Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2020 Oct 1.
Published in final edited form as: Obstet Gynecol. 2019 Oct;134(4):695–707. doi: 10.1097/AOG.0000000000003434

Association Between Severe Maternal Morbidity and Psychiatric Illness Within One Year of Hospital Discharge After Delivery

Adam K LEWKOWITZ 1, Joshua I ROSENBLOOM 1, Matt KELLER 2, Julia D LÓPEZ 1, George A MACONES 1, Margaret A OLSEN 2, Alison G CAHILL 1
PMCID: PMC7035949  NIHMSID: NIHMS1533196  PMID: 31503165

Abstract

Objectives:

To estimate whether severe maternal morbidity is associated with increased risk of psychiatric illness in the year after delivery hospital discharge.

Methods:

This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes within Florida’s Healthcare Cost and Utilization Project’s databases. The first liveborn singleton delivery from 2005-2015 was included; women with ICD-9-CM codes for psychiatric illness or substance use disorder during pregnancy were excluded. The exposure was ICD-9-CM codes during delivery hospitalization of severe maternal morbidity, as per the CDC. The primary outcome was ICD-9-CM codes in ED encounter or inpatient admission within one year of hospital discharge of composite psychiatric morbidity (suicide attempt, depression, anxiety, post-traumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was a composite of ICD-9-CM codes for substance use disorder. We compared women with severe maternal morbidity to those without severe maternal morbidity using multivariable logistic regression adjusting for sociodemographic factors and medical comorbidities. Cox proportional hazard models identified the highest risk period after hospital discharge for the primary outcome.

Results:

Fifteen thousand five-hundred ten women with severe maternal morbidity and 1,178,458 without severe maternal morbidity were included. Within one year of hospital discharge, 2.9% (n=452) of women with SMM had the primary outcome versus 1.6% (n=19,279) of women without SMM, resulting in an adjusted odds ratio (aOR) 1.74 (95% Confidence Interval (CI) 1.58 – 1.91)).”The highest risk interval was within four months of discharge (adjusted hazard ratio (aHR) 2.53 (95% CI 2.05 – 3.12)). Most severe maternal morbidity conditions were associated with higher risk of postpartum psychiatric illness. Women with severe maternal morbidity had nearly twofold higher risk of postpartum substance use disorder (170 (1.1%) versus 6861 (0.6%); aOR 1.91 (95% CI 1.64 – 2.23)).

Conclusions:

Though absolute numbers were modest, severe maternal morbidity was associated with increased risk of severe postpartum psychiatric morbidity and substance use disorder. The highest period of risk extended to four months after hospital discharge.

Précis:

After delivery of liveborn singletons, the risk of need for acute psychiatric care within one year is significantly increased after severe maternal morbidity complications.

Introduction

Severe maternal morbidity, historically described only as a “near miss” for peripartum maternal mortality,1 has increased by 45% in the United States from 2006 to 2015.2 Severe maternal morbidity has recently been formally defined via a composite by the Centers for Disease Control and Prevention (CDC) including indices of both severe peripartum medical conditions such as eclampsia or sepsis and procedures such as blood transfusion or hysterectomy performed during delivery hospitalization.3 Severe maternal morbidity has been associated with maternal mortality, increased hospital costs, and prolonged delivery hospitalizations.4 In addition, having severe maternal morbidity during delivery has been identified as a risk factor for postpartum Emergency Department (ED) encounters for medical care5 and postpartum inpatient readmission.6

Childbirth is known to be a potent trigger for the onset of psychiatric illness,7,8 and various factors, ranging from unexpected cesarean delivery9 to miscarriage,10 stillbirth,11–13 and perception of negative or traumatic birth experience14 have been associated with increased risk of psychiatric illness after delivery. Although severe maternal morbidity is, by definition, life-threatening and there is a clear association between adverse life events and new-onset postpartum psychiatric morbidity,15 the impact of severe maternal morbidity on postpartum psychiatric illness remains unclear. The only published data available from the United States are limited by small sample size and self-disclosure of “pregnancy complications,” of which nearly 75% were first trimester miscarriage.16 To shed light on the potential association between severe maternal morbidity and postpartum psychiatric morbidity in the United States, large, population-based studies are needed that utilize robust clinician-generated diagnoses for both severe maternal morbidity and psychiatric conditions.

Using a state database, we aimed to determine the incidence of presentation for acute psychiatric care in the ED or inpatient hospital in the year after hospital discharge from delivery of a liveborn singleton and to ascertain whether having severe maternal morbidity during delivery was associated with increased risk of acute psychiatric illness within one year of hospital discharge compared to deliveries without severe maternal morbidity. We hypothesized that liveborn singleton deliveries with severe maternal morbidity would be associated with increased risk of psychiatric morbidity in the year after hospital discharge when compared to deliveries without severe maternal morbidity.

Methods

We conducted a retrospective cohort study using the Florida State Inpatient Database and Emergency Department Database of the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (HCUP)17 from 2005 to 2015, including all in-hospital deliveries from the fourth quarter of 2005 through December 31, 2014. The Inpatient and Emergency Department (ED) databases were linked at a patient-level via a visit linkage variable (VisitLink) in tandem with a timing variable (DaysToEvent)17; as such, we could include multiple hospital or Emergency Department (ED) visits in Florida across time while adhering to HCUP privacy regulations.17 Deliveries in women aged 13-54 years were identified using a validated algorithm that utilizes International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes.18 For study purposes, the index delivery was defined as the first delivery within the database during the study timeframe, regardless of parity or subsequent deliveries; the duration of postpartum follow-up was defined as 365 days after hospital discharge. Only the index delivery was included for analysis. Deliveries were restricted to liveborn singletons (ICD-9-CM codes 650 or V270). Women whose index deliveries were coded as both liveborn singletons and stillbirth ≥23 weeks gestation (ICD-9-CM codes 656.40, 656.41, and V271) or multiple gestation (ICD-9-CM codes 651.00, 651.01, 651.10, 651.11, 651.20, 651.21, V272.2 – V27.7) were excluded from analysis because stillbirth19 and multiple gestation20 have each been associated with increased risk of postpartum psychiatric morbidity, which would have confounded our analyses. Patients who were listed as “male” were excluded, as were women who did not reside in Florida as their long-term outcomes may not be captured in our database. In addition, women coded during an inpatient hospitalization or ED encounter in the 252 days (9 months, a proxy for pregnancy) prior to hospital discharge of the index delivery for any condition within the primary and secondary composite outcomes were excluded from analysis due to pre-existing psychiatric morbidity or substance use disorder. Sociodemographic data analyzed included age, race/ethnicity (non-Hispanic black, non-Hispanic white, Hispanic, and other), and payer (private, public, or other). We also identified and analyzed underlying maternal medical comorbidities and maternal conditions present at delivery via a previously validated maternal comorbidity index4 (Appendix 1). Tobacco use was not included in our study population as this variable has been shown to be under-coded in the HCUP database overall and within the state of Florida specifically.21

The primary exposure was the CDC’s severe maternal morbidity composite (Box 1); the individual indices were extracted using ICD-9-CM diagnosis and procedure codes as defined by the CDC3 (Appendix 2). Due to concerns that blood transfusion was under-coded via variations in coding practices between hospitals,22 secondary exposures included the individual indices within the severe maternal morbidity composite.

