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Am J Perinatol 2016; 33(06): 590-599
DOI: 10.1055/s-0035-1570380
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Association between Hospital Birth Volume and Maternal Morbidity among Low-Risk Pregnancies in Rural, Urban, and Teaching Hospitals in the United States

Katy B. Kozhimannil
1   Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
,
Viengneesee Thao
1   Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
,
Peiyin Hung
1   Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
,
Ellen Tilden
2   Department of Nurse-Midwifery, Oregon Health and Sciences University School of Nursing, Portland, Oregon
,
Aaron B. Caughey
3   Department of Obstetrics and Gynecology, Oregon Health and Sciences University School of Medicine, Portland, Oregon
,
Jonathan M. Snowden
3   Department of Obstetrics and Gynecology, Oregon Health and Sciences University School of Medicine, Portland, Oregon
› Author Affiliations
Further Information

Publication History

03 November 2015

10 November 2015

Publication Date:
05 January 2016 (online)

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Abstract

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.

Keywords

maternal morbidity - birth volume - teaching hospitals - rural hospitals - postpartum hemorrhage
 

  • References

  • 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.
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 14 Shahian DM. Improving cardiac surgery quality—volume, outcome, process?. JAMA 2004; 291 (2) 246-248
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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.
    PubMedGoogle Scholar
  • 26 D'Alton ME, Main EK, Menard MK, Levy BS. The National Partnership for Maternal Safety. Obstet Gynecol 2014; 123 (5) 973-977
    CrossrefPubMedGoogle Scholar
  • 27 Ayanian JZ, Weissman JS. Teaching hospitals and quality of care: a review of the literature. Milbank Q 2002; 80 (3) 569-593 , v
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 30 Williams RL. A note on robust variance estimation for cluster-correlated data. Biometrics 2000; 56 (2) 645-646
    CrossrefPubMedGoogle Scholar
  • 31 Kupersmith J. Quality of care in teaching hospitals: a literature review. Acad Med 2005; 80 (5) 458-466
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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.
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar