National Confidential Enquiry into Patient Outcome and Death

Evidence related to anemia in early pregnancy, and its resolution or persistence by late pregnancy, is limited. We evaluated pregnancy outcomes associated with anemia in early pregnancy and resolution compared with persistence in late pregnancy. We used the Merative™ Marketscan ® Commercial Database of nationwide insurance claims (2018-2023) and included pregnant individuals without hereditary anemias. We used hemoglobin and hematocrit to identify anemia in early pregnancy (before 14 weeks of gestation) and late pregnancy (at or after 24 weeks of gestation). Pregnancy outcomes included preeclampsia, placenta previa, placental abruption, severe postpartum hemorrhage, blood products transfusion, cesarean birth, nontransfusion severe maternal morbidity (SMM), spontaneous preterm birth, medically indicated preterm birth, and small-for-gestational-age (SGA) birth weight. We used modified Poisson regression to estimate associations between: 1) anemia in early pregnancy and pregnancy outcomes; and 2) anemia resolution by late pregnancy and pregnancy outcomes, adjusting for confounders by inverse probability weighting. Among 73,586 individuals, 4.4% (95% CI, 4.3-4.6%) had anemia in early pregnancy. Early pregnancy anemia was associated with higher risk of each outcome assessed, with the exception of placenta previa, with the highest associated risk of blood products transfusion (2.4% vs 0.8%; adjusted risk ratio [aRR] 2.45; 95% CI, 1.91-3.13). Of those with early pregnancy anemia and laboratory values in late pregnancy (72.1%), 53.4% had persistent anemia and 46.6% had resolved anemia. Persistent anemia was associated with nontransfusion SMM (2.6% vs 1.1%, aRR 1.64; 95% CI, 1.13-2.37), blood products transfusion (2.9% vs 0.8%, aRR 2.60; 95% CI, 1.84-3.69), and SGA birth weight (8.5% vs 6.8%, aRR 1.23; 95% CI, 1.01-1.50), compared with those without anemia in the first trimester. The resolution of anemia by late pregnancy was not associated with nontransfusion SMM (1.6% vs 1.1%; aRR 1.07; 95% CI, 0.65-1.74) but was associated with blood products transfusion (1.6% vs 0.8%; aRR 1.64; 95% CI, 1.01-2.67) and SGA birth weight (10.0% vs 6.8%; aRR 1.38; 95% CI, 1.15-1.67) compared with those without anemia in the first trimester. Anemia in the first trimester was associated with adverse maternal and neonatal outcomes. The resolution of anemia by late pregnancy eliminated the association with nontransfusion SMM but not other outcomes, emphasizing the importance of treating anemia in early pregnancy and before pregnancy.

BackgroundUK General Internal Medicine (GIM) registrars are traditionally expected to be able to perform pleural procedures out-of-hours (OOH) if required. Pleural exposure for GIM registrars has declined, with procedures increasingly performed by specialists in-hours. Pleural procedures can cause significant harm. We explored the role of the GIM registrar in performing OOH pleural procedures, with particular focus on competence and confidence.MethodsAn anonymous survey was distributed to GIM registrars and respiratory consultants across the UK.ResultsResponses were received from 391 non-respiratory GIM registrars and 93 respiratory consultants. 37% of registrars reported being ‘signed-off’ as independent in chest drain insertion for pneumothorax. 69% had not done a pleural procedure for at least a year. Regarding perceived confidence for OOH chest drain insertion for pneumothorax, 42% reported no confidence to perform the procedure even if directly supervised, with only 11% feeling confident to proceed unsupervised. Consultants rated the pleural competence of an average non-respiratory GIM registrar; only 4% felt they could perform the procedure unsupervised. Common themes in the free text included anxiety surrounding pleural procedures, patient safety concerns, insufficient available training opportunities to maintain competency and differing opinions on the evolving role of the medical registrar and who should be expected to perform OOH pleural procedures.ConclusionsThe majority of UK GIM registrars are neither confident nor perceived by trainers as competent to independently perform OOH chest drain insertion. This has implications for patient safety and service delivery, informing broader discussions regarding GIM training, curriculum and the need to establish local OOH pleural pathways.