Box 1: Medical Conditions in the Center for Disease Control and Prevention’s Severe Maternal Morbidity Composite.

Medical Condition

Acute myocardial infarction

Aneurysm

Acute renal failure

Adult Respiratory Distress Syndrome

Amniotic Fluid Embolism

Cardiac arrest/ventricular fibrillation

Conversion of cardiac rhythm

Disseminated intravascular coagulation

Eclampsia

Heart failure/arrest during surgery or procedure

Puerperal cerebrovascular disorders

Pulmonary edema/Acute Heart Failure

Severe anesthesia complications

Sepsis

Shock

Sickle cell disease with crisis

Air and thrombotic embolism

Hysterectomy

Temporary tracheostomy

Ventilation

Blood transfusion

Data from Centers for Disease Control and Prevention. Severe maternal morbidity indicators and corresponding ICD codes during delivery hospitalizations. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm. Retrieved May 10, 2018.

Because the HCUP database includes admission and discharge dates for all patients but does not include delivery date for all women with normal spontaneous vaginal delivery, outcomes were extracted from the day after index delivery hospital discharge through 365 days after discharge. The primary outcome was an ICD-9-CM code during a postpartum ED presentation or readmission to an inpatient hospital for psychiatric illness, defined as a condition within the psychiatric morbidity composite. Our primary outcome combined psychiatric composites that have been previously utilized in the Obstetric literature,8,10,11,15,23 including suicide attempt, depression, anxiety, psychosis, post-traumatic stress disorder (PTSD), acute stress reaction, and adjustment disorder. The secondary outcome was a substance use disorder composite, including alcohol or recreational drug use or dependence, obtained using the Elixhauser comorbidity algorithm, a dichotomous categorization of ICD-9-CM code-based morbidity that has been well-validated for administrative datasets.24 The ICD-9-CM codes for each condition within the primary and secondary outcomes are included in Appendix 3. Only the first ED presentation or hospital admission meeting our primary or secondary outcome definition during the time interval was included as an outcome. Coding for either primary or secondary diagnoses of any condition within each composite during a postpartum encounter was included as an outcome. Women could have both the primary and secondary outcome if they were coded for conditions in both composites during the same ED or hospital encounter, but having ICD-9-CM coding for one outcome excluded women from being eligible for the other outcome at subsequent encounters. Patients included in each composite outcome may have had more than one diagnosis within the composite but were only counted once per composite.

Demographic and baseline clinical data were compared between women with severe maternal morbidity versus without severe maternal morbidity using the X2 test or Fisher exact test for categorical variables as appropriate. Observations were censored by the first of the following conditions: 365 day interval after the index delivery hospital discharge, death, or subsequent hospitalization coded for pregnancy. The first subsequent hospitalization coded for pregnancy was identified via ICD-9-CM diagnosis and procedure codes for pregnancy-related conditions or delivery after the index delivery (Appendix 3). Unadjusted logistic regression was conducted for all primary and secondary outcomes. In addition, multivariable logistic regression analyses were conducted for all conditions within the psychiatric and substance use disorder composites that had more than 50 women with severe maternal morbidity coded for that individual outcome. Multivariable logistic regression analyses were adjusted for differences between sociodemographic and medical factors of women with versus without severe maternal morbidity during delivery hospitalization that were identified to be statistically significant: age, race–ethnicity, payer, income quartile by zip code, mode of delivery, and maternal medical comorbidities. Sickle cell disease and eclampsia were conditions included within the severe maternal morbidity composite, but some ICD-9-CM codes used for these conditions were also included within the morbidity composite; thus, we were unable to adjust for Sickle cell disease or eclampsia in the multivariable models. Demographic data missing from the database was recoded as an indicator variable in order to ensure all patients were included in the multivariable analyses. A two-sided p <0.05 was considered statistically significant in all analyses. Due to HCUP restrictions designed to preserve patient privacy, counts <11 for an exposure were presented as n<11 while counts <11 for an outcome were reported as “--”.

Additional pre-specified analyses were performed to further evaluate our findings. First, the risk of the primary and secondary outcomes were compared with each of the individual conditions within the severe maternal morbidity composite to identify whether specific morbidities were associated with increased risk of postpartum psychiatric illness or substance use disorder or dependence. Unadjusted logistic regression was conducted for all conditions within the severe maternal morbidity composite. In addition, multivariable logistic regression analyses were conducted for blood transfusion and for the severe maternal morbidity composite excluding blood transfusion. Second, we conducted Cox proportional hazard ratios to examine the association between stillbirth (and term livebirth) and the primary outcome over the 12-month follow-up period. The logrank test was used to compare survival functions. The proportional hazards assumption was assessed by significance testing of a time-dependent interaction. In anticipation that the risk of postpartum psychiatric morbidity was not consistent during the year-long follow-up period, additional Cox proportional hazard models were created to explore the highest risk window for postpartum psychiatric morbidity in clinically relevant intervals: the 12-month follow-up period was to be divided into six-month, four-month, and three-month intervals if needed. Once significance testing of a time-dependent interaction showed the proportional hazards assumption was not violated, the Heaviside unit step function was utilized to accommodate for variations in time-dependent interactions in the follow-up period.25 Third, we tested whether significant interactions existed between independent variables within the primary logistic model. Fourth, we re-defined our outcomes to include only hospital admissions alone (i.e. excluding ED encounters) to analyze the impact of severe maternal morbidity on postpartum psychiatric morbidity severe enough to require inpatient psychiatric care.

Lastly, we conducted several sensitivity analyses. First, we re-defined the exclusion period for pre-existing psychiatric comorbidity as two years prior to the index delivery to exclude women with significant psychiatric illness who did not have any acute events during their pregnancy (i.e. only deliveries from 2007 to 2014 were included). Second, we excluded women who had medical comorbidities identified during their delivery hospitalization as medical comorbidities alone26 or in combination27 have been associated with increased risk of depression or PTSD.28 Thus, we could ensure medical comorbidities were not confounding the association between severe maternal morbidity and postpartum psychiatric morbidity. Third, we removed psychosis as both an exclusion for a pre-existing psychiatric morbidity and as a condition within the primary composite outcome. This was done because, while psychosis has been described as a mood disorder in obstetric literature,8,15,29 psychosis is categorized as a psychotic disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).30

The study was exempted from review by the Washington University in St. Louis Human Research Protection Office because the HCUP data consist of limited datasets with no personally identifiable information. SAS version 9.3 (SAS Institute, Cary NC) was used for all analyses.

Results

A total of 1,229,835 patients with liveborn singleton pregnancies were identified: 16,408 (1.3%) deliveries with severe maternal morbidity and 1,213,427 (98.7%) deliveries without severe maternal morbidity. Eight hundred ninety-eight deliveries with severe maternal morbidity (5.5%) and 34,969 deliveries without severe maternal morbidity (2.9%) were excluded due to prior psychiatric morbidity or substance use disorder. Appendix 4, compares the conditions identified during the index pregnancy or during the index delivery hospitalization that resulted in exclusion from analysis. After excluding for pre-existing psychiatric illness and prior ED visits or inpatient admissions for substance use disorder, the final analytic population of liveborn singleton pregnancies included 15,510 deliveries with severe maternal morbidity and 1,178,458 deliveries without severe maternal morbidity.

Sociodemographic and obstetric characteristics between women with severe maternal morbidity during delivery compared to those without severe maternal morbidity during delivery are shown in Table 1. Women with severe maternal morbidity during delivery were significantly older and more like to have cesarean delivery, be Black, and have public insurance. Among those with available income data, women with severe maternal morbidity were significantly more likely to be in the two poorest income quartiles by zip code compared to women without severe maternal morbidity. They were also more likely to have medical comorbidities.

Table 1:

Comparison of baseline characteristics among women without coding for preexisting psychiatric illness in the nine months prior to delivery of liveborn singleton neonates with versus without severe maternal morbidity

Liveborn, singleton with SMM (n=15,510) Liveborn, singleton without SMM (n=1,178,458) Unadjusted Odds Ratio (95% Confidence Interval (CI))1
Maternal age at delivery (n (%))
< 18 years 724 (4.7) 45,356 (3.9) 1.30 (1.20 – 1.40)
18–34 years 11,779 (76.0) 958,429 (81.3) Reference
35–39 years 2216 (14.3) 138,162 (11.7) 1.31 (1.25 – 1.37)
≥ 40 years 791 (5.1) 36,511 (3.1) 1.76 (1.64 – 1.90)
Race/Ethnicity (n (%))2
White 6318 (41.3) 596,251 (51.3) Reference
Black 5060 (33.1) 252,952 (21.8) 1.89 (1.82 – 1.96(
Latina 2937 (19.2) 236,875 (20.4) 1.17 (1.12 – 1.22)
Other 982 (6.4) 76,112 (6.5) 1.22 (1.14 – 1.30)
Insurance Type (n (%))
Private Insurance 6636 (42.8) 573,882 (48.7) Reference
Public Insurance 8355 (53.9) 568,966 (48.3) 1.27 (1.23 – 1.31)
Other 519 (3.3) 35,610 (3.1) 1.26 (1.15 – 1.38)
Income Quartile, based on Zip code (n (%))3
Quartile 1 (Poorest) 4825 (35.9) 308,826 (31.5) 1.37 (1.29 – 1.46)
Quartile 2 4174 (31.1) 301,272 (30.7) 1.21 (1.14 – 1.29)
Quartile 3 3143 (23.4) 258,898 (26.4) 1.06 (1.00 – 1.13)
Quartile 4 (Wealthiest) 1284 (0.6) 112,351 (11.4) Reference
Mode of Delivery (n (%))
Spontaneous Vaginal 4700 (30.3) 685,947 (58.2) Reference
Operative Vaginal 629 (4.1) 52,226 (4.6) 1.69 (1.56 – 1.84)
Cesarean 10,181 (65.6) 438,285 (37.2) 3.30 (3.27 – 3.51)
Maternal Comorbidities4
Maternal Comorbidity Composite (n (%)) 8777 (56.6) 351,002 (29.8) p < 0.0001
Pulmonary Hypertension 124 (0.8) 209 (0.02) p < 0.0001
Placenta Previa 617 (4.0) 6046 (0.5) p < 0.0001
Preeclampsia or gestational hypertension without severe features 2311 (14.9) 86,575 (7.4) p < 0.0001
Preeclampsia with severe features 2618 (16.9) 16,617 (1.4) p < 0.0001
Chronic kidney disease 241 (1.6) 2279 (0.2) p < 0.0001
Chronic hypertension 929 (6.0) 23,320 (2.0) p < 0.0001
Ischemic heart disease 15 (0.1) 118 (0.01) p < 0.0001
Congenital Heart Disease 60 (0.4) 960 (0.08) p < 0.0001
Sickle Cell Disease 617 (4.0) 6046 (0.5) p < 0.0001
Systemic Lupus Erythematosus 77 (0.5) 1269 (0.1) p < 0.0001
Human immunodeficiency virus 124 (0.8) 2984 (0.3) p < 0.0001
Cardiac valvular disease 272 (1.8) 7749 (0.7) p < 0.0001
Chronic congestive heart failure5 -- 0 (0.0) p < 0.0001
Asthma 677 (4.4) 32,844 (2.8) p < 0.0001
Preexisting diabetes mellitus 294 (1.9) 10,034 (0.9) p < 0.0001
Gestational diabetes mellitus 1014 (6.5) 63,408 (5.4) p < 0.0001
Obesity 1115 (7.2) 49,036 (4.2) p < 0.0001
Cystic fibrosis5 -- 99 (0.01) p = 0.8
Previous cesarean delivery 2476 (16.0) 134,809 (11.4) p < 0.0001
Open in a new tab
1

Unless otherwise noted.

2

Missing data from 213 deliveries with SMM and 16,268 deliveries without SMM

3

Missing data from 2084 deliveries with SMM and 197,111 deliveries without SMM

4

Data from Bateman B, M JM, Hernandez-Diaz S, KF H. Fischer M, Creanga A, Callaghan W, Gagne J. Development of a comorbidity index for use in obstetric patients. Obstet Gynecol 2013;122:957–65.

5

Unable to report (<11 persons)

Primary and secondary outcomes are shown in Table 2 stratified by deliveries with severe maternal morbidity versus without severe maternal morbidity and adjusted for maternal age, race/ethnicity, insurance type, income quartile by zip code, and maternal medical-comorbidities. After singleton liveborn deliveries without severe maternal morbidity, 1.6% of women (n=19,279) received primary or secondary diagnosis codes for psychiatric illness within one year of hospitalization discharge, during either ED presentations (n=12,328) or hospital admissions (n=7041). The risk of readmission or ED encounter with coding for psychiatric illness was nearly 75% higher after deliveries with severe maternal morbidity (n=452 (2.9%) with 222 admissions and 230 ED visits; adjusted odd ratios (aOR) 1.74 (95% Confidence Interval (CI): 1.58 – 1.91); risk attributable to severe maternal morbidity: 1.3%). Depression and anxiety were the most common psychiatric morbidities, and the risk was significantly higher among deliveries with severe maternal morbidity versus without severe maternal morbidity for both conditions (aOR 1.86 (95% CI 1.60 – 2.16) for depression with 0.6% risk attributable to severe maternal morbidity; aOR 1.78 (95% CI 1.56 – 2.03) for anxiety with 0.7% risk attributable to severe maternal morbidity). Overall, with the exception of suicide attempt and acute stress reaction, severe maternal morbidity was associated with significantly higher risk of presenting for each individual condition within the primary psychiatric outcome. Women also had nearly two times higher risk of being coded for drug or alcohol use or dependence in an inpatient admission or ED encounter in the year following delivery with severe maternal morbidity than without severe maternal morbidity (168 (1.1%) versus 6856 (0.6%); aOR 1.89 (95% CI 1.62 – 2.21); 0.5% risk attributable to severe maternal morbidity). Of note, a higher proportion of women who had severe maternal morbidity had their follow-up period censored by death within 365 days of discharge from delivery compared to those who did not have severe maternal morbidity (n=330 (2.18%) versus n=243 (n=0.02%).

Table 2:

Risk of psychiatric morbidity coded during an Emergency Department (ED) or hospitalization within one year of delivery of a liveborn singleton neonate with versus without severe intrapartum morbidity among women without preexisting psychiatric conditions

Outcome Liveborn, singleton with SMM (n=15,510) Liveborn, singleton without SMM (n=1,178,458) Unadjusted Odds Ratio (95% Confidence Interval) Adjusted Odds Ratio (95% Confidence Interval)1 Attributable Risk due to SMM
Composite Psychiatric Morbidity (n (%)) 452 (2.9) 19,279 (1.6) 1.81 (1.64 – 1.98) 1.74 (1.58 – 1.91) 1.3%
Suicide Attempt2 -- 552 (0.05) 0.69 (0.29 −1.66) *** --
Depression 186 (1.2) 7533 (0.6) 1.89 (1.63 – 2.19) 1.86 (1.60 – 2.16) 0.6%
Anxiety 230 (1.5) 9573 (0.8) 1.84 (1.61 – 2.10) 1.78 (1.56 – 2.03) 0.7%
Psychosis 95 (0.6) 4575 (0.4) 1.58 (1.29 – 1.94) 1.52 (1.24 – 1.87) 0.2%
PTSD 11 (0.07) 330 (0.03) 2.53 (1.39 – 4.62) *** 0.04%
Acute Stress Reaction 14 (0.09) 622 (0.05) 1.71 (1.01 – 2.91) *** 0.04%
Adjustment Disorders 34 (0.2) 827 (0.07) 3.13 (2.22 – 4.41) *** 0.13%
Composite Substance Use (n (%)) 168 (1.1) 6856 (0.6) 1.90 (1.65 -2.24) 1.89 (1.62 – 2.21) 0.5%
Drug Use and Dependence 136 (0.9) 5261 (0.5) 1.99 (1.69 – 2.38) 1.98 (1.67 – 2.36) 0.4%
Alcohol Use and Dependence 50 (0.3) 2330 (0.2) 1.63 (1.23 – 2.16) *** 0.1%
Open in a new tab
1

Adjusted for maternal age, race/ethnicity, insurance type, income quartile by zip code, mode of delivery, and maternal medical comorbidities. Adjusted Odds Ratios calculated for conditions within the composite in which than 50 women were coded (if not calculated; denoted as “***”)

2

Unable to report (<11 women had this psychiatric morbidity)

Cox proportional hazard ratios were used to examine the association between severe maternal morbidity and the primary outcome over the 12-month follow-up period. The proportional hazards assumption was violated for the 12-month (p < 0.001) and six-month (p = 0.003) follow-up periods but not violated when follow-up was limited to the first four months (p = 0.2). After adjusting for maternal age, race–ethnicity, insurance status, and income quartile by zip code, we found a statistically significant association between severe maternal morbidity compared to no severe maternal morbidity and the development of the primary outcome for the first four months after hospital discharge (adjusted hazard ratio of 2.53 (95% CI 2.05 – 3.12)).

Multivariable analyses testing whether significant interactions between independent variables existed in the primary outcome’s model are shown in Appendix 5. The p values for interactions were not statistically significant for payer type or mode of delivery (p = 0.07 and p = 0.05, respectively) but were statistically significant for race/ethnicity (p = 0.003), income quartile by zip code (p <0.001), and maternal co-morbidities (p <0.001). After adjusting for other variables, postpartum psychiatric morbidity was twice as likely among women with private insurance or who were aged 35-39 years who had severe maternal morbidity as those with private insurance or who were aged 35-39 years who did not have severe maternal morbidity (aOR 1.99 (95% CI 1.66 – 2.38) for private insurance; aOR 2.04 (95% CI 1.55 – 2.68) for age 35-39 years)). Similarly, women who were Black or Latina who had severe maternal morbidity were twice as likely to have postpartum psychiatric morbidity than Black or Latina women who did not have severe maternal morbidity (aOR 1.97 (95% CI 1.67 – 2.33) for Black women; aOR 2.17 (95% CI 1.71 – 2.745 for Latina women). Lastly, women who had primary or secondary diagnosis codes during delivery hospitalization of at least one condition within the maternal morbidity composite were nearly twice as likely as those who did not to have postpartum psychiatric morbidity (aOR 1.91 (95% CI 1.66 – 2.20)).

Table 3 presents the risk of postpartum psychiatric morbidity adjusted by whether the delivery did or did not have individual conditions within the severe maternal morbidity composite. The majority of severe maternal morbidity indices, including blood transfusion, were associated with increased risk of ED or hospitalization coded for acute psychiatric illness in the year after delivery. Some of the more common conditions within the severe maternal morbidity composite were associated with increased risk of postpartum psychiatric morbidity, including acute renal failure and adult respiratory distress syndrome (unadjusted OR 3.87 (95% CI 2.72 – 5.51) with 4.4% risk attributable to SSM; unadjusted OR 3.67 (95% CI 2.81 – 4.80) with 4.1% risk attributable to severe maternal morbidity; respectively). Other conditions, including acute myocardial infarction and temporary tracheostomy occurred rarely but were associated with particularly high risk for postpartum psychiatric morbidity during an ED or inpatient hospitalization.

Table 3:

Risk of an Emergency Department (ED) encounter or hospitalization within one year of delivery of liveborn, singleton neonate coded for psychiatric morbidity with and without severe intrapartum morbidity, among women without psychiatric illness in the nine months prior to delivery

