The effect of maternal health conditions on maternal morbidity in women with a prior cesarean: the role of elective repeat cesarean delivery

Abstract

Background: We evaluated women with a prior cesarean delivery (CD) who were eligible for elective repeat CD or trial of labor to test whether the risk of severe maternal morbidity (SMM) was: 1) directly associated with important pre-existing and gestational conditions or 2) indirectly associated (significantly increased or decreased) with the decision to undergo elective repeat CD.

Methods: Women with a prior CD who had inborn, liveborn, term, singleton, vertex deliveries were identified in California 2010-2011 hospital discharge datasets. Using discharge codes, this population was stratified into two groups: attempted labor and elective repeat CD. A mediation model (stratified by younger vs. older women [>35 years]) was built for each of the following maternal conditions (exposure): chronic/gestational diabetes mellitus (DM), chronic/gestational hypertension, heart disease, obesity, and mental health diagnoses. Elective repeat CD was the mediator and SMM was the outcome.

Results: Of 141,535 eligible deliveries, 72.7% had an elective repeat CD; 2.3% had SMM, which occurred in 2.2% of younger vs. 2.6% of older women. For younger and older women respectively, the modeled total effect odds ratios (95% CI) for heart disease were: 10.7 (8.5, 13.5) and 8.8 (6.4, 12.2); for hypertension: 1.7 (1.4, 1.9) and 2.0 (1.6, 2.4); and for mental health diagnoses: 1.9 (1.6, 2.3) and 1.7 (1.3, 2.3). Neither DM nor obesity demonstrated a direct effect. Odds ratios for indirect effects were negligible for all models.

Conclusion: Among women with a prior CD, in the presence of important health conditions, the increased risk of SMM mediated by an elective repeat CD was negligible.

Keywords

Prior cesarean delivery / Vaginal birth after cesarean / Severe maternal morbidity / Mediation analysis

References

[1] Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System. Trends in pregnancy-related deaths. Available at: http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html (Accessed July 12, 2019).

[2] Fingar KF, Hambrick MM, Heslin KC, et al. Trends and disparities in delivery hospitalizations involving severe maternal morbidity, 2006-2015. HCUP Statistical Brief #243. September 2018. Agency for Healthcare Research and Quality, Rockville, MD. Available at: www.hcup-us.ahrq.gov/reports/statbriefs/sb243-Severe-Maternal-Morbidity-Delivery-Trends-Disparities.pdf (Accessed July 12, 2019).

[3] Centers for Disease Control and Prevention. Severe maternal morbidity in the United States. Trends in severe maternal morbidity in the United States 1993-2014. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html

[4] Grobman WA, Bailit JL, Rice MM, et al. For the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Frequency of and factors associated with severe maternal morbidity. Obstet Gynecology. 2014; 123: 804-810. PMid:24785608. https://doi.org/10.1097/AOG.0000000000000173

[5] Wen SW, Huang L, Liston R, et al. For the Maternal Health Study Group, Canadian Perinatal Surveillance System. Severe maternal morbidity in Canada, 1991-2001. CMAJ. 2005; 173(7):759-764. PMid:16186582. https://doi.org/10.1503/cmaj.045156

[6] Lutomski JE, Greene RA, Byrne BM. Severe maternal morbidity during childbirth hospitalisation: a comparative analysis between the Republic of Ireland and Australia. Eur J Obstet Gynecol Reprod Biol. 2012; 163: 148-153. PMid:22640728. https://doi.org/10.1016/j.ejogrb.2012.05.003

[7] Gray KE, Wallace ER, Nelson KR, Reed SD, Schiff MA. Population-based study of risk factors for severe maternal morbidity. Paediatr Perinatal Epidemiol. 2012; 26: 506-514. PMid:23061686. https://doi.org/10.1111/ppe.12011

[8] Berg CJ, MacKay AP, Cheng Q, et al. Overview of maternal morbidity during hospitalization for labor and delivery in the United States: 1993-1997 and 2001-2005. Obstet Gynecol. 2009; 113(5): 1075-1081. PMid:19384123. https://doi.org/10.1097/AOG.0b013e3181a09fc0

