Emergency Care Use During Pregnancy and Severe Maternal Morbidity.

Importance: Pregnant individuals who repeatedly use emergency care during pregnancy represent a population who could be disproportionately vulnerable to harm, including severe maternal morbidity (SMM).

Objective: To explore patterns of unscheduled care visits during pregnancy and ascertain its association with SMM at the time of birth.

Design, Setting, And Participants: This cohort study used data from a statewide database that linked hospital records to births and fetal deaths occurring between October 1, 2002, and March 31, 2020, in Massachusetts.

Leveraging a Longitudinally Linked Dataset to Assess Recurrence of Severe Maternal Morbidity.

Objectives: Among those with a severe maternal morbidity (SMM) event and a subsequent birth, we examined how the risk of a second SMM event varied by patient characteristics and intrapartum hospital utilization.

Methods: We used a Massachusetts population-based dataset that longitudinally linked in-state births, hospital discharge records, prior and subsequent births, and non-birth-related hospital utilizations for birthing individuals and their children from January 1, 1999, to December 31, 2018, representing 1,460,514 births by 907,530 birthing people. We restricted our study sample to 2,814 people who had their first SMM event associated with a singleton birth and gave birth a second time within the study period.

Prior Hospitalization, Severe Maternal Morbidity, and Pregnancy-Associated Deaths in Massachusetts From 2002 to 2019.

Objective: To examine demographic and clinical precursors to pregnancy-associated deaths overall and when pregnancy-related deaths are excluded.

Methods: We conducted a retrospective cohort study based on a Massachusetts population-based data system linking data from live birth and fetal death certificates to corresponding delivery hospital discharge records and a birthing individual's nonbirth hospital contacts and associated death records. Exposures included maternal demographics, severe maternal morbidity (without transfusion), hospitalizations in the 3 years before pregnancy, comorbidities during pregnancy, and opioid use.

Preconception and perinatal hospitalizations as indicators of risk for severe maternal morbidity in primiparas.

Background: Severe maternal morbidity includes unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health. A statewide longitudinally linked database was used to examine hospitalization during and before pregnancy for birthing people with severe maternal morbidity at delivery.

Objective: This study aimed to examine the association between hospital visits during pregnancy and 1 to 5 years before pregnancy and severe maternal morbidity at delivery.

State Variation in Severe Maternal Morbidity Among Individuals With Medicaid Insurance.

Objective: To measure variation in delivery-related severe maternal morbidity (SMM) among individuals with Medicaid insurance by state and by race and ethnicity across and within states.

Methods: We conducted a pooled, cross-sectional analysis of the 2016-2018 TAF (Transformed Medicaid Statistical Information System Analytic Files). We measured overall and state-level rates of SMM without blood transfusion for all individuals with Medicaid insurance with live births in 49 states and Washington, DC.

Changes in Pregnancy-Related Mortality Associated With the Coronavirus Disease 2019 (COVID-19) Pandemic in the United States.

Objective: To examine pregnancy-related mortality ratios before (January 2019-March 2020) and during (April 2020-December 2020 and 2021) the coronavirus disease 2019 (COVID-19) pandemic overall, by race and ethnicity, and by rural-urban classifications using vital records data.

Methods: Mortality and natality data (2019-2021) were obtained from the Centers for Disease Control and Prevention's WONDER database to estimate pregnancy-related mortality ratios, which correspond to any death during pregnancy or up to 1 year after the end of a pregnancy from causes related to the pregnancy per 100,000 live births. Pregnancy-related mortality ratios were determined from International Classification of Diseases, Tenth Revision codes A34, O00-O96, and O98-O99.

Development and testing of a decision aid to achieve shared decision-making for routine labor induction.

Background: This quality improvement project aimed to create a decision aid for labor induction in healthy pregnancies at or beyond 39 weeks that met the needs of pregnant people least likely to experience shared decision-making and to identify and test implementation strategies to support its use in prenatal care.

Methods: We used quality improvement and qualitative methods to develop, test, and refine a patient decision aid. The decision aid was tested in three languages by providers across obstetrics, family medicine, and midwifery practices at a tertiary care hospital and two community health centers.

