings, and was essential to the toolkit's enthusiastic adoption at the unit/service level in facilities across the state.

    View details for DOI 10.1097/NMC.0b013e318227c75f

    View details for Web of Science ID 000294047700006

    View details for PubMedID 21857200

    View details for PubMedCentralID PMC3203841

  • Excess gestational weight gain is associated with gestational hypertension/preeclampsia and cesarean birth 31st Annual Scientific Meeting of the Society-of-Maternal-Fetal-Medicine (SMFM) Melsop, K., Main, E., Caughey, A. B., Gilbert, W., Walker, C., Chung, J. MOSBY-ELSEVIER. 2011: S232–S232
  • Increasing maternal body mass index is strongly associated with gestational diabetes, gestational hypertension/preeclampsia and cesarean delivery 31st Annual Scientific Meeting of the Society-of-Maternal-Fetal-Medicine (SMFM) Melsop, K., Main, E., Caughey, A. B., Gilbert, W., Walker, C., Chung, J. MOSBY-ELSEVIER. 2011: S231–S232
  • Interrelationship between gestational weight gain and race/ethnicity on perinatal outcomes 31st Annual Scientific Meeting of the Society-of-Maternal-Fetal-Medicine (SMFM) Main, E., Melsop, K., Caughey, A. B., Gilbert, W., Walker, C., Chung, J. MOSBY-ELSEVIER. 2011: S50–S50
  • Interrelationship between race/ethnicity and obesity on perinatal outcomes 31st Annual Scientific Meeting of the Society-of-Maternal-Fetal-Medicine (SMFM) Main, E., Melsop, K., Caughey, A. B., Gilbert, W., Walker, C., Chung, J. MOSBY-ELSEVIER. 2011: S313–S313
  • Effective Implementation Strategies and Tactics for Leading Change on Maternity Units JOURNAL OF PERINATAL & NEONATAL NURSING Bingham, D., Main, E. K. 2010; 24 (1): 32-42

    Abstract

    Change implementation within organizations is a complex and dynamic process that is not always successful. Tailoring the implementation strategies and tactics to address the identified barriers to change is one method that has been shown to be effective. Examples of 3 broad types of interrelated strategies used by frontline leaders when implementing quality improvement (QI) projects are (1) discourse (communication), (2) education (formal and informal), and (3) data (audit). Examples of common barriers to implementation are leaders' and clinicians' knowledge, attitudes, and practices, the QI topic characteristics, and the implementation climate. External pressures from national organizations such as the National Quality Forum, the Leapfrog Group, and The Joint Commission likely facilitate change. Knowledgeable, tenacious, and creative frontline physician and nurse leaders may have the greatest impact on QI implementation effectiveness because they are the individuals who decide how the strategies and tactics will be tailored.

    View details for DOI 10.1097/JPN.0b013e3181c94a24

    View details for Web of Science ID 000275333600008

    View details for PubMedID 20147828

  • Cesarean delivery rates and neonatal morbidity in a low-risk population OBSTETRICS AND GYNECOLOGY Gould, J. B., Danielsen, B., Korst, L. M., Phibbs, R., Chance, K., Main, E., Wirtschafter, D. D., Stevenson, D. K. 2004; 104 (1): 11-19

    Abstract

    To estimate the relationship between case-mix adjusted cesarean delivery rates and neonatal morbidity and mortality in infants born to low-risk mothers.This retrospective cohort study used vital and administrative data for 748,604 California singletons born without congenital abnormalities in 1998-2000. A total of 282 institutions was classified as average-, low-, or high-cesarean delivery hospitals based on their cesarean delivery rate for mothers without a previous cesarean delivery, in labor at term, with no evidence of maternal, fetal, or placental complications. Neonatal mortality, diagnoses, and therapeutic interventions determined by International Classification of Diseases, 9th Revision, Clinical Modification codes, and neonatal length of stay were compared across these hospital groupings.Compared with average-cesarean delivery-rate hospitals, infants born to low-risk mothers at low-cesarean delivery hospitals had increased fetal hemorrhage, birth asphyxia, meconium aspiration syndrome, feeding problems, and electrolyte abnormalities (P <.02). Infused medication, pressors, transfusion for shock, mechanical ventilation, and length of stay were also increased (P <.001). This suggests that some infants born in low-cesarean delivery hospitals might have benefited from cesarean delivery. Infants delivered at high-cesarean delivery hospitals demonstrated increased fetal hemorrhage, asphyxia, birth trauma, electrolyte abnormalities, and use of mechanical ventilation (P <.001), suggesting that high cesarean delivery rates themselves are not protective.Neonatal morbidity is increased in infants born to low-risk women who deliver at both low- and high-cesarean delivery-rate hospitals. The quality of perinatal care should be assessed in these outlier hospitals.III

    View details for DOI 10.1097/01.AOG.0000127035.64602.97

    View details for PubMedID 15228995