Composite Psychiatric Morbidity
Liveborn singleton with SMM (n (%)) Liveborn singleton without SMM (n=1,178,458) (n (%)) Unadjusted Odds Ratio (95% Confidence Interval) Adjusted Odds Ratio (95% Confidence Interval)1 Attributable Risk due to SMM
Overall Severe Maternal Morbidity Composite (N=15,510) 452 (2.9) 19,279 (1.6) 1.81 (1.64 – 1.98) 1.74 (1.58 – 1.91) 1.3%
Transfusion (N=9780) 267 (2.7) 19,464 (1.6) 1.68 (1.49 – 1.90) 1.60 (1.41 – 1.81) 1.1%
Composite Severe Maternal Morbidity Without Transfusion (N=5730) 185 (3.2) 19,546 (1.6) 2.00 (1.72 – 2.31) 1.94 (1.67 – 2.25) 1.6%
Acute Myocardial Infarction2 (N=28) -- -- 7.14 (2.16 – 23.66) *** --
Aneurysm (N=11) 0 (0.0) 19,731 (1.7) -- *** 0.0%
Acute renal failure (N=541) 33 (6.1) 19,711 (1.7) 3.87 (2.72 – 5.51) *** 4.4%
Adult Respiratory Distress Syndrome
(N =983)		 57 (5.8) 19,674 (1.7) 3.67 (2.81 – 4.80) *** 4.1%
Amniotic Fluid Embolism2 (N=51) -- -- 1.19 (0.16 – 8.62) *** --
Cardiac Arrest / Ventricular Fibrillation2 (N=104) -- -- 3.01 (1.23 – 7.38) *** --
Conversion of Cardiac arrhythmia2 (N=209) -- -- 2.37 (1.17 – 4.80) *** --
Disseminated Intravascular Coagulation (N=2552) 47 (1.8) 19,684 (1.7) 1.12 (0.84 – 1.49) *** 0.1%
Eclampsia (N=1137) 46 (4.1) 19,685 (1.7) 2.51 (1.87 – 3.38) *** 2.4%
Heart Failure/Arrest During Surgery or Procedure2 (N=167) -- -- 2.22 (0.98 – 5.01) *** --
Puerperal Cerebrovascular Disorder (N=359) 18 (5.0) 19,713 (1.7) 3.14 (1.96 – 5.05) *** 3.3%
Pulmonary Edema / Acute heart failure (N=618) 24 (3.9) 19,707 (1.7) 2.41 (1.60 – 3.62) *** 2.2%
Severe Anesthesia Complication2 (N=218) -- -- 2.27 (1.12 – 4.60) *** --
Sepsis (N=426) 28 (6.6) 19,703 (1.7) 4.20 (2.86 – 6.15) *** 4.9%
Shock (N=314) 13 (4.1) 19,718 (1.7) 2.57 (1.48 – 4.48) *** 2.4%
Sickle Cell Disease with Crisis (N=212) 29 (13.7) 19,702 (1.7) 9.44 (6.38 – 13.98) *** 12.0%
Air and Thrombotic Embolism2 (N=197) -- -- 3.18 (1.69 – 6.02) *** --
Hysterectomy (N=879) 22 (2.5) 19,709 (1.7) 1.53 (1.00 – 2.33) *** 0.8%
Temporary tracheostomy2 (N=43) -- -- 11.58 (5.15 – 26.02) *** --
Ventilation2 (N=101) -- -- 1.82 (0.58 – 5.75) *** --
Open in a new tab
1

Adjusted for maternal age, race/ethnicity, insurance type, income quartile by zip code, mode of delivery, and maternal medical comorbidities. Adjusted Odds Ratios calculated for SMM composite, blood transfusion alone, and SMM composite without blood transfusion. If not calculated, denoted as “***”

2

Unable to report (less than 11 women had the primary psychiatric outcome).

The risk of the substance use disorder outcome adjusted for each condition within the severe maternal morbidity composite is presented in Table 4. The majority of severe maternal morbidity conditions, including blood transfusion, were associated with increased risk of coding for substance use disorder during presentation in the ED or inpatient hospitalization coded within one year after discharge from delivery hospitalization. Some of the more common conditions within the severe maternal morbidity composite were associated with high risk of the substance use disorder composite, including sepsis (unadjusted OR 4.20 (95% CI 2.86 – 6.15)) and pulmonary edema (unadjusted OR 2.41 (95% CI 1.60 – 3.62)).

Table 4:

Risk of an Emergency Department (ED) encounter or hospitalization within one year of delivery of liveborn singleton neonate coded for substance use, with and without severe intrapartum morbidity, among women without preexisting psychiatric illness in the nine months prior to delivery

Composite Substance Use Morbidity
Liveborn singleton with SMM (n (%)) Liveborn singleton without SMM (n=1,178,458) (n (%)) Unadjusted Odds Ratio (95% Confidence Interval) Adjusted Odds Ratio (95% Confidence Interval)1 Attributable Risk due to SMM
Overall Severe Maternal Morbidity Composite (N=15,510) 168 (1.1) 6856 (0.6) 1.90 (1.65 -2.24) 1.89 (1.62 – 2.21) 0.5%
Transfusion (N=9780) 98 (1.4) 6926 (0.6) 1.72 (1.41 – 2.10) 1.69 (1.38 – 2.07) 0.8%
Composite Severe Maternal Morbidity Without Transfusion (N=5730) 70 (1.2) 6954 (0.6) 2.18 (1.72 – 2.76) 2.17 (1.71 – 2.75) 0.6%
Acute Myocardial Infarction2 (N=28) 0 (0.0) 7024 (0.6) -- *** 0.0%
Aneurysm (N=11) 0 (0.0) 7024 (0.6) -- *** 0.0%
Acute renal failure (N=541) -- -- 3.87 (2.72 – 5.51) *** --
Adult Respiratory Distress Syndrome (N =983) 14 (1.4) 7010 (0.6) 2.44 (1.44 – 4.14) *** 0.8%
Amniotic Fluid Embolism2 (N=51) 0 (0.0) 7024 (0.6) -- *** 0.0%
Cardiac Arrest / Ventricular Fibrillation2 (N=104) -- -- 1.64 (0.23 – 11.76) *** --
Conversion of Cardiac arrhythmia2 (N=209) -- -- 2.46 (0.79 – 7.70) *** --
Disseminated Intravascular Coagulation (N=2552) 19 (0.7) 7005 (0.6) 1.27 (0.81 – 1.99) *** 0.1%
Eclampsia2 (N=1137) -- -- 1.05 (0.50 – 2.20) *** --
Heart Failure/Arrest During Surgery or Procedure2 (N=167) 0 (0.0) 7024 (0.6) -- *** 0.0%
Puerperal Cerebrovascular Disorder2 (N=359) -- -- 1.43 (0.46 – 4.44) *** --
Pulmonary Edema / Acute heart failure (N=618) 15 (2.4) 7009 (0.6) 2.41 (1.60 – 3.62) *** 1.8%
Severe Anesthesia Complication2 (N=218) -- -- 0.78 (0.11 – 5.55) *** --
Sepsis2 (N=426) -- -- 4.20 (2.86 – 6.15) *** --
Shock2 (N=314) -- -- 1.63 (0.52 – 5.08) *** --
Sickle Cell Disease with Crisis (N=212) 25 (11.8) 6999 (0.6) 22.67 (14.93 – 34.44) *** 10.4%
Air and Thrombotic Embolism2 (N=197) -- -- 1.73 (0.43 – 6.98) *** --
Hysterectomy2 (N=879) -- -- 1.55 (0.77 – 3.12) *** --
Temporary tracheostomy2 (N=43) -- -- 4.02 (0.55 – 29.24) *** --
Ventilation2 (N=101) -- -- 5.18 (1.65 – 16.34) *** --
Open in a new tab
1

Adjusted for maternal age, race/ethnicity, insurance type, income quartile by zip code, mode of delivery, and maternal medical comorbidities. Adjusted Odds Ratios calculated for SMM composite, blood transfusion alone, and SMM composite without blood transfusion. If not calculated, denoted as “***”

2

Unable to report (less than 11 women had at least one condition within the substance use composite)

Subgroup and sensitivity analyses are shown in Appendixes 6–19. When presentations to the ED were excluded, the association between postpartum psychiatric morbidity and severe maternal morbidity remained significant (Appendixes 6 and 7). Overall, the risk of being coded for any of the conditions within the psychiatric composite condition during a postpartum inpatient hospitalization was 2.36 times higher after a delivery with severe maternal morbidity versus without severe maternal morbidity (n=230 (1.5%) versus 7041 (0.6%); aOR 2.36 (2.07 – 2.70)). Excluding women who received ICD-9-CM codes during ED visits or inpatient admissions for two years prior to delivery hospitalization for the primary or secondary outcomes (Appendixes 8–11) or who had any comorbidities within our maternal comorbidity composite4 (Appendixes 12–15) did not significantly change our results. Removing psychosis as a condition for exclusion and from the primary outcome composite did not significantly change the findings (Appendixes 16–19).