[9] Fridman M, Korst LM, Chow J, et al. Trends in maternal morbidity before and during pregnancy in California. Am J Public Health 2014; 104 (Suppl): 1:S49-S57. PMid:24354836. https://doi.org/10.2105/AJPH.2013.301583

[10] Arendt KW. The 2016 Hughes Lecture: what’s new in maternal morbidity and mortality. In J Obstet Anesth. 2016; 26: 59-70. PMid:26847944. https://doi.org/10.1016/j.ijoa.2015.12.003

[11] Campanharo FF, Cecatti JG, Haddad SM, et al. Brazilian Network for Surveillance of Severe Maternal Morbidity Study Group. The impact of cardiac diseases during pregnancy on severe maternal morbidity and mortality in Brazil. PLoS ONE. 2015; 10(12): e0144385. PMid:26650684. https://doi.org/10.1371/journal.pone.0144385

[12] Kilpatrick SJ, Abreo A, Greene N, et al. Severe maternal morbidity in a large cohort of women with acute severe intrapartum hypertension. Am J Obstet Gynecol. 2016; 215(1): 91. e1-7. PMid:26829504. https://doi.org/10.1016/j.ajog.2016.01.176

[13] Johnson JL, Farr SL, Dietz PM, et al. Trends in gestational weight gain: the Pregnancy Risk Assessment Monitoring System, 2000-2009. Am J Obstet Gynecol. 2015; 212: 806. e1-8. PMid:25637844. https://doi.org/10.1016/j.ajog.2015.01.030

[14] Huisman CM, Zwart JJ, Roos-Hesselink JW, et al. Incidence and predictors of maternal cardiovascular mortality and severe morbidity in the Netherlands: a prospective cohort study. PLOS ONE. 2013; 8(2): e56494. PMid:23457576. https://doi.org/10.1371/journal.pone.0056494

[15] Zwart JJ, Richters JM, de Vries JIP, et al. Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population-based study of 371,000 pregnancies. BJOG. 2008; 115: 842-850. PMid:18485162. https://doi.org/10.1111/j.1471-0528.2008.01713.x

[16] Creanga AA, Berg CJ, Ko JY, et al. Maternal mortality and morbidity in the United States: where are we now? J Womens Health. 2014; 23(1): 3-9. PMid:24383493. https://doi.org/10.1089/jwh.2013.4617

[17] Geller SE, Cox SM, Kilpatrick SJ. A descriptive model of preventability in maternal morbidity and mortality. J Perinatol. 2006; 26: 79-84. PMid:16407964. https://doi.org/10.1038/sj.jp.7211432

[18] American College of Obstetricians and Gynecologists (ACOG). Levels of maternal care. Obstetric Care Consensus No. 2. Obstet Gynecol. 2015; 125(2): 502-515. PMid:25611640. https://doi.org/10.1097/01.AOG.0000460770.99574.9f

[19] Zanette E, Parpinelli MA, Surita FG, et al. Brazilian Network for Surveillance of Severe Maternal Morbidity Group. Maternal near miss and death among women with severe hypertensive disorders: a Brazilian multicenter surveillance study. Reprod Health. 2014; 11: 4. PMid:24428879. https://doi.org/10.1186/1742-4755-11-4

[20] Bateman BT, Tsen LC. Anesthesiologist as epidemiologist: insights form registry studies of obstetric anesthesia-related complications. Anesthesiol. 2014; 120: 1311-1312. PMid:24845916. https://doi.org/10.1097/ALN.0000000000000252

[21] Regitz-Zagrosek V, Geibel-Zehender A, Gohlke-Barwolf C, et al. Cardiovascular diseases in pregnancy. Dtsch Arztebl Int. 2011; 108(16): 267-73. PMid:21603561. https://doi.org/10.3238/arztebl.2011.0267

[22] Zollner J, Curry R, Johnson M. The contribution of heart disease to maternal mortality. Curr Opin Obstet Gynecol. 2013; 25: 91-97. PMid:23411474. https://doi.org/10.1097/GCO.0b013e32835e0f11

[23] Curry R, Swan L, Steer PJ. Cardiac disease in pregnancy. Curr Opin Obstet Gynecol. 2009; 21: 508-513. PMid:19779340. https://doi.org/10.1097/GCO.0b013e328332a762

[24] Amorim MMR, Katz L, Barros AS, et al. Maternal outcomes according to mode of delivery in women with severe preeclampsia: a cohort study. J Matern Fetal Neonatal Med. 2015; 28(6): 654-660. PMid:24866351. https://doi.org/10.3109/14767058.2014.928689

[25] American College of Obstetricians and Gynecologists (ACOG). Task Force on Hypertension in Pregnancy. Hypertension in Pregnancy. Washington, DC: ACOG 2013.

