BACKGROUND: In contrast to other high-resource countries, the US has experienced increases in the rates of severe maternal morbidity. The US also has pronounced racial/ethnic disparities in severe maternal morbidity, especially for non-Hispanic Black people, who have twice the rate as non-Hispanic White people.

OBJECTIVE(S): The objective of this study was to examine if the racial/ethnic disparities in severe maternal morbidity extended beyond the rates of these complications to include disparities in maternal costs and lengths of stay, which could indicate differences in the case severity.

STUDY DESIGN: This study used California's linkage of birth certificates to inpatient maternal and infant discharge data for 2009-2011. Of the 1.5 million linked records, 250,000 were excluded due to incomplete data, for a final sample of 1,262,862. Cost-to-charge ratios were used to estimate costs from charges (including readmissions) after adjusting for inflation to December 2017. Mean diagnostic-related group-specific reimbursement was used to estimate physician payments. We used the Centers for Disease Control and Prevention definition of severe maternal morbidity, including readmissions up to 42 days postpartum. Adjusted Poisson regression models estimated the differential risk of severe maternal morbidity for each racial/ethnic group, compared with the non-Hispanic White group. Generalized linear models estimated the associations of race/ethnicity with costs and length of stay.

RESULTS: Asian/Pacific Islander, Non-Hispanic Black, Hispanic, and Other race/ethnicity patients all had higher rates of severe maternal morbidity than non-Hispanic White patients. The largest disparity was between non-Hispanic White and non-Hispanic Black patients, with unadjusted overall rates of severe maternal morbidity of 1.34% and 2.62%, respectively (adjusted risk ratio 1.61, p<0.001). Among patients with severe maternal morbidity, the adjusted regression estimates showed that non-Hispanic Black patients had 23% (p<0.001) higher costs (marginal effect $5,023) and 24% (p<0.001) longer hospital stays (marginal effect 1.4 days) compared to non-Hispanic White patients. These effects changed when cases where a blood transfusion was the only indication of severe maternal morbidity were excluded, with 29% higher costs (p<0.001) and 15% longer length of stay (p<0.001). For other racial/ethnic groups, the increases in costs and length of stay were smaller than those observed for non-Hispanic Black patients, and many were not significant different from non-Hispanic White patients. Hispanic patients had higher rates of severe maternal morbidity than non-Hispanic White patients but significantly lower costs and length of stay.

CONCLUSION(S): There were racial/ethnic differences in the costs and length of stay among patients with severe maternal morbidity across the groupings that we examined. The differences were especially large for non-Hispanic Black patients compared with non-Hispanic White patients. Non-Hispanic Black patients experienced twice the rate of severe maternal morbidity; additionally, the higher relative costs and longer lengths of stay for non-Hispanic Black patients with severe maternal morbidity supports greater case severity in that population. These findings suggest that efforts to address racial/ethnic inequities in maternal health need to consider differences in case severity in addition to the differences in the rates of severe maternal morbidity and that these differences in case severity merit additional investigation.

<p><strong>OBJECTIVE: </strong>To examine the association between severe maternal morbidity (SMM) and infant health using the additional infant costs and length of stay (LOS) as markers of added clinical complexity.</p>

<p><strong>STUDY DESIGN: </strong>Secondary data analysis using California linked birth certificate-patient discharge data for 2009-2011 (N = 1,260,457). Regression models were used to estimate the association between SMM and infant costs and LOS.</p>

<p><strong>RESULTS: </strong>The 16,687 SMM-exposed infants experienced a $6550 (33%) increase in costs and a 0.7 (18%) day increase in LOS. Preterm infants had ($11,258 (18%) added costs and 1.3 days (8.1%) longer LOS) than term infants ($2539 (38%) added costs and 0.5 days (22%) longer LOS).</p>

<p><strong>CONCLUSIONS: </strong>SMM was associated with increased infant costs and LOS, suggesting that SMM may have adverse health effects for infants, including term infants. The relatively larger effect on costs indicates an increase in treatment intensity (clinical severity) greater than additional LOS.</p>

<p><strong>INTRODUCTION: </strong>The objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases.</p>

<p><strong>METHODS: </strong>California linked birth certificate-patient discharge data for 2009 through 2011 (n&nbsp;=&nbsp;1,262,862) with complete costs and LOS were used in a secondary data analysis. Cost-to-charge ratios were used to estimate costs from charges, adjusting for inflation. Physician payments were estimated from the mean payments for specific diagnosis-related groups. Generalized linear models estimated the association between SMM and costs and LOS.</p>

<p><strong>RESULTS: </strong>Excluding readmissions and physician costs, SMM was associated with a 60% increase in hospital costs (marginal effect [ME], $3,550) and a 33% increase in LOS (ME 0.9&nbsp;days). These increased to 70% (ME $5,806) and 46% (ME 1.3&nbsp;days) when physician costs and readmissions were included. The effects of SMM were roughly one-half as large for patients who only required a blood transfusion (49% [ME $4,056] and 31% [ME 0.9&nbsp;days]) as for patients who had another indicator for SMM (93% [ME $7,664] and 62% [ME 1.7&nbsp;days]).</p>

<p><strong>CONCLUSIONS: </strong>Postpartum hospital readmissions and physician costs are important and previously unreported contributors to the costs of SMM. Excess costs and LOS associated with SMM vary considerably by indication. Cost effects were larger than the LOS effects, indicating that SMM increases treatment intensity beyond increasing LOS, and decreasing SMM may have broader health and cost benefits than previously understood.</p>

<p><strong>OBJECTIVE: </strong>To examine the relative contributions of preterm delivery and congenital anomalies to neonatal mortality.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective analysis of 2009-2011 linked birth cohort-hospital discharge files for California, Missouri, Pennsylvania and South Carolina. Deaths were classified by gestational age and three definitions of congenital anomaly: any ICD-9 code for an anomaly, any anomaly with a significant mortality risk, and anomalies recorded on the death certificate.</p>

<p><strong>RESULT: </strong>In total, 59% of the deaths had an ICD-9 code for an anomaly, only 43% had a potentially fatal anomaly, and only 34% had a death certificate anomaly. Preterm infants (&lt;37 weeks GA) accounted for 80% of deaths; those preterm infants without a potentially fatal anomaly diagnosis comprised 53% of all neonatal deaths. The share of preterm deaths with a potentially fatal anomaly decreases with GA.</p>

<p><strong>CONCLUSION: </strong>Congenital anomalies are responsible for about 40% of neonatal deaths while preterm without anomalies are responsible for over 50%.</p>