Trends and inequities in severe maternal morbidity in Massachusetts: A closer look at the last two decades.

It is estimated that 50,000-60,000 pregnant people in the United States (US) experience severe maternal morbidity (SMM). SMM includes life-threatening conditions, such as acute myocardial infarction, acute renal failure, amniotic fluid embolism, disseminated intravascular coagulation, or sepsis. Prior research has identified both rising rates through 2014 and wide racial disparities in SMM.

All-Cause Maternal Mortality in the US Before vs During the COVID-19 Pandemic.

This cross-sectional study analyzes the factors associated with deaths during and after pregnancy among Black, Hispanic, and White women.

Using Longitudinally Linked Data to Measure Severe Maternal Morbidity.

Objective: To assess whether application of a standard algorithm to hospitalizations in the prenatal and postpartum (42 days) periods increases identification of severe maternal morbidity (SMM) beyond analysis of only the delivery event.

Methods: We performed a retrospective cohort study using data from the PELL (Pregnancy to Early Life Longitudinal) database, a Massachusetts population-based data system that links records from birth certificates to delivery hospital discharge records and nonbirth hospital records for all birthing individuals. We included deliveries from January 1, 2009, to December 31, 2018, distinguishing between International Classification of Diseases Ninth (ICD-9) and Tenth Revision (ICD-10) coding.

The Association Between Continuity Of Marketplace Coverage During Pregnancy And Receipt Of Prenatal Care.

Insurance disruptions before, during, and after pregnancy are common in the United States, but little is known about the enrollment patterns of pregnant people in the Affordable Care Act Marketplaces. Data from the Pregnancy Risk Assessment Monitoring System from the period 2016-18 show that among respondents enrolled in Marketplace coverage, approximately one-third reported continuous Marketplace enrollment from preconception through the postpartum period. Compared with respondents who were continuously enrolled in Marketplace coverage from preconception through postpartum, respondents who enrolled in Marketplace plans during pregnancy had a 10.

Being Known: A Grounded Theory Study of the Meaning of Quality Maternity Care to People of Color in Boston.

Introduction: Experiences of people of color with maternity care are understudied but understanding them is important to improving quality and reducing racial disparities in birth outcomes in the United States. This qualitative study explored experiences with maternity care among people of color to describe the meaning of quality maternity care to the cohort and, ultimately, to inform the design of a freestanding birth center in Boston.

Methods: Using a grounded theory design and elements of community-based participatory research, community activists developing Boston's first freestanding birth center and academics collaborated on this study.

Factors Associated with Unplanned Primary Cesarean Birth: Secondary Analysis of the Listening to Mothers in California Survey.

Background: In many countries, cesarean section has become the most common major surgical procedure. Most nations have high cesarean birth rates, suggesting overuse. Due to the excess harm and expense associated with unneeded cesareans, many health systems are seeking approaches to safe reduction of cesarean rates.

Communications Between Pregnant Women and Maternity Care Clinicians.

This survey study assesses patients’ self-reported communication experiences with their maternity care clinicians and examines the association of these experiences with women’s reports of feeling pressure to have interventions during delivery.

Intrapartum Care and Experiences of Women with Midwives Versus Obstetricians in the Listening to Mothers in California Survey.

Introduction: Many studies based on hospital records or vital statistics have found that childbearing women experience benefits of lower rates of intervention with midwifery care versus obstetric care during labor and birth. Surveys of women's views and experiences can provide a richer analysis when comparing intrapartum care of midwives and obstetricians.

Methods: This study was a secondary analysis of data from the population-based Listening to Mothers in California survey.

Distinguishing Subgroups in Opposition to Infant Immunization: Results From the Survey.

Objective: To investigate factors associated with parental intention of refusing or altering their child's vaccination schedule.

Methods: Data were from the 2011-2012 Listening to Mothers III survey ( = 1,053). Weighted bivariate and multivariate analyses examined factors related to refusing or altering vaccination.