[26] Pallasmaa N, Ekblad U, Gissler M. The impact of maternal obesity, age, pre-eclampsia and insulin dependent diabetes on severe maternal morbidity by mode of delivery - a register-based cohort study. Arch Gynecol Obstet 2015;291:311-318. PMid:25115277. https://doi.org/10.1007/s00404-014-3352-z

[27] Cunningham FG, Bangdiwala S, Brown SS, et al. National Institutes of Health Consensus Development Conference Statement: Vaginal Birth After Cesarean: New Insights. March 8-10, 2010. Obstet Gynecol. 2010; 115(6): 1279-1295.

[28] Gregory KD, Jackson S, Korst L, et al. Cesarean versus vaginal delivery: whose risks? Whose benefits? Am J Perinatol. 2012; 29(1): 7-18. PMid:21833896. https://doi.org/10.1055/s-0031-1285829

[29] Liu S, Liston RM, Joseph KS, et al. For the Maternal Health Study Group of the Canadian Perinatal Surveillance System. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ. 2007; 176(4): 455-460. PMid:17296957. https://doi.org/10.1503/cmaj.060870

[30] Pallasmaa N, Ekblad U, Gissler M. Severe maternal morbidity and the mode of delivery. Acta Obstet Gynecol Scan. 2008; 86: 662-668. PMid:18568466. https://doi.org/10.1080/00016340802108763

[31] Patel RM, Jain L. Delivery after previous cesarean: short-term perinatal outcomes. Semin Perinatol. 2010; 34: 272-280. PMid:20654778. https://doi.org/10.1053/j.semperi.2010.03.007

[32] Srinivas SK, Stamilio DM, Stevens EJ, et al. Predicting failure of a vaginal birth attempt after Cesarean delivery. Obstet Gynecol. 2007; 109: 800-805. PMid:17400839. https://doi.org/10.1097/01.AOG.0000259313.46842.71

[33] Lindquist AC, Kurinczuk JJ, Wallace EM, et al. Risk factors for maternal morbidity in Victoria, Australia: a population-based study. BMJ Open 2015;5e007903. PMid:26307615. https://doi.org/10.1136/bmjopen-2015-007903

[34] Wen SW, Rusen ID, Walker M, et al. For the Maternal Health Study Group, Canadian Perinatal Surveillance System. Am J Obstet Gynecol. 2004; 191: 1263-1269. PMid:15507951. https://doi.org/10.1016/j.ajog.2004.03.022

[35] American College of Obstetricians and Gynecologists (ACOG). Vaginal Birth after previous cesarean delivery. ACOG Practice Bulletin No. 115. Washington DC:ACOG, 2010.

[36] Schisterman EF, Cole SR, Platt RW. Overadjustment bias and unnecessary adjustment in epidemiologic studies. Epidemiol. 2009; 20(4): 488-495. PMid:19525685. https://doi.org/10.1097/EDE.0b013e3181a819a1

[37] Fridman M, Greene NH, Lawton E, et al. Evaluating the effect of maternal health conditions on severe maternal morbidity adjusting for cesarean delivery: a mediation analysis approach. J Epidemiol Res. 2016; 2(2): Jan 20. https://doi.org/10.5430/jer.v2n2p36

[38] Gilbert WM, Nesbitt TS, Danielsen B. The cost of prematurity: quantification by gestational age and birthweight. Obstet Gynecol. 2003; 102: 488-492. PMid:12962929. https://doi.org/10.1097/00006250-200309000-00011

