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Association between Hospital Birth Volume and Maternal Morbidity among Low-Risk Pregnancies in Rural, Urban, and Teaching Hospitals in the United States
03 November 2015
10 November 2015
05 January 2016 (online)
Objectives This study aims to examine the relationship between hospital birth volume and multiple maternal morbidities among low-risk pregnancies in rural hospitals, urban non-teaching hospitals, and urban teaching hospitals, using a representative sample of U.S. hospitals.
Study Design Using the 2011 Nationwide Inpatient Sample from 607 hospitals, we identified 508,146 obstetric deliveries meeting low-risk criteria and compared outcomes across hospital volume categories. Outcomes include postpartum hemorrhage (PPH), chorioamnionitis, endometritis, blood transfusion, severe perineal laceration, and wound infection.
Results Hospital birth volume was more consistently related to PPH than to other maternal outcomes. Lowest-volume rural (< 200 births) and non-teaching (< 650 births) hospitals had 80% higher odds (adjusted odds ratio [AOR] = 1.80; 95% CI = 1.56–2.08) and 39% higher odds (AOR = 1.39; 95% CI = 1.26–1.53) of PPH respectively, than those in corresponding high-volume hospitals. However, in urban teaching hospitals, delivering in a lower-volume hospital was associated with 14% lower odds of PPH (AOR = 0.86; 95% CI = 0.80–0.93). Deliveries in rural hospitals had 31% higher odds of PPH than urban teaching hospitals (AOR = 1.31; 95% CI = 1.13–1.53).
Conclusions Low birth volume was a risk factor for PPH in both rural and urban non-teaching hospitals, but not in urban teaching hospitals, where higher volume was associated with greater odds of PPH.
- 1 Pfuntner A, Wier LM, Stocks C. Most frequent conditions in US hospitals. September 2011. Available at: http://www.ncbi.nlm.nih.gov/books/NBK169248/ . Accessed March 24, 2015.
- 2 Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 2012; 120 (5) 1029-1036
- 3 Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg 2010; 110 (5) 1368-1373
- 4 Creanga AA, Berg CJ, Ko JY , et al. Maternal mortality and morbidity in the United States: where are we now?. J Womens Health (Larchmt) 2014; 23 (1) 3-9
- 5 Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS , et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384 (9947) 980-1004
- 6 Beard JL, Hendricks MK, Perez EM , et al. Maternal iron deficiency anemia affects postpartum emotions and cognition. J Nutr 2005; 135 (2) 267-272
- 7 Furuta M, Sandall J, Cooper D, Bick D. The relationship between severe maternal morbidity and psychological health symptoms at 6-8 weeks postpartum: a prospective cohort study in one English maternity unit. BMC Pregnancy Childbirth 2014; 14: 133
- 8 Sundaram S, Harman JS, Cook RL. Maternal morbidities and postpartum depression: an analysis using the 2007 and 2008 Pregnancy Risk Assessment Monitoring System. Womens Health Issues 2014; 24 (4) e381-e388
- 9 Prior E, Santhakumaran S, Gale C, Philipps LH, Modi N, Hyde MJ. Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature. Am J Clin Nutr 2012; 95 (5) 1113-1135
- 10 Korst LM, Fridman M, Lu MC , 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.e1-268.e16
- 11 Glance LG, Dick AW, Glantz JC , et al. Rates of major obstetrical complications vary almost fivefold among US hospitals. Health Aff (Millwood) 2014; 33 (8) 1330-1336
- 12 Kozhimannil KB, Hung P, Prasad S, Casey M, Moscovice I. Rural-urban differences in obstetric care, 2002-2010, and implications for the future. Med Care 2014; 52 (1) 4-9
- 13 Srinivas SK, Fager C, Lorch SA. Variations in postdelivery infection and thrombosis by hospital teaching status. Am J Obstet Gynecol 2013; 209 (6) 567.e1-567.e7
- 14 Shahian DM. Improving cardiac surgery quality—volume, outcome, process?. JAMA 2004; 291 (2) 246-248
- 15 Phibbs CS, Bronstein JM, Buxton E, Phibbs RH. The effects of patient volume and level of care at the hospital of birth on neonatal mortality. JAMA 1996; 276 (13) 1054-1059