To evaluate referral patterns and care delay for the growing population of patients with limited English proficiency (LEP) who seek treatment with gynecologic oncologists. This is a retrospective cohort study of all patients seen by gynecologic oncologists at a National Cancer Institute-designated cancer center from 2013 to 2024 (referral cohort). Our primary outcome was the time to receipt of first treatment after the initial referral, by LEP status (among patients receiving treatment with a gynecologic oncologist-the treatment cohort) and with delay categorized using 4- and 6-week cutoffs. We compared referral patterns and sociodemographic, clinical, and temporal data by LEP status , defined as documented need for an interpreter. We employed χ 2 tests for categorical variables and two-sided t tests or Mann-Whitney U tests for continuous variables. Multivariable linear regression was performed. Of 9,915 patients seen for consultation, 5.8% (n=573) had LEP. Patients with LEP were significantly more likely to have referrals originating from the emergency department (6.5% vs 1.0%, P <.001), require multiple referrals to a gynecologic oncologist before initial consultation (9.4% vs 5.1%, P <.001), and be referred to other obstetrics and gynecology specialties before reaching gynecologic oncology (15.9% vs 8.7%, P <.001). Of 5,329 patients who received treatment with gynecologic oncologists, those with LEP were more likely to experience delays in receiving treatment after the initial diagnosis-related referral (63.2% with LEP vs 52.4% without LEP waiting more than 4 weeks, P <.001; 43.5% with LEP vs 35.7% without LEP waiting more than 6 weeks, P <.001). The time from consultation to treatment did not differ by language status. After adjusting for race, insurance status, and ethnicity, the time from referral to treatment remained 16.0% longer for patients with LEP. In this large, diverse cohort, patients with LEP experienced inequitable, cumulative health care delays. Inefficient referral patterns created delay before initial gynecologic oncology consultation.

To examine the receipt of screening, services, and counseling during prepregnancy reproductive health, prenatal care, and postpartum care visits by disability status among people with recent live births in the United States. Cross-sectional data were from 24 states in PRAMS (Pregnancy Risk Assessment Monitoring System) that included the WGSS (Washington Group Short Set of Questions) on Disability (October 2018-December 2020). Participants reported receipt of screening, services, and counseling during prepregnancy reproductive health care visits, prenatal care visits, and a postpartum checkup at 4-6 weeks postdelivery. Associations between the extent of disability (some and a lot of difficulty vs none) and components of health care visits were estimated using modified Poisson regression, adjusted for sociodemographic characteristics (adjusted prevalence ratios [aPRs] and 95% CIs). A total of 41,027 participants were included in analyses; 33.7% (n=14,047) reported having some difficulty and 6.2% (n=2,714) reported having a lot of difficulty. Differences were observed for screening, services, and counseling received at health care visits by disability status. During prepregnancy reproductive health care visits, people with any difficulty reported similar receipt of care as those with no difficulty, with the exception of a lower prevalence of discussions about improving their health (aPR 0.92; 95% CI, 0.86-0.98) and sexually transmitted infections (aPR 0.89; 95% CI, 0.83-0.95). During prenatal and postpartum visits, people with any difficulty had a lower prevalence of discussions about lifestyle behaviors, pregnancy weight gain and weight loss, interpersonal violence, mental health, breastfeeding, and birth control, as well as being tested for diabetes (aPR ranged from 0.72-0.99). Perinatal health care visits provide opportunities to improve health and assist in the transition to parenthood. Our findings highlight the need for strategies to reduce barriers to care for people with disabilities and facilitate effective communication during visits.