Discussion

In this large retrospective cohort study, we provide insight into the incidence of year-long postpartum psychiatric morbidity in women with liveborn singleton pregnancies with and without severe maternal morbidity. In women without severe maternal morbidity, presentation to the ED or admission to the hospital for either acute psychiatric care or management of drug or alcohol use or dependence was not uncommon within one year of delivery hospitalization discharge (1.6% and 0.6%, respectively). However, the risk was higher for both the psychiatric morbidity composite and substance use disorder composite when deliveries with severe maternal morbidity were compared to those without severe maternal morbidity, though the absolute numbers and risk attributable to SSM were both modest. We also identified specific conditions within the severe maternal morbidity composite—both common (adult respiratory distress syndrome) and rare (acute myocardial infarction)—that were associated with increased risk of psychiatric morbidity and substance use disorder. Lastly, we identified that the highest risk of postpartum psychiatric morbidity was in the first four months after hospital discharge from delivery with severe maternal morbidity vs without severe maternal morbidity (adjusted hazard ratio 2.53 (95% CI 2.05 – 3.12)), suggesting that access to medical and mental healthcare is needed beyond the six-week postpartum period traditionally covered by public health insurance.

Our findings support prior studies. First, similar to our findings, demographic factors such as race–ethnicity, payer status, and income have been associated with increased odds of postpartum readmission or ED presentation overall4,6,31 and specifically for psychiatric morbidity including postpartum depression,7 post-traumatic stress disorder16 or a composite of psychiatric conditions.8 Second, our findings support one prior population-wide study analyzing the association between severe maternal morbidity and physician-diagnosed postpartum psychiatric illness32 as well as smaller studies describing the association between severe maternal morbidity and patient-reported psychological symptoms.33,34 Third, the increased risk within our study population of postpartum psychiatric illness and specific conditions within the severe maternal morbidity composite support prior data suggesting that patients have increased risk of longstanding residual depression after tracheostomy,35 surviving acute myocardial infarction,36 or diagnosis of adult respiratory distress syndrome.37

Lastly, the finding that postpartum psychiatric morbidity was not uncommon after delivery of a liveborn singleton without severe maternal morbidity, aligns with recent data that routine deliveries and postpartum periods are powerful stimulants for psychiatric illness,7,8particularly depression and anxiety.29 The association with severe maternal morbidity and increased risk of psychiatric illness reinforces the growing body of literature suggesting that unanticipated obstetric events such as unplanned cesarean delivery,9 miscarriage,10 or stillbirth11–13 increase the risk of psychiatric morbidity above that of baseline. Taken together, these findings should encourage clinicians to heed the American College of Obstetricians and Gynecologists (ACOG)’s recent recommendations to not only screen all women for depression and anxiety after delivery29 but also provide individualized care with additional in-person visits as needed for three months postpartum38 and throughout the interpregnancy interval.39

More specifically, our findings have significant public health ramifications. Though the absolute number of women with risk attributable to severe maternal morbidity was modest, women who have severe maternal morbidity have a significantly increased risk of postpartum psychiatric morbidity for a year after hospital discharge from their delivery, and that this risk was highest in the first four months. Women with increased risk of severe maternal morbidity were non-White, in the lowest income quartiles by zip code, and had public insurance, which often discontinues at six weeks postpartum. Thus, women at higher risk for severe maternal morbidity may be left without access to medical or psychiatric care during the highest risk time for acute psychiatric morbidity, which extends for months after their hospital discharge. Our findings suggest that public insurance should extend medical and mental health benefits beyond six weeks postpartum, particularly for women with severe maternal morbidity during delivery.

Furthermore, our identification of specific morbidities within the severe maternal morbidity composite and specific maternal demographic factors that were associated with significantly increased risk of acute postpartum psychiatric illness and substance use disorder lays the groundwork for the development of a novel clinical calculator used to predict patients’ risk of developing postpartum psychiatric morbidity based on their personal risk factors.

Our study offers several strengths. First, the data are derived from a comprehensive all-payer database that includes nearly all in-patient admissions and ED presentations to a hospital in the state of Florida for nearly a decade, increasing the generalizability of our results. Second, we linked the HCUP ED and inpatient databasesto more accurately exclude women with antepartum psychiatric morbidity and identify postpartum outcomes until one year after hospital discharge from delivery, which provides a longer postpartum follow-up period thanprior North American studies 40.5 Third, our study population was restricted to livebirth singletons, which decreased the potential for confounding given both stillbirth13,19 and multiple gestation20 are associated with increased risk of postpartum psychiatric morbidity. Fourth, our ICD-9-CM coding has been validated for all critical variables included in this analysis, including deliveries,18 psychiatric morbidity,8,15 drug and alcohol use and dependence,24 maternal medical comorbidities,4 and severe maternal morbidity,3 strengthening our findings.

Lastly, our multiple sensitivity analyses tested the robustness of the association between severe maternal morbidity and psychiatric illness by varying potential confounders. For example, a recent meta-analysis concluded that, compared to adults who are Black, have government insurance, or are lower income, those who are white, have private insurance, and higher income are less likely to utilize Emergency Department services41; this mirrors the sociodemographic differences in our study population among women with and without severe maternal morbidity. To eliminate a potential confounder—ED visit utilization variation by demographic factors—we excluded ED encounters as an outcome, and the association between severe maternal morbidity and postpartum psychiatric morbidity strengthened. Similarly, though nearly one third of non-maternal and non-neonatal hospitalizations in the United States in 2012 included diagnosis codes of mental or substance use disorders,42 psychiatric and substance use disorder diagnoses may be under-coded in HCUP.43,44 However, extending the exclusion period for antepartum psychiatric or substance use disorder morbidity to two years prior to delivery increased the likelihood that women with psychiatric morbidity were identified and excluded from our analyses without significant changing the association between severe maternal morbidity and postpartum psychiatric morbidity.

Nevertheless, limitations to our study should be considered. First, as with any retrospective study, causality cannot be established. Furthermore, the unadjusted and adjusted odds ratios for most of our findings are less than 4, which is within the zone of potential bias.45 Thus, though our findings persisted in multiple sensitivity analyses ,the relatively weak association we found between severe maternal morbidity and our primary outcome could be the result of a Type I error. Second, HCUP database not contain gestational age or neonatal outcomes, which may confound our results given Neonatal Intensive Care Unit admission is a risk factor for postpartum depression and anxiety.46 Third, because women who had severe maternal morbidity are more likely to have prolonged delivery hospitalizations,47 our follow-up period of one year after hospital discharge was more likely to extend beyond one-year of delivery for women with severe maternal morbidity compared to those without severe maternal morbidity, potentially leading to ascertainment bias. Fourth, women who had severe maternal morbidity had higher rates of death within one year of hospital discharge, which may confound our findings since women censored by death could not have either outcome. Fifth, we limited identification of comorbidities to the delivery hospitalization, which may have decreased our ability to identify all comorbidities within our study population.