The Scope of Midwifery Practice Regulations and the Availability of the Certified Nurse-Midwifery and Certified Midwifery Workforce, 2012-2016.

Introduction: Studies have linked midwifery practice laws to the availability of midwives but have generally not related workforce data to potential demand for reproductive health services. We examined state regulatory structure for midwives and its relationship to midwifery distribution and vital statistics data at the state and county level.

Methods: Midwifery distribution data came from the Area Health Resources Files, distribution of women of reproductive age came from the US Census, and birth statistics came from US Natality Files from 2012 to 2016.

Does maternity care decision-making conform to shared decision- making standards for repeat cesarean and labor induction after suspected macrosomia?

Background: In a national United States survey, we investigated whether crucial shared decision-making standards were met for 2 common maternity care decisions.

Methods: Secondary analysis of Listening to Mothers III. A sequence of validated questions concerning shared decision-making was adapted to 2 maternity care decisions: to induce labor or wait for spontaneous onset of labor among women who were told their baby may be "getting quite large" (N = 349); and for women with 1 or 2 prior cesareans (N = 393), the decision to have a repeat cesarean.

Relationship Between Labor and Delivery Unit Management Practices and Maternal Outcomes.

Objective: To define, measure, and characterize key competencies of managing labor and delivery units in the United States and assess the associations between unit management and maternal outcomes.

Methods: We developed and administered a management measurement instrument using structured telephone interviews with both the primary nurse and physician managers at 53 diverse hospitals across the United States. A trained interviewer scored the managers' interview responses based on management practices that ranged from most reactive (lowest scores) to most proactive (highest scores).

Assisted Reproductive Technology and Birth Defects: Effects of Subfertility and Multiple Births.

Background: Assisted reproductive technology (ART) has been associated with birth defects, but the contributions of multiple births and underlying subfertility remain unclear. We evaluated the effects of subfertility and mediation by multiple births on associations between ART and nonchromosomal birth defects.

Methods: We identified a retrospective cohort of Massachusetts live births and stillbirths from 2004 to 2010 among ART-exposed, ART-unexposed subfertile, and fertile mothers using linked information from fertility clinics, vital records, hospital discharges, and birth defects surveillance.

Birth Outcomes by Infertility Treatment: Analyses of the Population-Based Cohort: Massachusetts Outcomes Study of Assisted Reproductive Technologies (MOSART).

Objective: To evaluate pregnancy and birth outcomes by type of infertility treatment received.

Study Design: Assisted reproductive technology (ART) data on women who were both treated and gave birth in Massachusetts were linked to vital records and hospital data. Singleton and twin live births were categorized by ART treatment parameters.

Assisted Reproductive Technology and Early Intervention Program Enrollment.

Objectives: We examined the prevalence of Early Intervention (EI) enrollment in Massachusetts comparing singleton children conceived via assisted reproductive technology (ART), children born to mothers with indicators of subfertility but no ART (Subfertile), and children born to mothers who had no indicators of subfertility and conceived naturally (Fertile). We assessed the natural direct effect (NDE), the natural indirect effect (NIE) through preterm birth, and the total effect of ART and subfertility on EI enrollment.

Methods: We examined maternal and infant characteristics among singleton ART (n = 6447), Subfertile (n = 5515), and Fertile (n = 306,343) groups and characteristics associated with EI enrollment includingpreterm birth using χ(2) statistics (α = 0.

Severe Maternal Morbidity and the Use of Assisted Reproductive Technology in Massachusetts.

Objective: To assess whether risk of severe maternal morbidity at delivery differed for women who conceived using assisted reproductive technology (ART), those with indicators of subfertility but no ART ("subfertile"), and those who had neither ART nor subfertility ("fertile").

Methods: This retrospective cohort study was part of the larger Massachusetts Outcomes Study of Assisted Reproductive Technology. To construct the Massachusetts Outcomes Study of Assisted Reproductive Technology database and identify ART deliveries, we linked ART treatment records to birth certificates and maternal and infant hospitalization records occurring in Massachusetts between 2004 and 2010.