To evaluate whether there is an association between the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI) score and postpartum care attendance. This is a retrospective cohort study of patients who delivered at 20 0/7 weeks of gestation or later at any of three hospitals within a New York City health care system from January 1, 2022, to February 1, 2024, and had at least one prenatal outpatient visit at an affiliated site before delivery. The primary outcome was at least one outpatient in-person obstetric visit within 12 weeks of delivery. The exposure was CDC-defined SVI score, with a validated technique for geocoding patient addresses used to assign overall SVI score and SVI theme scores. The SVI score was categorized into quartiles representing low to high social vulnerability. Demographic, medical, and obstetric factors were examined with univariable and multivariable logistic regression. Of 21,539 eligible patients, 14,026 (65.1%) attended an in-person postpartum visit within 12 weeks of delivery. In-person postpartum visit attendance was documented in 2,147 (50.3%) of those with high social vulnerability, 3,020 (64.4%) of those with medium-to-high SVI score, 4,568 (70.6%) of those with low-to-medium SVI score, and 4,191 (70.6%) of those with low SVI score. In univariable analysis, both medium-to-high SVI score and high SVI score were associated with lower odds of attending a postpartum visit (odds ratio [OR] 0.75 [95% CI, 0.70-0.82] and 0.42 [95% CI, 0.39-0.46], respectively) compared with those with low SVI score. These associations were also detected among the SVI socioeconomic, household composition, and racial and ethnic minority themes but not housing type and transportation theme. However, only high SVI score was associated with decreased odds of attending an in-person postpartum visit in multivariable models (adjusted OR 0.85 [95% CI, 0.78-0.94]). A high SVI score was associated with lower likelihood of in-person postpartum visit attendance within 12 weeks of delivery.

Discussions around racial disparities in obstetrics occur in varied silos including the media, communities, and medical institutions. Yet, whether and how these discussions occur in the context of the patient-clinician relationship is unknown. We sought to explore clinician perspectives on conversations with patients regarding racial disparities in maternal health using a qualitative approach. We enrolled perinatal clinicians (N=14) across two hospitals within one academic health system from August 2023 to March 2024, purposively sampled by self-identified race or ethnicity and role until thematic saturation was achieved. Semistructured interviews using the Health Equity Implementation Framework evaluated prior experience with and optimization of disparities counseling, focusing on patient-clinician race concordance, comfort levels, barriers, ideal circumstances, and recommended content for conversations about racial disparities in maternal health. Interviews were coded with a content analysis approach by two coders with high interrater reliability (κ>0.8). Clinicians universally recognized the effect of race, specifically racism, on U.S. maternal outcomes. Conversations about racial disparities most frequently arose 1) when Black patients voiced fears of dying or concerns about bias in their care or 2) in the context of recommending aspirin for preeclampsia risk reduction. Black clinicians felt more comfortable with these discussions, attributed to lived experience and practice. Although most clinicians agreed that conversations with patients about racial disparities are important, they identified barriers such as fear of patient reactions (particularly with discordant race), time constraints, and unclear actionable response. Our findings, along with ongoing work on the patient perspective, highlight the need for respectful, informed conversations centering patient experiences. As awareness of racial disparities grows, perinatal clinicians must develop capabilities for discussing race constructively, practicing relationship-centered care, and promoting psychologic safety for Black patients.

Iron deficiency is the most common cause of anemia in pregnancy. Iron requirements increase to meet the demands of maternal red cell expansion and fetal development. As part of a quality-improvement project, ferritin levels were obtained in all patients (N=1,858) presenting in the first trimester to identify iron deficiency. Anemia (hemoglobin less than 11 g/dL) was present in 75 patients (4.0%, 95% CI, 3.2–5.0) and iron deficiency (ferritin level less than 30 ng/mL) in 757 (40.7%, 95% CI, 38.5–43.0). Hemoglobin was 11 g/dL or higher in 707 (93.4%) patients with iron deficiency. Anemia was present in 25 of 1,101 (2.3%, 95% CI, 1.5–3.3) patients with normal ferritin levels. Additional research is required to determine whether earlier supplementation decreases the incidence of anemia later in pregnancy and improves outcomes.