Lastly, the HCUP databases include only inpatient admissions and visits to hospital EDs. The lack of outpatient data potentially impacts our results in two ways. Women with pre-existing psychiatric illness who remained stable in the outpatient setting would not have been excluded in our analyses despite their increased risk of postpartum psychiatric illness.29 However, this exclusion likely resulted in non-differential misclassification because women with well-controlled psychiatric illness are not thought to have increased risk of severe maternal morbidity during delivery.29 Conversely, the lack of outpatient data means that we could not capture women who developed new-onset postpartum psychiatric morbidity or drug or alcohol abuse managed entirely in the outpatient setting. Given that the majority of postpartum psychiatric morbidity is managed in the outpatient setting,29 our analyses may underestimate the prevalence of postpartum psychiatric morbidity. However, it is impossible to determine whether this underestimation biases our results toward or against the null. More research is needed in a validated database that combines inpatient and outpatient medical care to determine the true prevalence of postpartum psychiatric morbidity.

In conclusion, we found that postpartum psychiatric illness and substance use disorder within one year of hospital discharge occurs significantly more often among women who suffer intrapartum severe maternal morbidity during delivery of a liveborn singleton compared to those who do not have severe maternal morbidity, though the absolute numbers and risk attributable to severe maternal morbidity were both modest. We also identified specific conditions within the severe maternal morbidity composite such as acute myocardial infarction and temporary tracheostomy that were associated with high risk of postpartum psychiatric illness and substance use disorder or dependence. These findings suggest that additional psychosocial support—as well as access to medical and mental healthcare—should be available to all women in the year after delivery, particularly those with intrapartum severe maternal morbidity in the first four months after hospital discharge.

Supplementary Material

Supplemental Digital Content_1
Supplemental Digital Content_2

Acknowledgments

Dr. Lewkowitz is supported in part by a National Institutes of Health training grant T32-HD-55172-9. The Center for Administrative Data is supported in part by the Washington University Institute of Clinical and Translational Sciences grant UL1 TR002345 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH) and Grant Number R24 HS19455 through the Agency for Healthcare Research and Quality (AHRQ). The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official view of the NIH.

Footnotes

Financial Disclosure

Margaret Olsen received funds from Pfizer, Sanofi Pasteur, and Merck for work unrelated to this study. The other authors did not report any potential conflicts of interest.

Presented at the 39th Annual Pregnancy Meeting of the Society for Maternal-Fetal Medicine in Las Vegas, Nevada (February 11 – February 16, 2019).