- 16 Phibbs CS, Baker LC, Caughey AB, Danielsen B, Schmitt SK, Phibbs RH. Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants. N Engl J Med 2007; 356 (21) 2165-2175
- 17 Chung JH, Phibbs CS, Boscardin WJ , et al. Examining the effect of hospital-level factors on mortality of very low birth weight infants using multilevel modeling. J Perinatol 2011; 31 (12) 770-775
- 18 Snowden JM, Cheng YW, Kontgis CP, Caughey AB. The association between hospital obstetric volume and perinatal outcomes in California. Am J Obstet Gynecol 2012; 207 (6) 478.e1-478.e7
- 19 Snowden JM, Cheng YW, Emeis CL, Caughey AB. The impact of hospital obstetric volume on maternal outcomes in term, non-low-birthweight pregnancies. Am J Obstet Gynecol 2015; 212 (3) 380.e1-380.e9
- 20 Goff SL, Pekow PS, Avrunin J, Lagu T, Markenson G, Lindenauer PK. Patterns of obstetric infection rates in a large sample of US hospitals. Am J Obstet Gynecol 2013; 208 (6) 456.e1-456.e13
- 21 Janakiraman V, Lazar J, Joynt KE, Jha AK. Hospital volume, provider volume, and complications after childbirth in U.S. hospitals. Obstet Gynecol 2011; 118 (3) 521-527
- 22 Chang JJ, Stamilio DM, Macones GA. Effect of hospital volume on maternal outcomes in women with prior cesarean delivery undergoing trial of labor. Am J Epidemiol 2008; 167 (6) 711-718
- 23 Kyser KL, Lu X, Santillan DA , et al. The association between hospital obstetrical volume and maternal postpartum complications. Am J Obstet Gynecol 2012; 207 (1) 42.e1-42.e17
- 24 D'Alton ME, Bonanno CA, Berkowitz RL , et al. Putting the “M” back in maternal-fetal medicine. Am J Obstet Gynecol 2013; 208 (6) 442-448
- 25 Supporting Healthy and Normal Psysiologic Childbirth. A Consensus Statement. Available at: http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000272/Physiological%20Birth%20Consensus%20Statement-%20FINAL%20May%2018%202012%20FINAL.pdf . Accessed December 18, 2014.
- 26 D'Alton ME, Main EK, Menard MK, Levy BS. The National Partnership for Maternal Safety. Obstet Gynecol 2014; 123 (5) 973-977
- 27 Ayanian JZ, Weissman JS. Teaching hospitals and quality of care: a review of the literature. Milbank Q 2002; 80 (3) 569-593 , v
- 28 Kuklina EV, Whiteman MK, Hillis SD , et al. An enhanced method for identifying obstetric deliveries: implications for estimating maternal morbidity. Matern Child Health J 2008; 12 (4) 469-477
- 29 Kozhimannil KB, Law MR, Virnig BA. Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Aff (Millwood) 2013; 32 (3) 527-535
- 30 Williams RL. A note on robust variance estimation for cluster-correlated data. Biometrics 2000; 56 (2) 645-646
- 31 Kupersmith J. Quality of care in teaching hospitals: a literature review. Acad Med 2005; 80 (5) 458-466
- 32 Snyder CC, Wolfe KB, Loftin RW, Tabbah S, Lewis DF, Defranco EA. The influence of hospital type on induction of labor and mode of delivery. Am J Obstet Gynecol 2011; 205 (4) 346.e1-346.e4
- 33 Goff SL, Pekow PS, Markenson G, Knee A, Chasan-Taber L, Lindenauer PK. Validity of using ICD-9-CM codes to identify selected categories of obstetric complications, procedures and co-morbidities. Paediatr Perinat Epidemiol 2012; 26 (5) 421-429
- 34 Lain SJ, Hadfield RM, Raynes-Greenow CH , et al. Quality of data in perinatal population health databases: a systematic review. Med Care 2012; 50 (4) e7-e20
- 35 Board on Children, Youth, and Families; Institute of Medicine; National Research Council. An update on research issues in the assessment of birth settings: Workshop summary. Washington (DC): National Academies Press (US); September 23, 2013. Available at: http://www.ncbi.nlm.nih.gov/books/NBK201939/ . Accessed February 13, 2015.
- 36 Kozhimannil KB, Hung P, Prasad S, Casey M, McClellan M, Moscovice IS. Birth volume and the quality of obstetric care in rural hospitals. J Rural Health 2014; 30 (4) 335-343
- 37 Menard MK, Kilpatrick S, Saade G , et al; American College of Obstetricians and Gynecologists and Society for Maternal–Fetal Medicine. Levels of maternal care. Am J Obstet Gynecol 2015; 212 (3) 259-271