To assess national U.S. trends in self-reported prepregnancy cardiometabolic risk factors and counseling about improving cardiometabolic health. We analyzed data from the Centers for Disease Control and Prevention's PRAMS (Pregnancy Risk Assessment Monitoring System), a nationally representative population-based survey of postpartum individuals who had live births from 2016 to 2022. We identified prepregnancy cardiometabolic risk factors (obesity, overweight, hypertension, diabetes mellitus, smoking cigarettes or electronic cigarettes). We then tested for age-standardized trends in both cardiometabolic risk factors and prepregnancy counseling using logistic regression with survey year as a continuous variable. We examined whether patient sociodemographic factors were associated with self-reported prepregnancy counseling about cardiometabolic health, adjusting for clinical characteristics. Among 225,431 participants (weighted n=11,052,761), the majority (61.6%) reported having at least one prepregnancy cardiometabolic risk factor and 14.8% reported having two or more risk factors. Only 38.4% of individuals had optimal prepregnancy cardiometabolic health (no risk factors). The age-standardized prevalence of having a cardiometabolic risk factor increased from 59.1% in 2016 to 62.8% in 2022 ( P <.001) and was driven by an increase in the prevalence of obesity from 22.4% to 28.4% ( P <.001). Only 58.3% reported receiving any type of prepregnancy counseling about cardiometabolic risk, with screening for smoking most common (54.4%), followed by counseling about maintaining a healthy weight (26.9%), counseling about improving health before pregnancy (21.4%), and counseling about controlling medical conditions such as diabetes or high blood pressure (10.4%). Lower income, lower education, rural residence, and no health insurance were associated with lower odds of being counseled about cardiometabolic health. Prepregnancy cardiometabolic risk factors were common among U.S. birthing people and have increased over time. Self-reported prepregnancy counseling about cardiometabolic health remains suboptimal, and there were disparities by income, education, geography, and insurance status.

To quantify mortality trends among female individuals of childbearing age (15-49 years) across global regions from 1990 to 2021, systematically evaluating persistent geographic inequities in preventable deaths. We analyzed data from the GBD (Global Burden of Diseases, Injuries, and Risk Factors Study) 2021, focusing on five leading causes of maternal mortality: hemorrhage, hypertensive disorders, sepsis and infections, obstructed labor and uterine rupture, and abortion and miscarriage. We calculated estimated annual percent change (APC) in age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) for these conditions, stratified by age group and sociodemographic index, to examine temporal trends. Joinpoint regression identified trends and inflection points in age and sociodemographic index stratification. Spearman correlation analysis assessed the relationship between ASIRs and sociodemographic index levels. Globally, an estimated 102,854,299 new incident cases of the five major maternal disorders and 129,331 deaths were reported in 2021. Between 1990 and 2021, the ASIR declined annually by -1.4% (95% CI, -1.5% to -1.3%) (estimated APC), and the ASMR decreased even more substantially at -3.6% (95% CI, -3.7% to 3.4%) per year. Annual declining trends in ASIR and ASMR were observed across all leading causes of maternal mortality. However, regions such as Central Sub-Saharan Africa still reported persistently high rates. Epidemiologic curves revealed peak mortality in the age stratum of 20-24 years, with progressive attenuation to nadir levels in individuals aged 45-49 years. Although abortion or miscarriage became increasingly prevalent as a cause of death worldwide over three decades, maternal hemorrhage remained the leading cause of death, accounting for 35.8% of deaths globally. Higher sociodemographic index correlated with declining ASIR and ASMR trends overall. Notably, sepsis-related mortality increased in younger cohorts, and high-middle-sociodemographic index regions achieved the steepest ASMR and ASIR reductions from 1990 to 2006. Joinpoint regression identified inflection points in incidence and mortality trends in age- and sociodemographic index-stratified populations over time. There was a substantial global reduction in maternal mortality between 1990 and 2021; however, Central Sub-Saharan Africa persists as the most critical regional hotspot. Maternal hemorrhage was the leading cause of death. The Sociodemographic index serves as a robust predictor of mortality, necessitating precision-targeted interventions that prioritize geographic regions with both elevated risk and obstetric complications.