References

  • 1.American College of Obstetricians and Gynecologists. Severe maternal morbidity: screening and review. Obstetric Care Consensus No. 5. Obstet Gynecol. 2016;128:e54–60. [DOI] [PubMed] [Google Scholar]
  • 2.Fingar KR, Hambrick MM, Heslin KC, Moore JE. Trends and Disparities in Delivery Hospitalizations Involving Severe Maternal Morbidity, 2006–2015: Statistical Brief #243. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. http://www.ncbi.nlm.nih.gov/pubmed/30371995. Published 2018. [PubMed]
  • 3.Severe Maternal Morbidity Indicators and Corresponding ICD Codes during Delivery Hospitalizations. Centers for Disease Control and Prevention; https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm. Published 2018. Accessed May 10, 2018. [Google Scholar]
  • 4.Bateman B, M JM, Hernandez-Diaz S, H KF, Fischer M, Creanga A, Callaghan W, Gagne J. Development of a comorbidity index for use in obstetric patients. Obs Gynecol. 2014;122:957–965. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Sheen JJ, Smith HA, Tu B, Liu Y, Sutton D, Bernstein PS. Risk Factors for Postpartum Emergency Department Visits in an Urban Population. Matern Child Health J. 2019;23:557–566. [DOI] [PubMed] [Google Scholar]
  • 6.Aziz A, Gyamfi-bannerman C, Siddiq Z, Wright JD, Goffman D, Sheen J, Alton MED, Friedman AM. Maternal outcomes by race during postpartum readmissions. Am J Obstet Gynecol. 2019;(February):E pub ahead of print. doi: 10.1016/j.ajog.2019.02.016 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.França UL, McManus ML. Frequency, trends, and antecedents of severe maternal depression after three million U.S. births. PLoS One. 2018;13:e0192854. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Meltzer-Brody S, Maegbaek ML, Medland SE, Miller WC, Sullivan P, Munk-Olsen T. Obstetrical, pregnancy and socio-economic predictors for new-onset severe postpartum psychiatric disorders in primiparous women. In: Psychological Medicine. Vol 47 ; 2017:1427–1441. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Houston KA, Kaimal AJ, Nakagawa S, Gregorich SE, Yee LM, Kuppermann M. Mode of delivery and postpartum depression: The role of patient preferences. Am J Obstet Gynecol. 2015;212:229e1–229.e7. [DOI] [PubMed] [Google Scholar]
  • 10.Lok IH, Neugebauer R. Psychological morbidity following miscarriage. Best Pract Res Clin Obstet Gynaecol. 2007;21:229–247. [DOI] [PubMed] [Google Scholar]
  • 11.Weng S-C, Chang J-C, Yeh M-K, Wang S-M, Lee C-S, Chen Y-H. Do Stillbirth and Abortion Increase Risks of Attempted and Completed Suicide Within a Year? A Population-Based Nested Case-Control Study. BJOG An Int J Obstet Gynaecol. 2017:1–8. [DOI] [PubMed] [Google Scholar]
  • 12.Sit D, Luther J, Buysse D, Dills JL, Eng H, Okun M, Wisniewski S, Wisner KL. Suicidal ideation in depressed postpartum women: Associations withchildhood trauma, sleep disturbance and anxiety. J Psychiatr Res. 2015;66-67:95–104. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Lewkowitz AK, Rosenbloom JI, Keller M, Lopez J, Macones GA, Olsen MA, Cahill AG. Association between stillbirth and acute psychiatric illness within one year of delivery. Am J Obs Gynecol. 2019;E pub head: [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Sorenson DS, Tschetter L. Prevalence of negative birth perception, disaffirmation, perinatal trauma symptoms, and depression among postpartum women. Perspect Psychiatr Care. 2010;46:14–25. [DOI] [PubMed] [Google Scholar]
  • 15.Meltzer-Brody S, Larsen JT, Petersen L, Guintivano J, Florio A Di, Miller WC, Sullivan PF, Munk-Olsen T. Adverse life events increase risk for postpartum psychiatric episodes: A population-based epidemiologic study. Depress Anxiety. 2018;35:160–167. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Forray A, Mayes LC, Magriples U, Epperson CN. Prevalence of post-traumatic stress disorder in pregnant women with prior pregnancy complications. J Matern Neonatal Med. 2009;22:522–527. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Agency for Healthcare Research and Quality. Agency for Healthcare Research AndHCUP Database Healthcare Cost and Utilization Project (HCUP). Rockville, MD: http://www.hcup-us.ahrq.gov/databases.jsp. [PubMed] [Google Scholar]
  • 18.Kuklina E V, Whiteman MK, Hillis SD, Jamieson DJ, Meikle SF, Posner SF, Marchbanks PA. An enhanced method for identifying obstetric deliveries: Implications for estimating maternal morbidity. Matern Child Health J. 2008;12:469–477. [DOI] [PubMed] [Google Scholar]
  • 19.Munk-Olsen T, Bech BH, Vestergaard M, Li J, Olsen J, Laursen TM. Psychiatric disorders following fetal death: A population-based cohort study. BMJ Open. 2014;4:e005187. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Choi Y, Bishai D, Minkovitz CS. Multiple Births Are a Risk Factor for Postpartum Maternal Depressive Symptoms. Pediatrics. 2009;123:1147–1154. [DOI] [PubMed] [Google Scholar]
  • 21.Al Kazzi ES, Lau B, Li T, Schneider EB, Makary MA, Hutfless S. Differences in the prevalence of obesity, smoking and alcohol in the United States Nationwide Inpatient Sample and the Behavioral Risk Factor Surveillance System. PLoS One. 2015;10:e0140165. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Berthelsen C Evaluation of coding data quality of the HCUP National Inpatient Sample. Top Heal Inf Manag. 2000;21:10–23. [PubMed] [Google Scholar]
  • 23.Martin JL, McLean G, Cantwell R, Smith DJ. Admission to psychiatric hospital in the early and late postpartum periods: Scottish national linkage study. BMJ Open. 2016;6:1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity Measures for Use with Administrative Data. Med Care. 1998;36:8–27. [DOI] [PubMed] [Google Scholar]
  • 25.Bracewell RN. The Fourier Transform and Its Applications: Third Edition New York: McGraw-Hill; 2000. [Google Scholar]
  • 26.Khaledi M, Haghighatdoost F, Feizi A, Aminorroaya A. The prevalence of comorbid depression in patients with type 2 diabetes: an updated systematic review and meta-analysis on huge number of observational studies. Acta Diabetol. 2019;2019(ePub ahead of print). doi: 10.1007/s00592-019-01295-9 [DOI] [PubMed]
  • 27.Read JR, Sharpe L, Modini M, Dear BF. Multimorbidity and depression: A systematic review and meta-analysis. J Affect Disord. 2017;15:36–46. [DOI] [PubMed] [Google Scholar]
  • 28.Furuta M, Sandall J, Bick D. A systematic review of the relationship between severe maternal morbidity and post-traumatic stress disorder. BMC Pregnancy Childbirth. 2012;12:125. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.American College of Obstetricians and Gynecologists. Screening for perinatal depression. ACOG Committee Opinion No. 757. Obs Gynecol. 2018;132:208–212. [Google Scholar]
  • 30.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5.; 2013. [Google Scholar]
  • 31.Admon LK, Winkelman TNA, Zivin K, Terplan M, Mhyre JM, Dalton VK. Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the United States, 2012-2015. Obstet Gynecol. 2018;132:1158–1166. [DOI] [PubMed] [Google Scholar]
  • 32.Wall-Wieler E, Carmichael SL, Urquia ML, Liu C, Hjern A. Severe maternal morbidity and postpartum mental health-related outcomes in Sweden: a population-based matched-cohort study. Arch Womens Ment Health. 2018:E pub ahead of print. doi: 10.1007/s00737-018-0917-z [DOI] [PMC free article] [PubMed]
  • 33.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. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Silveira MS, Gurgel RQ, Barreto ÍD de C, Galvão LPL, Vargas MM. Severe Maternal Morbidity: post-traumatic suffering and social support. Rev Bras Enferm. 2018;71(supple:2139–2145. [DOI] [PubMed] [Google Scholar]
  • 35.Chen AM, Daly ME, Vazquez E, Courquin J, Luu Q, Donald PJ, Farwell DG. Depression among long-term survivors of head and neck cancer treated with radiation therapy. JAMA Otolaryngol - Head Neck Surg. 2013;139:885–889. [DOI] [PubMed] [Google Scholar]
  • 36.Bass EB, Ziegelstein RC, Bush DE, Thombs BD, Stewart KJ, Patel U, Tsilidis KK, Fauerbach JA, Ford DE. Prevalence of depression in survivors of acute myocardial infarction. J Gen Intern Med. 2005;21:30–38. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Bienvenu OJ, Friedman LA, Colantuoni E, Dinglas VD, Sepulveda KA, Mendez-Tellez P, Shanholz C, Pronovost PJ, Needham DM. Psychiatric symptoms after acute respiratory distress syndrome: a 5-year longitudinal study. Intensive Care Med. 2018;44:38–47. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.American College of Obstetricians and Gynecologists. Optimizing postpartum care. ACOG Committee Opinion No. 736. Obs Gynecol. 2018;131:e140–150. [DOI] [PubMed] [Google Scholar]
  • 39.American College of Obstetricians and Gynecologists. Interpregnancy Care. Obstetric Care Consensus No. 8. Obstet Gynecol. 2019;133:e51–72. [DOI] [PubMed] [Google Scholar]
  • 40.Batra P, Fridman M, Leng M, Gregory KD. Emergency department care in the postpartum period: California births, 2009-2011. Obstet Gynecol. 2017;130:1073–1081. [DOI] [PubMed] [Google Scholar]
  • 41.Hazlett SB, McCarthy ML, Londner MS, Onyike CU. Epidemiology of Adult Psychiatric Visits to U.S. Emergency Departments. Acad Emerg Med. 2004;11:193–195. [PubMed] [Google Scholar]
  • 42.Heslin KC, Elixhauser A, Steiner CA. Hospitalizations Involving Mental and Substance Use Disorders Among Adults, 2012. HCUP Statistical Brief #191. Healthcare Cost and Utilization Project: Statistical Brief #191. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb191-Hospitalization-Mental-Substance-Use-Disorders2012.pdf.%0D. Published 2015. Accessed February 5, 2018. [PubMed]
  • 43.Doktorchik C, Patten S, Eastwood C, Peng M, Chen G, Beck CA, Jetté N, Williamson T, Quan H. Validation of a case definition for depression in administrative data against primary chart data as a reference standard. BMC Psychiatry. 2019;19:9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Mark TL, Vandivort-Warren R, Owens PL, Buck JA, Levit KR, Coffey RM, Stocks C. Psychiatric Discharges in Community Hospitals With and Without Psychiatric Units: How Many and for Whom? Psychiatr Serv. 2014;61:562–568. [DOI] [PubMed] [Google Scholar]
  • 45.Grimes D, Schulz K. False alarms and pseudo-epidemics: The limitations of observational epidemiology. Obstet Gynecol. 2012;120:920–927. [DOI] [PubMed] [Google Scholar]
  • 46.Mendelson T, Cluxton-Keller F, Vullo GC, Tandon SD, Noazin S. NICU-based Interventions To Reduce Maternal Depressive and Anxiety Symptoms: A Meta-analysis. Pediatrics. 2017;193:pii: e20161870. [DOI] [PubMed] [Google Scholar]
  • 47.Callaghan WM, Creanga AA, Kuklina E V. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. 2012;120:1029–1036. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Digital Content_1
NIHMS1533196-supplement-Supplemental_Digital_Content_1.pdf (601.5KB, pdf)
Supplemental Digital Content_2
NIHMS1533196-supplement-Supplemental_Digital_Content_2.pdf (390.8KB, pdf)

RESOURCES