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Racial and ethnic differences in severe maternal morbidity among singleton stillbirth deliveries

      BACKGROUND

      Despite growing evidence suggesting racial or ethnic disparities in the risk of severe maternal morbidity among live births, there is little research investigating potential differences in severe maternal morbidity risk among stillbirths across race and ethnicity.

      OBJECTIVE

      This study aimed to compare the risk of severe maternal morbidity by race and ethnicity among patients with singleton stillbirth pregnancies.

      STUDY DESIGN

      We used the California Linked Birth File database to perform a retrospective analysis of singleton stillbirth pregnancies delivered at 20 to 42 weeks’ gestation between 2007 and 2011. The database contained information from fetal death certificates linked to maternal hospital discharge records. We defined severe maternal morbidity using the Centers for Disease Control and Prevention composite severe maternal morbidity indicator and compared rates of severe maternal morbidity across racial and ethnic groups. Multivariable regression analysis was used to examine how race and ethnicity were associated with severe maternal morbidity risk after accounting for the influence of patients’ clinical risk factors, socioeconomic characteristics, and attributes of the delivery hospital.

      RESULTS

      Of the 9198 patients with singleton stillbirths, 533 (5.8%) experienced severe maternal morbidity. Non-Hispanic Black patients had a significantly higher risk of severe maternal morbidity (10.6% vs 5.2% in non-Hispanic White patients, 5.2% in Hispanic patients, and 5.1% in patients with other race or ethnicity; P<.001). The higher risk of severe maternal morbidity among non-Hispanic Black patients persisted even after adjusting for patients’ clinical, socioeconomic, and hospital characteristics (adjusted odds ratio for non-Hispanic Black vs non-Hispanic White patients, 1.74; 95% confidence interval, 1.21–2.50). Further analysis separating blood-transfusion and nontransfusion severe maternal morbidity showed a higher risk of blood transfusion in non-Hispanic Black patients, which remained significant after adjusting for patients’ clinical, socioeconomic, and hospital characteristics (adjusted odds ratio for non-Hispanic Black vs non-Hispanic White patients, 1.64; 95% confidence interval, 1.11–2.43). However, the higher risk of nontransfusion severe maternal morbidity in non-Hispanic Black patients was no longer significant after adjusting for patients’ clinical risk factors (adjusted odds ratio for non-Hispanic Black vs non-Hispanic White patients, 1.38; 95% confidence interval, 0.83–2.30).

      CONCLUSION

      Severe maternal morbidity occurred in 5.8% of patients with a singleton stillbirth. Risk of severe maternal morbidity in stillbirth was higher in patients with non-Hispanic Black race, which was likely owing to a higher risk of hemorrhage, as evidenced by increased rate of blood transfusion.

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      References

      1. Centers for Disease Control and Prevention. Severe maternal morbidity in the United States. 2021. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html. Accessed July 20, 2022

        • Grobman WA
        • Bailit JL
        • Rice MM
        • et al.
        Racial and ethnic disparities in maternal morbidity and obstetric care.
        Obstet Gynecol. 2015; 125: 1460-1467
        • Howell EA
        • Egorova NN
        • Janevic T
        • et al.
        Race and ethnicity, medical insurance, and within-hospital severe maternal morbidity disparities.
        Obstet Gynecol. 2020; 135: 285-293
        • Howland RE
        • Angley M
        • Won SH
        • et al.
        Determinants of severe maternal morbidity and its racial/ethnic disparities in New York City, 2008-2012.
        Matern Child Health J. 2019; 23: 346-355
        • Petersen EE
        • Davis NL
        • Goodman D
        • et al.
        Racial/ethnic disparities in pregnancy-related deaths - United States, 2007-2016.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 762-765
        • Singh GK.
        Trends and social inequalities in maternal mortality in the United States, 1969-2018.
        Int J MCH AIDS. 2021; 10: 29-42
        • Leonard SA
        • Main EK
        • Scott KA
        • Profit J
        • Carmichael SL.
        Racial and ethnic disparities in severe maternal morbidity prevalence and trends.
        Ann Epidemiol. 2019; 33: 30-36
        • Pruitt SM
        • Hoyert DL
        • Anderson KN
        • et al.
        Racial and ethnic disparities in fetal deaths - United States, 2015-2017.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 1277-1282
        • Gregory EC
        • Valenzuela CP
        • Hoyert DL.
        Fetal mortality: United States, 2019.
        Natl Vital Stat Rep. 2021; 70: 1-20
        • Reddy UM
        • Laughon SK
        • Sun L
        • Troendle J
        • Willinger M
        • Zhang J.
        Prepregnancy risk factors for antepartum stillbirth in the United States.
        Obstet Gynecol. 2010; 116: 1119-1126
        • Willinger M
        • Ko CW
        • Reddy UM.
        Racial disparities in stillbirth risk across gestation in the United States.
        Am J Obstet Gynecol. 2009; 201 (469.e1–8)
        • Gold KJ
        • Mozurkewich EL
        • Puder KS
        • Treadwell MC.
        Maternal complications associated with stillbirth delivery: a cross-sectional analysis.
        J Obstet Gynaecol. 2016; 36: 208-212
        • Wall-Wieler E
        • Carmichael SL
        • Gibbs RS
        • et al.
        Severe maternal morbidity among stillbirth and live birth deliveries in California.
        Obstet Gynecol. 2019; 134: 310-317
        • Lewkowitz AK
        • Rosenbloom JI
        • López JD
        • et al.
        Association between stillbirth at 23 weeks of gestation or greater and severe maternal morbidity.
        Obstet Gynecol. 2019; 134: 964-973
        • Brown CC
        • Adams CE
        • George KE
        • Moore JE.
        Associations between comorbidities and severe maternal morbidity.
        Obstet Gynecol. 2020; 136: 892-901
        • Howell EA
        • Egorova N
        • Balbierz A
        • Zeitlin J
        • Hebert PL.
        Black-white differences in severe maternal morbidity and site of care.
        Am J Obstet Gynecol. 2016; 214 (122.e1–7)
        • Howell EA
        • Egorova NN
        • Balbierz A
        • Zeitlin J
        • Hebert PL.
        Site of delivery contribution to black-white severe maternal morbidity disparity.
        Am J Obstet Gynecol. 2016; 215: 143-152
        • Howell EA
        • Egorova NN
        • Janevic T
        • Balbierz A
        • Zeitlin J
        • Hebert PL.
        Severe maternal morbidity among Hispanic women in New York City: investigation of health disparities.
        Obstet Gynecol. 2017; 129: 285-294
        • Wang E
        • Glazer KB
        • Howell EA
        • Janevic TM.
        Social determinants of pregnancy-related mortality and morbidity in the United States: a systematic review.
        Obstet Gynecol. 2020; 135: 896-915
        • Williams AD
        • Wallace M
        • Nobles C
        • Mendola P.
        Racial residential segregation and racial disparities in stillbirth in the United States.
        Health Place. 2018; 51: 208-216
      2. California Department of Health Care Access and Information (HCAI). Linked birth files. Available at: https://hcai.ca.gov/data-and-reports/research-data-request-information/#linked-birth-files. Accessed November 26, 2021.