[39] Korst L, Fridman M, Lu M, et al. Monitoring childbirth morbidity using hospital discharge data: further development and application of a composite measure. Am J Obstet Gynecol. 2014; 211(3): 268. e1-e16. PMid:24631432. https://doi.org/10.1016/j.ajog.2014.03.011

[40] Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. 2012; 120: 1029-1036. PMid:23090519. https://doi.org/10.1097/AOG.0b013e31826d60c5

[41] Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed adequacy of prenatal care utilization index. Am J Public Health. 1994; 84: 1414-1420. PMid:8092364. https://doi.org/10.2105/AJPH.84.9.1414

[42] Valeri L, VanderWeele TJ. Mediation analysis allowing for exposure-mediator interactions and causal interpretation: theoretical assumptions and implementation with SAS and SPSS macros. Psychol Methods. 2013; 18(2): 137-150. PMid:23379553. https://doi.org/10.1037/a0031034

[43] Hosmer DW, Lemeshow S. A goodness-of-fit test for the multiple logistic regression model. Communications in Statistics. 1980; A10: 1043-1069. https://doi.org/10.1080/03610928008827941

[44] Friedman AM, Ananth CV, Huang Y, et al. Hospital delivery volume, severe obstetrical morbidity, and failure to rescue. Am J Obstet Gynecol. 2016; 215(6): 795. e1-795.e14. PMid:27457112. https://doi.org/10.1016/j.ajog.2016.07.039

[45] Zhang J, Meikle S, Trumble A. Severe maternal morbidity associated with hypertensive disorders in pregnancy in the United States. Hypertens Pregnancy. 2003; 22(2): 203-12. PMid:12909005. https://doi.org/10.1081/PRG-120021066

[46] Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol. 2009; 113: 1299-1306. PMid:19461426. https://doi.org/10.1097/AOG.0b013e3181a45b25

[47] Gilbert WM, Young AL, Danielsen B. Pregnancy outcomes in women with chronic hypertension: a population-based study. J Reprod Med. 2007; 52: 1046-51.

[48] Thompson JL, Kuklina EV, Bateman BT, et al. Medical and obstetric outcomes among pregnant women with congenital heart disease. Obstet Gynecol. 2015; 126: 346-354. PMid:26241425. https://doi.org/10.1097/AOG.0000000000000973

[49] Maeda A, Bateman BT, Clancy CR, et al. Opioid abuse and dependence during pregnancy: temporal trends and obstetrical outcomes. Anesthesiol. 2014; 121: 1158-1165. PMid:25405293. https://doi.org/10.1097/ALN.0000000000000472

[50] Farr SL, Hayes DK, Bitsko RH, et al. Depression, diabetes, and chronic disease risk factors among U.S. women of reproductive age. Prev Chronic Dis. 2011; 8.

[51] Schummers L, Hutcheon JA, Bodnar LM, et al. Risk of adverse pregnancy outcomes by prepregnancy body mass index: a population-based study to inform prepregnancy weight loss counseling. Obstet Gynecol. 2015; 125: 133-143. PMid:25560115. https://doi.org/10.1097/AOG.0000000000000591

[52] Mourad M, Silverstein M, Bender S, et al. The effect of maternal obesity on outcomes in patients undergoing tertiary or higher cesarean delivery. J Mat Fetal Neonatal Med. 2015; 28(9): 898-993. PMid:25058127. https://doi.org/10.3109/14767058.2014.941284

[53] Howell EA, Egorova N, Balbierz A, et al. Black-white differences in severe maternal morbidity and site of care. Am J Obstet Gynecol. 2016; 214: 122. e1-7. PMid:26283457. https://doi.org/10.1016/j.ajog.2015.08.019

[54] Creanga AA, Bateman BT, Kuklina EV, et al. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010. Am J Obstet Gynecol. 2014; 210: 435. e1-8. PMid:24295922. https://doi.org/10.1016/j.ajog.2013.11.039

[55] Nair M, Kurinczuk JJ, Knight M. Ethnic variations in severe maternal morbidity in the UK- a case control study. PLoS One. 2014; 9(4): e95086. PMid:24743879. https://doi.org/10.1371/journal.pone.0095086