Maternal and Infant Morbidity and Mortality in Relation to Delivery Mode in a Large U.S. Health Care Claims Database in 2019 and 2020

Abstract

Objective

This study aimed to provide contemporary data on maternal and infant outcomes after delivery to better understand risks of cesarean section (CS).

Study Design

Data for deliveries in 2019 and 2020 were obtained from a large U.S. commercial health care claims database. Maternal morbidity measures included 20 severe maternal morbidity (SMM) outcomes and seven additional obstetric and mental health outcomes. Infant morbidity measures included eight outcomes related to respiratory health, digestive health, atopic dermatitis, and birth trauma. Outcome prevalence was ascertained at 42 days (maternal only) and 360 days after delivery. Logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) for prevalence adjusted for risk factors for delivery mode and each outcome. Analyses were conducted for 2019 and 2020 to assess the influence of the coronavirus disease 2019 pandemic.

Results

A total of 436,991 deliveries were identified (145,061 CS; 291,930 vaginal). The prevalence of SMM was 3.3% at 42 days and 4.1% at 360 days. The covariate-adjusted odds of SMM were higher among CS than vaginal deliveries at 42 days (OR: 2.0, 95% CI: 1.9, 2.1) and 360 days (OR: 1.7, 95% CI: 1.7, 1.8). There were 226,983 infants available for analysis of outcomes at 360 days. Most adverse infant outcomes were more prevalent at 360 days among CS than vaginal deliveries, and the covariate-adjusted odds of any adverse infant outcome at 360 days were higher among CS than vaginal deliveries (OR: 1.2; 95% CI: 1.1, 1.3). Respiratory morbidity was most affected by delivery mode. Maternal and infant mortality up to 360 days was rare. Similar trends were observed in the 2019 and 2020 cohorts.

Conclusion

This observational study, performed using recent data obtained from a large U.S. commercial claims database, provides contemporary evidence of risks to mothers and infants of CS relative to vaginal delivery.

Key Points

• In a large commercially insured population, one-third of deliveries were by CS.

• Most maternal and infant outcomes were more prevalent among CS deliveries than vaginal deliveries.

• Respiratory conditions were most strongly related to delivery mode among infants.

• Maternal and infant mortality up to 360 days was rare in this population.

• Results were similar in 2019 and 2020, indicating a small impact of the COVID-19 pandemic.

Keywords

delivery mode - cesarean section - SMM - mortality - maternal - infant - COVID-19 - real-world data

Publication History

Received: 20 February 2024

Accepted: 20 September 2024

Accepted Manuscript online:
24 September 2024

Article published online:
29 October 2024

• References

• 1 Fink DA, Kilday D, Cao Z. et al. Trends in maternal mortality and severe maternal morbidity during delivery-related hospitalizations in the United States, 2008 to 2021. JAMA Netw Open 2023; 6 (06) e2317641-e2317641
• 2 Martin JA, Hamilton BE, Osterman MJK. Births in the United States, 2022. NCHS Data Brief 2023; (477) 1-8
• 3 Osterman MJ. Changes in primary and repeat cesarean delivery: United States 2016–2021. NVSS Vital Statistics Rapid Release; 2022
• 4 Stephenson J. Rate of first-time cesarean deliveries on the rise in the US. JAMA Health Forum 2022; 3 (07) e222824
• 5 Caughey AB, Cahill AG, Guise JM, Rouse DJ. American College of Obstetricians and Gynecologists (College), Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210 (03) 179-193
• 6 Dahlquist K, Stuart A, Källén K. Planned cesarean section vs planned vaginal delivery among women without formal medical indication for planned cesarean section: a retrospective cohort study of maternal short-term complications. Acta Obstet Gynecol Scand 2022; 101 (09) 1026-1032
• 7 Gregory KD, Jackson S, Korst L, Fridman M. Cesarean versus vaginal delivery: whose risks? Whose benefits?. Am J Perinatol 2012; 29 (01) 7-18
• 8 National Institutes of Health. State-of-the-science conference statement: cesarean delivery on maternal request March 27-29, 2006. Obstet Gynecol 2006; 107 (06) 1386-1397
• 9 Mylonas I, Friese K. Indications for and risks of elective cesarean section. Dtsch Arztebl Int 2015; 112 (29–30): 489-495
• 10 Sandall J, Tribe RM, Avery L. et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet 2018; 392 (10155): 1349-1357
• 11 WHO. WHO statement on caesarean section rates. 2015
• 12 Antoine C, Young BK. Cesarean section one hundred years 1920-2020: the good, the bad and the ugly. J Perinat Med 2020; 49 (01) 5-16
• 13 Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis. PLoS Med 2018; 15 (01) e1002494
• 14 CDC. Severe maternal morbidity in the United States. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; 2021. . Accessed February 15, 2023 at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html
• 15 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 (09) 1414-1420
• 16 Leonard SA, Main EK, Carmichael SL. The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity. BMC Pregnancy Childbirth 2019; 19 (01) 16
• 17 Kilpatrick SK, Ecker JL. American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine. Severe maternal morbidity: screening and review. Am J Obstet Gynecol 2016; 215 (03) B17-B22
• 18 Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS. 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 (04) 455-460
• 19 Lumbiganon P, Laopaiboon M, Gülmezoglu AM. et al; World Health Organization Global Survey on Maternal and Perinatal Health Research Group. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08. Lancet 2010; 375 (9713) 490-499
• 20 Pallasmaa N, Ekblad U, Gissler M. Severe maternal morbidity and the mode of delivery. Acta Obstet Gynecol Scand 2008; 87 (06) 662-668
• 21 Souza JP, Gülmezoglu A, Lumbiganon P. et al; WHO Global Survey on Maternal and Perinatal Health Research Group. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on maternal and perinatal health. BMC Med 2010; 8 (01) 71
• 22 van Dillen J, Zwart JJ, Schutte J, Bloemenkamp KW, van Roosmalen J. Severe acute maternal morbidity and mode of delivery in the Netherlands. Acta Obstet Gynecol Scand 2010; 89 (11) 1460-1465
• 23 Villar J, Carroli G, Zavaleta N. et al; World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ 2007; 335 (7628) 1025
• 24 Hall GC, Lanes S, Bollaerts K, Zhou X, Ferreira G, Gini R. Outcome misclassification: impact, usual practice in pharmacoepidemiology database studies and an online aid to correct biased estimates of risk ratio or cumulative incidence. Pharmacoepidemiol Drug Saf 2020; 29 (11) 1450-1455
• 25 Hall GC, Sauer B, Bourke A, Brown JS, Reynolds MW, LoCasale R. Guidelines for good database selection and use in pharmacoepidemiology research. Pharmacoepidemiol Drug Saf 2012; 21 (01) 1-10
• 26 Funk MJ, Landi SN. Misclassification in administrative claims data: quantifying the impact on treatment effect estimates. Curr Epidemiol Rep 2014; 1 (04) 175-185