      3. California Perinatal Quality Care Collaborative. Available at: https://www.cpqcc.org/. Accessed November 29, 2021.

      4. American Hospital Association. AHA Annual Survey Database. Available at: https://www.ahadata.com/aha-annual-survey-database. Accessed November 29, 2021.

        • Callaghan WM
        • Creanga AA
        • Kuklina EV.
        Severe maternal morbidity among delivery and postpartum hospitalizations in the United States.
        Obstet Gynecol. 2012; 120: 1029-1036
        • Leonard SA
        • Kennedy CJ
        • Carmichael SL
        • Lyell DJ
        • Main EK.
        An expanded obstetric comorbidity scoring system for predicting severe maternal morbidity.
        Obstet Gynecol. 2020; 136: 440-449
        • Korst LM
        • Gregory KD
        • Nicholas LA
        • et al.
        A scoping review of severe maternal morbidity: describing risk factors and methodological approaches to inform population-based surveillance.
        Matern Health Neonatol Perinatol. 2021; 7: 3
        • Baron RM
        • Kenny DA.
        The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations.
        J Pers Soc Psychol. 1986; 51: 1173-1182
        • Carr RC
        • McKinney DN
        • Cherry AL
        • Defranco EA.
        Maternal age-specific drivers of severe maternal morbidity.
        Am J Obstet Gynecol MFM. 2022; 4100529
        • Siddiqui A
        • Azria E
        • Egorova N
        • Deneux-Tharaux C
        • Howell EA.
        Contribution of prepregnancy obesity to racial and ethnic disparities in severe maternal morbidity.
        Obstet Gynecol. 2021; 137: 864-872
        • American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics
        Anemia in pregnancy: ACOG Practice Bulletin, Number 233.
        Obstet Gynecol. 2021; 138: e55-e64
        • Hamm RF
        • Wang EY
        • Levine LD
        • Srinivas SK.
        Association between race and hemoglobin at delivery or need for transfusion when using race-based definitions for treatment of antepartum anemia.
        Obstet Gynecol. 2021; 138: 108-110
        • Marill MC.
        Rethinking race in medicine: ACOG removes a race-based cutoff for anemia in pregnancy.
        Health affairs blog. 2021; https://doi.org/10.1377/hblog20210816.198602
        • Teal EN
        • Anudokem K
        • Baer RJ
        • Jelliffe-Pawlowski L
        • Mengesha B.
        Racial disparities in the rates of and indications for cesarean delivery in California: are they changing over time?.
        Am J Perinatol. 2021; ([Epub ahead of print])
        • Romero R
        • Copel JA
        • Hobbins JC.
        Intrauterine fetal demise and hemostatic failure: the fetal death syndrome.
        Clin Obstet Gynecol. 1985; 28: 24-31
        • Muin DA
        • Haslacher H
        • Koller V
        • Kiss H
        • Scharrer A
        • Farr A.
        Impact of fetal maceration grade on risk of maternal disseminated intravascular coagulation after intrauterine fetal death - a retrospective cohort study.
        Sci Rep. 2018; 8: 12742
        • Muin DA
        • Scharrer A
        • Farr A
        • Kiss H
        • Haslacher H.
        Timing of hospital admission for stillbirth delivery on maternal and obstetric outcome: a retrospective cohort study.
        Sci Rep. 2021; 11: 18854
        • Conway DL
        • Hansen NI
        • Dudley DJ
        • et al.
        An algorithm for the estimation of gestational age at the time of fetal death.
        Paediatr Perinat Epidemiol. 2013; 27: 145-157
        • Maslow AD
        • Breen TW
        • Sarna MC
        • Soni AK
        • Watkins J
        • Oriol NE.
        Prevalence of coagulation abnormalities associated with intrauterine fetal death.
        Can J Anaesth. 1996; 43: 1237-1243
        • Chakhtoura NA
        • Reddy UM.
        Management of stillbirth delivery.
        Semin Perinatol. 2015; 39: 501-504
        • Wall-Wieler E
        • Butwick AJ
        • Gibbs RS
        • et al.
        Maternal health after stillbirth: postpartum hospital readmission in California.
        Am J Perinatol. 2021; 38: e137-e145